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 Obama voters want the Affordable Care Act  (ACA, also known as Obama care) implemented and not repealed.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!

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 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.

As the elections get closer and the debates are finally over, I feel a need to add one more comment. Again please excuse the fact that I’m becoming medically political, but I can’t help it…nor it seems can the Brits! The recent issue of the British journal, Lancet had in it’s World Report section a summary of the US presidential candidates’ outline on health policies. Once more the positive aspects of the Affordable Care Act for women was emphasized: “In addition to an array of free preventative healthcare services that the law requires for all patients, the ACA also empowers the US Department of Health and Human Services to add other preventative healthcare benefits specifically for women. These additional benefits which took effect in August, include HIV testing and all birth-control methods approved by the FDA.” The article’s author reminds us that Romney opposes the law’s requirement that employee sponsored plans cover contraception. But remember most Americans have health policies through their jobs! And although most voters in United States will be looking at the issues of domestic health reform (or I hope they might at least consider it), their are those who might want to factor in proposed global health policies and expenditures.

President Obama has expanded funding for the President’s Emergency Plan for AIDS Relief (PREPAR), which has a goal of providing treatment to 8 million people worldwide by 2015. The Romney campaign has declined to answer questions about the fate of such initiatives should Romney win the presidency. He did make a statement last July at the International AIDS Conference in Washington DC praising ” the significant progress in research, education, delivery of drugs” and said that more needed to be done. He went on to say ” America is a compassionate nation it has been -  and must continue to be – a beacon of hope for innovative research and support as we seek to overcome the global challenge of AIDS.” But that does not mean he will support ongoing or increased global health initiatives. He is running on a campaign of decreasing government expenditures. And unless overturned, automatic cuts in foreign and domestic spending are scheduled to take effect in January if Congress fails to trim the budget by about $1 trillion from the federal budget.

So there we are…neither campaign has explicitly promised to increase support for future research and science. But if you care about our domestic health and welfare, as well as that of women and children in the world we live in, I hope you will consider the specificity of statements, the promises and the health related agendas of the candidates when you vote.

It’s amazing to realize that it was just 10 years ago that the Women’s Health Initiative results were released with extraordinary media brouhaha, causing as many as 70% of women who were taking menopausal hormone therapy (usually Prempro) to cease and desist…and in many instances flush, flash and lose sleep. But with time, additional studies and empathy, the experts (members of the North American Medical Society, gynecology department heads at major universities, and editors of the American Society for Reproductive Medicine and The Endocrine Society to name just some) now agree on key points regarding the safety and efficacy of hormone therapy in menopause. And since the following is generally what I tell my patients, I am delighted to recap the recommendations just published in several of the major journals.

In a overview, they agree that systemic therapy is an “acceptable” option for relatively young (up to 59 or within 10 years of menopause) and healthy women who are troubled by moderate to severe menopausal symptoms. There is no one therapy fits all, and consideration should be given to a woman’s quality- of- life priorities as well as her risk factors such as age, time since menopause risk of blood clots, heart disease, and stroke and breast cancer. Their consensus then deals with individual issues

Hormone Therapy Risks

Vascular risks Although both estrogen and estrogen with progestogen increase the chance of clots (deep vein thrombosis and pulmonary embolism as well as certain types of strokes) the risk is rare in the 50- to 59- year old age group. Moreover, observational studies have found that transdermal estrogen therapy ( with patches, creams, and sprays) and lowdose oral estrogen therapy have been associated with lower risks of these type of clot caused events.
Breast cancer
An increased risk of breast cancer is seen within 5 years or more of continuous estrogen and progestogen therapy. The risk is not great and risk declines after hormone therapy is discontinued. There is even less risk for women who have had a hysterectomy and don’t need to add progestogen to their estrogen therapy. Use of estrogen alone for a mean of 7 years does not seem to increase risk of breast cancer.
Duration of therapy

This is where everyone sites the same sentence: ” The lowest dose of therapy shouldbe used for the shortest anoint of time to manage menopausal symptoms.” they thenadd that duration should be individualized. I add that if more or longer therapy is neededto achieve quality of life, the patient and her physician should discuss this laststatement. And estrogen therapy alone, allows more flexibility in duration. There arereports of increased risk after 10 or 15 years of use in large observational studies.
Additional information

Evidence is lacking that custom compounded bio identical hormone therapy is safe oreffective. Many medical organizations and societies agree in recommending againsttheir use, particularly given concerns regarding content, purity and labeling. Finally thereis a lack of safety data supporting the use of estrogen or estrogen and progestogentherapy in women who have had breast cancer.

