Every once in a while I have a culinary break down and snack on potato chips….they gratify so many tastes: salt, fat, crispy carbs and empower a feeling of “so what.”  Turns out that I (and you) would be better off snacking on nuts. At least that’s the conclusion of a prospective investigation of lifestyle behaviors and diet published in the June issue of The New England Journal of Medicine. The authors combined questionnaires on lifestyle factors and weight change for 120,877 women and men who were free of chronic disease and who participated in 3 studies with follow-up periods ranging from 1986 to 2006 (The Nurses Health Study), 1991 to 2003 (the Nurses Health Study II…this involved younger nurses; Nurses I and II were all women) and 1986 to 2006 (the Health Professionals Follow-up Study… all male). Their diets were assessed as to consumption of fruits, vegetables, whole grains, refined grains (what I call the white stuff), potatoes (including boiled, mashed potatoes and french fries), potato chips, whole-fat dairy products, low-fat dairy products, sugar-sweetened beverages, sweets and desserts, processed meats, unprocessed red meats, fried foods and trans fats. In other words, pretty much everything we know that can be bad for our health. The studies also evaluated nuts, 100%-fruit juices, diet sodas and subtypes of dairy products and potatoes. The participants were questioned about their physical activity, television watching, alcohol use, sleep duration and cigarette smoking.

The participants’ food and weight changes were assessed every 4 years. When the average weight gain was calculated for the 3 groups it was 3.35 lb…doesn’t sound like a huge amount, but when calculated over 20 years this comes to 16.8 lb. (There goes a size 6, an 8 and even a10!) And here are the foods and behaviors that were associated with weight gain, as well as those that were related to weight loss:

I’m sure you will (and should) now ask: How many potato chips or nuts does one have to consume to gain or lose weight during that 4 year period? Just one serving per day! (And for the amount that constitutes a serving, you have to look on the package or bottle insert and/or use common nutritional sense.)

Please note that the weight gain that was associated with refined grains was similar to that of a serving of sweets and desserts. Inverse associations with weight gain (i.e. loss) were seen with the consumption of vegetables, whole grains, fruits, nuts and yogurt. No significant differences in weight gain were seen for high-fat versus low-fat and skim milk. The authors weren’t sure why yogurt consumption helped prevent weight gain. They hypothesized that changes in colonic bacteria caused by the yogurt might prevent weight gain. And they thought that even though vegetables, nuts, fruits and whole grains provide calories (and according to thermodynamic law a calorie is a calorie and energy put in the body will be stored unless it is used up); their consumption reduced the intake of  the other foods that were more likely to cause weight gain. It was interesting that drinking 100%-fruit juice was associated with less weight gain than sugar-sweetened beverages. The reason may be that the fruit juices are consumed in smaller portions. (It’s hard to drink a “big gulp” of orange juice!)

Finally, (and we would expect this) the women and men with who exercised daily lost 1.76 pounds within each 4-year period.

Now for the smoking issue… I don’t want this data to stop anyone from deciding to stop.  Smoking is thought to alter the distribution of body fat, promoting internal abdominal fat (called visceral fat) rather than fat on the rest of the body. So weight might be less while smoking but this visceral fat is dangerous and is linked to a high risk of diabetes. Any so called weight loss from smoking is ultimately harmful. (Just think of the fat going invisibly inside your abdomen as your thighs, arms and the tush lose circumference; and that this bad fat can kill you!),  The immediate weight gain that can occur after smoking cessation actually represents a healthier distribution of fat, moreover that weight eventually declines.
Here are some stats that match the overall data from these 3 studies: Between 1971 and 2004 the average dietary intake of calories in the United States increased by 22% among women and 10% among men, mainly due to increased consumption of refined carbohydrates, starches and sugar-sweetened beverages. Just 50 to 150 extra calories a day will cause the gradual weight gains, and over time those pounds add up and demolish our figures (and health).

Bottom line: Eat those vegetables, whole grains, fruits, nuts and yogurt.  Cut down on all those processed carbs and starches. Limit your TV time (you are more likely to eat the bad stuff while sitting there watching TV, even if you Tivo out the commercials for potato chips), make sure you exercise (at least 30 minutes most every day) stop smoking as soon as possible (better yet never start) and  sleep 7 to 8 hours a day. Well our mothers knew all that!

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.

I just returned from Israel and frankly would not be able to function without a caffeine push. To add to my thanks for that cappuccino (or 2) is a new study that appeared in the journal Stroke. (Yes, there are journals that are titled for diseases.) Researchers at the very well known Karolinska Institute in Stockholm followed 35,670 women (ages 49 to 83 years) who did not have a history pf cardiovascular disease or cancer over a 10 year period of time. (These women were actually participating in the Swedish Mammography Cohort study looking at links between diet, lifestyle and disease.) They assessed coffee consumption using a self-administered questionnaire. The questionnaire made no distinction between caffeinated and decaffeinated cups of coffee, but it is well known (reference The Girl with the Dragon Tattoo as well as the other novels by Steg Larsson) that decaffeinated consumption of coffee in Sweden is low.