Conclusion

Leading medical societies devoted to the care of menopausal women agree that the decision to initiate hormone therapy should be for the indication of menopause-related symptoms.

Bottom line: there is no question that hormone therapy plays an important role in
managing the symptoms so many women experience during menopause. As usual, we
all recommend that therapy be individualized. So talk to your doctor!

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As you know when you come for your annual gynecologic visit, the receptionist requests that you update your information, sign a confidentiality form, and she checks on your insurance. The nurse then hands you a small plastic cup and asks you to give a urine sample. So there you are in a cramped bathroom trying to aim the stream into what now seems like an impossibly narrow container and thinking: (a) this is humiliating, (b) why is this necessary, I have no problems with my bladder? and possibly (c) I can’t go, so what am I supposed to do now?

A new article in the Journal Obstetrics and Gynecology aptly titled “In the Trenches” emphasizes the importance of checking your urine.

An immediate urine test can be performed with a “dipstick”, a strip of paper that is specially treated to check for white cells (often present if there is an infection) red blood cells or RBC’s (and the rest of this newsletter will deal with this… if blood is present in the urine, the medical term is hematuria), protein (if elevated, a sign of kidney or even systemic disease), glucose (present in urine if blood levels are high), ketones (elevated with kidney problems or dehydration), bilirubin (elevated in liver disease) and pH (acidity).

The journal article dealt specifically with microscopic hematuria in women. “Microscopic” simply means that there is blood (or red blood cells) in urine but the urine doesn’t look bloody to the naked eye or toilet paper…(I realize this is getting a bit gross!) According to the American Urological Association, “significant microscopic hematuria” means there are three or more red blood cells (RBC’s) per high power field (magnified 40 times) on microscopic examination from two to three properly collected urinalysis specimens. To get a proper sample, the first drops of urine should not be included, just the midstream…all the more difficult to get into that cup. If you have your period, recently exercised vigorously, just had sex or vaginal trauma, obviously blood cells in the urine will not count and the test should be repeated another time.

Once a dip stick test is positive for RBC’s …I (or any doctor) will probably send the urine out for a complete urinalysis. The urine is spun down and the sediment is examined for the number of RBC’s, white cells, and/or bacteria. Often we also do a urine culture to rule out infection. (Most women, however, do know when they have a bladder infection…. they have urinary urgency, frequency and burning.)

So why is it so important to detect microscopic hematuria? Before I relate the possible causes and consequences listed in the journal article, I’ll tell the tale of a patient that I saw a few weeks ago. She was menopausal, had no signs of vaginal bleeding or urinary problems, but a routine urine dipstick test was positive for RBC’s. Her urine was sent out for culture (it was negative) and complete urinalysis. The latter confirmed the presence of a significant amount of RBC’s.. I asked her to repeat the test 2 weeks later and once more it showed RBC’s. I then referred her to a urologic specialist for a complete workup.. This ultimately consisted of cystoscopy and a CT scan of her pelvis and kidneys. She was found to have bladder cancer. It was resectable and curable.. This simple urine test probably saved her life.

The two most frequent causes of microscopic hematuria in non-pregnant women (46% of women do have hematuria during their pregnancy) are cystitis (bladder infection) and kidney stones. Additionally, some women seem to shed RBC’s in their urine without any pathology. But the cause that should be ruled out, especially in women over 40, is cancer. Bladder cancer is the 17th most common cancer in women worldwide. In the United States in 2008 there were 17,770 new cases of bladder cancer diagnosed and 4,270 deaths …that means that there were more deaths annually from bladder cancer in women than from cervical cancer! (A personal aside…. many years ago my paternal grandmother died from bladder cancer.)

The risk factors for urologic cancers in women include age over 40, smoking, a history of exposure to chemicals or dyes, a history of gross hematuria (the “gross” here is a medical term and means that urinary blood is visible), analgesic abuse and a history of pelvic radiation. And here is a fact that seems to appear whenever we discuss most cancers: up to 35% of female bladder cancer cases may be attributable to cigarette smoking!

The recommendations put forth in the article state that a complete work up of microscopic hematuria should include an evaluation of the lower urinary tract (the bladder) and upper urinary tract (the ureters and kidneys) in any “high-risk” patient. Once more, you are at risk if you are over 40, have smoked, have had chemical exposure (hair stylists), have a family history of bladder cancer (I guess that’s me) and/or recurrent urologic disease. The work up should include cystoscopy, x-rays with dye and CT scans.

We all know about the need for Pap smears. It turns out that a urine test is just as important. So please don’t bewail that request to pee in a cup.

My husband (and anyone else I drive with) says I’m borderline hysterical when I sit in the front passenger seat. Perhaps this is due to the fact that as a resident I worked in the emergency room and treated victims of road injuries, or  because I now listen to the horror stories related to me by many of my patients as they hobble into my office weeks, months or years after back, neck or even internal injuries from road accidents. And then there was that time I managed to crack the front window of our Beetle when I was in high school after a 5-car pile up on the New Jersey turnpike. (The subsequent financial settlement did pay for a year of my college education and I had no on-going head problems, at least as far as I know, but there are those who would argue this conclusion…)

So it was with some degree of self-vindication that I read The Lancet journal editorial titled “Reducing Road Dangers”. The author reported that next week the first Decade of Action for Road Safety 2011-2020, established by the UN General Assembly, will be launched.  And a global plan has been issued by the World Health Organization to provide a framework for this worldwide action. What struck me the most in this editorial (perhaps the use of the word “struck” is unfortunate) were the statistics that were presented. I would like to share them with you…

3000 people die each DAY in accidents on the roads worldwide!  In case that number doesn’t say enough, that’s nearly 1.3 million people a year. And in addition 20-50 million people are injured each year, many of whom will then have lifelong disabilities. As more and more cars fill the roads throughout the world (personally, I am just envisioning the 405 Freeway in LA), road-traffic deaths are predicted to be the fifth leading cause of death by 2030. In case you are wondering what the first 4 will be; they are heart attack, stoke, chronic obstructive pulmonary disease and respiratory infections. This 5th ranking will have “progressed” since 2004 when it was a still an inexcusable 9th.  And although this number is horrific, it doesn’t even take into account the effects of air pollution and climate change from motor vehicles or the impact that driving everywhere (instead of foot propelled ambulation) has on our epidemic of obesity.

Usually I write newsletters that give you information that you can use to improve your health or the health of others. This time, I guess, this is more of an address to public policy and the need to maintain and improve our infrastructure.  I am not suggesting you trade in your car for a bicycle. But I do want to relate the 5 pillars of action outlined in the global plan, just so you are aware that they exist. They are certainly topics for dinner (or driving) conversation…  (1) Developing national road-safety strategies and funding for their implementation and monitoring. (2) Improving safety of roads for everyone (this includes motorists, pedestrians, bicyclists and motorcyclists). (3) Improving vehicle safety. (4) Changing road users’ behaviors through education and enforcement (this means seat belts, speed restrictions, no cell phone or texting distractions, helmets for motorcyclists and tackling road rage) and (5) Improving emergency medical response to crashes.

What each of us can do is to slow down and pay attention to the road while driving. This means we should try not to drive when we are sleep deprived.  (Fatigue and diminished concentration is a real problem…more than 37% of the population gets less than 7 hours of sleep and a recent survey of drivers in 12 states in the U.S. found that a sixth of all drivers have reported nodding off at some point while driving!)   We all know that drivers and passengers should use seat belts, and certainly wear helmets when on motorcycles and bicycles, but that admonition is not mandated in every state and certainly not in most countries.

Finally, we should support initiatives to improve road safety in our community, state and country. (And if necessary, we have to be willing to pay the taxes to do this.) And perhaps it would be helpful to listen to the directions and concerns of front seat passengers.

As I read the current medical journals, I have to make use of a new “library” of terms that refer to our bodies’ genes, RNA messengers, proteins and enzymes, not to mention the generic names of the drugs meant to impact the molecular basis of disease. But as medical knowledge becomes more “micro,” we can’t discount the macro…the need for individuals to get basic screening, diagnosis and therapy of common disorders. There is no requirement for medical ten-dollar words to understand the recent “Vital Signs” article in JAMA. It was a report by the National Center for Health Statistics at the CDC, documenting the prevalence, treatment and control of hypertension in the United States.  Here are some of the stats that they reported, which could on their own make ones blood pressure go up by at least a few points. (I’m talking systolic here…)

• Every year, hypertension contributes to one out of seven deaths in the U.S. and tonearly half of all cardiovascular disease-related deaths (heart attack and stroke).Hypertension affects an estimated 68 million U.S. adults.
• If all individuals received adequate treatment for their hypertension, 46,000 deaths might be averted each year.
• Direct and indirect costs of hypertension are more than $93.5 billion per year
• Cardiovascular disease and stroke account for 17% of total health expenditures in the US annually
• Overall U.S prevalence of hypertension among adults after the age of 18 between 2005 and 2008 was 30.9% (and highest among persons at or older than 65). This prevalence has remained unchanged during the past 10 years.
• 30% of patients with hypertension are not being treated pharmacologically.
• Only 45.8% of those with hypertension have their blood pressure adequately controlled.

There are, of course, recommendations as to what should be done to deal with this pervasive disorder and the resultant disease. Blood pressure readings should be taken seriously (and regularly). Anyone who has a blood pressure that is 140/90 needs to consider medication and lifestyle changes. Physicians now think that blood pressure reductions below the threshold for clinical hypertension (115/75) can have health benefits over time. An analysis of over 61 prospective observational studies of blood pressure and mortality (you know the ones that follow large groups of individuals for years) have shown that for each 20 mmHG increase in usual systolic blood pressure (This is the top number in blood pressure readings and represents the pressure that your heart is exerting to get the blood to flow through your arteries) or 10mmHG increase in usual diastolic blood pressure (which represents the pressure of the vessels between heart beats) above 115/75 mmHG was associated with a doubling in stroke mortality and death from heart attack at ages 40 to 69.

Before I sound the “get thee medicated” alarm, let’s go over the behavioral changes that can impact blood pressure. They should be adopted by all of us. (I’m sure we all know them, but since the American Heart Association has made them official here they are: (1) achieving and maintaining a healthy body weight; (2) participating in regular leisure-time physical activity (and I don’t think shopping counts, unless you have to walk rapidly for a total of 30 minutes from store to store to car.) (3) adoption of a healthy diet, including reducing salt intake and increasing potassium intake; (4) smoking cessation; and (5) stress management) Note, the AHA gave no indication in this report as to how to do this and I’m not going to begin to tackle stress reduction  in this “brief” newsletter. It would require a treatise in philosophy, psychology, economics and the 24-hour news cycle!

There are, of course, multiple pharmacologic therapies and frequently more than one is needed to achieve adequate blood pressure control. That’s where a physician’s knowledge and choices of medication are needed (as well as health insurance to help pay for access to the physician, appropriate follow-up and purchase of the medications… According to this CDC report, one of the groups with the lowest prevalence of blood pressure control consists of individuals without health insurance.)

Molecular biology may help us understand the whys, wherefores and potential treatments of disease. But unless we self-maintain our own health by eating right, moving our derrieres off the chair (I guess you should get off your computer, iPad or Blackberry where you are currently reading this admonition), adhere to prescribed medication and improve access to care, that “one in seven” (deaths due to hypertension) will continue.

Bottom line: Make sure your blood pressure is checked regularly and if elevated, even “a bit” (over 115/75) work on your lifestyle. If 140/90 or over, check with your physician as to your need for medication and adhere to whatever is prescribed. The pressures of life (and death) start with your own!

Several months ago, I wrote about the shingles shot and recommended (or at least the article I cited did) that just about everyone receive it at or after the age of 60. Quite a few of my patients called and told me they had followed up and were vaccinated. Others who were not yet 60 questioned why they should wait. The new news is that the FDA just lowered the age range for the shingles vaccine.

In this week’s JAMA, it was reported that the US Food and Drug Administration (FDA) announced its approval of expanding the age range for the vaccine (marketed as Zostavax) to adults aged 50 to 59 as well as those aged 60 years and older. The Center for Biologics Evaluation and Research (I won’t even bother to give an acronym for that one) stated “The availability of Zostavaz to a younger age group provides an additional opportunity to prevent this often painful and debilitating disease.”

A quick shingles review: (I discussed it fully in a previous newsletter titled “Out, Out, Damn Pox!” posted January 2011.) Shingles is caused by the varicella zoster virus, a herpes virus which triggers chicken pox. (Sorry, I seem to be fixated on herpes viruses lately….I promise to become non-viral next week.) After a bout of chicken pox (which we can assume we have had if we are now 50 or older), the virus remains dormant in certain nerve cells. Then one day, decades later, perhaps due to a combination of factors including age and a weakened immune system, the virus awakens (obviously without need of a sleeping beauty kiss), “climbs up” the nerve root to the skin where it erupts as a cluster of blisters that appear on the part of the body that is enervated but the inflamed nerve. The result is pain that can be excruciating. Though the lesions eventually heal, the pain can remain for months and in some cases, years.

The CDC based its expanded approval on a study carried out in 4 countries on 22,000 participants aged 50 to 59. Half received the vaccine and half received a placebo. After just a year of follow-up, the vaccine reduced the risk of developing shingles by 70% compared with placebo. In the US about 200,000 adults between 50 and 59 develop shingles annually; hence the use of this vaccine could have a significant impact for these not-so-young-any-more baby boomers.

Merck manufactures the vaccine. It’s not cheap. The cost is in the range of $200. You can check with your insurance to see if it’s covered. Many drug stores have it on supply and (like the flu shot) will have a nurse administer it. You can also get it through your physician’s office; just call to make sure it’s in stock.

Bottom line: If you or a family member (or someone you care about) is over 50, a one time (and timely) shingles vaccine is advisable.

Over the years many of my patients have come in with the happy announcement that their home pregnancy test was positive, but then voice their concern: ” I drank (wine, beer, the hard stuff) before I knew I was pregnant. Does this mean that I damaged the pregnancy? Should I worry?” (This is LA, some were already planning the preschool, grade school, high school and ivy league school that the 7 week old fetus would eventually be attending and worry that her or his chances were ruined!)

Fetal alcohol syndrome has been recognized for over a century. (It obviously has been around for as long as fermented beverages have been consumed; although when I watch all those television series about 16th century nobility, the males seem to be imbibing while the erstwhile maids, women and even princesses and queens are rarely portrayed sipping wine or mead. Considering the absence of birth control, some must have been pregnant.) Full blown fetal alcohol syndrome is pretty hard to miss: it manifests as low set ears, facial changes small chin and jaw, small head circumference, joint contractures, cardiac defect, varying degrees of mental retardation, behavioral abnormalities, hyperactivity and developmental delays. This array of fetal malformations can vary but, in general, has been associated with alcohol abuse (5 or more drinks a day) that continues throughout the pregnancy. So, could a mere drink or two a week in the first trimester do harm?

This question was addressed in a study published in a 2010 British Journal of Obstetrics and Gynecology and recently reviewed in the journal titled Obstetrical and Gynecologic Survey. (The latter allows me to catch up on the myriad articles published in my field.) The article detailed a prospective study of 2900 pregnancies in Australia (where I guess alcohol is readily available) between 1989 and 1999. A 14-year follow up of the children born to the women allowed the researchers to ascertain if alcohol had been harmful to the children’s behavior and development.

During various times in their pregnancy, the women were asked if they were or had been abstaining from all alcohol or occasionally drank (up to one standard drink per week), drank lightly (2-6 standard drinks per week), moderately (7-10 standard drinks per week) or heavily (11 or more standard drinks per week). The children from their pregnancies were then studied at birth and at 2, 5, 8, 10 and 14 years. The researchers also tried to correct for variables that could influence a child’s behavior, such as maternal age and education, the occurrence of stressful events during the pregnancy, maternal smoking and the presence of the father in the home as well as family income.

The results were somewhat surprising: In this analysis, the offspring of women who drank 2 to 6 or 7 to 10 drinks per week during the first 3 months of pregnancy did not have behavior problems up to the age of 14, and in fact had better behavioral scores than the offspring of mothers who did not drink at all!
The author of the review article points out that fetal susceptibility to alcohol is now known to be partially dependent on how rapidly alcohol is metabolized by the mother. Those who metabolize it more slowly have a higher peak blood alcohol level for a longer time than “fast metabolizes”. Alcohol breakdown (not that of the drinker, but that of the intoxicant) is dependent on possessing certain alleles (or genes), called ADH1B2 and ADH1B3. (Of note ADH1B3 has a high frequency among African Americans; unfortunately, the Australian study did not report the race of their participants.) But then how many women know their alcohol allele status? So although the allele data is interesting, it probably won’t help most women’s concerns regarding their alcohol consumption, especially in early pregnancy.

Bottom line: There are many factors that influence fetal susceptibility to alcohol, and it’s certainly best to “play it safe” and just not drink during pregnancy. But the current study allows physicians to continue reassuring their patients that have drunk less than 11 drinks per week in their first trimester that this was unlikely to have caused adverse fetal affects. And I have to add…. no one can guarantee the “right” school admission