The researchers found that 1 to even more than 5 cups of coffee a day lowered risk for stroke, cerebral infarction (lack of oxygen and death of the tissue from an occlusion of an artery) as well as sub arachnoid hemorrhage by 25%! The amount of coffee did not seem to make a difference; it just had to be a daily beverage. And when they took into consideration smoking, weight, history of diabetes, hypertension and alcohol consumption, the decrease in stoke incidence was still there if coffee was consumed on a regular basis.  Wow! This doesn’t mean that the latter factors are not important…but even if they exist, coffee appears to decrease the risk of those women who are at risk.

The authors of the study suggested that coffee drinking reduces stroke by decreasing mild inflammation, acting as an antioxidant and improving insulin sensitivity. Right now, I just want it to keep me awake!

I’ve written several newsletters about potential side effects of bisphosphonates medications used to treat osteopenia and osteoporosis (Fosomax, Boniva, and Actonel….just to remind you of some brand names). This time I want to share some potentially good news about this bone density enhancing class of medications. And I am especially happy to share the report because it comes from a study conducted in Israel. (As many of you know, I have taught and worked there and indeed will be in Tel Aviv when this article appears.)

The Israeli researchers conducted a study entitled The Molecular Epidemiology of Colorectal Cancer. It was supported by the National Cancer Institute and published in the February issue of the American Journal of Clinical Oncology. (I hope I haven’t lost most of my readers by this point…just bear with me. So many of you or your relatives take bisphosphonates so that your skeletons can successfully bear your weight without an osteoporetic fracture)

They found that postmenopausal women who had taken an oral bisphosphonates longer than one year had a 59% reduced risk of colorectal cancer. Like the Scandinavian countries, pharmaceutical records in Israel are extremely well documented. (All the citizens have health insurance and most of their prescription medications are covered…I wish I could say the same for us!) The researchers used computerized pharmacy records and identified almost 2000 women who had colorectal cancer.

They found that in these women, compared to controls who were matched for age, weight, and religion, the use of bisphosphonates longer than 1 year, but not less than 1 year, reduced the risk of colorectal cancer by half, even when they adjusted for other factors that could perhaps lower colorectal cancer risk. (Here is where I list these factors to remind you that they too count in our “war on colorectal cancer”…as does screening. They include vegetable consumption, physical activity, and weight control, use of low-dose aspirin, statins, vitamin D and postmenopausal hormones.)

Ongoing research indicates that oral bisphosphonates may exert a cancer-protective effect (including breast and prostate cancer.)  Clearly this study is not large enough to persuade the FDA to approve any official indication that this class of medication will diminish colorectal cancer. So I’ll end with the phrase that is used in the conclusions of most medical articles: “Further studies are needed”. I felt , however, that a bit of good news about the medications that can lower the huge toll of osteoporotic fractures in women (and men) is welcome.

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!

Let’s discuss several hormonal scenarios: (1) You’ve been on hormones for several years and now think you may try to stop. (2) You have just started having hot flashes and you haven’t quite made up your mind as to whether you will want to take hormones during the menopausal transition. (3) You are not yet menopausal but worry about what you will experience when it inevitably develops.

The defining question for most women (at least in regards to quality of daily life) is: “How long will I experience hot flashes?” One would think that since menopause has been around before and since the written word that we could estimate the average duration of this pesky and sweaty symptom. (Well maybe not, 120 years ago the average life expectancy for women was 47 and most did not outlive their ovaries.)

Hot flashes generally begin when estrogen levels plummet in menopausal or during the premenopausal transitions. The ovaries run out of follicles that are capable of responding to pituitary messages to develop and hence produce estrogen. In the absence of said estrogen, the pituitary works harder (it’s trying to get those damn follicles to work), hence it puts out more and more FSH (follicle stimulating hormone). The pituitary gets its signals from the part of the brain called the hypothalamus which produces GnRH or gonadotropic releasing hormone, the master hormone that instigates FSH production. In the absence of “usual” estrogen production, GnRH and FSH levels soar and there is a veritable hypothalamic storm. This then causes a state of confusion in the central thermostat in the brain which begins to “think” that the body’s core temperature is too hot. In order to correct this, the hypothalamus sends out directives to dilate the small blood vessels in the skin (the flush) and causes water to evaporate from the skin’s surface (as sweat, facial and body perspiration) in order to cool the body down. All of this may lower the core body temperature by as much as half a degree. Often subsequent to a hot flash, a woman may shiver as small muscles contract to re-elevate the core body temperature.

Hot flashes are associated with poor sleep, decreased quality of life, may worsen depressive symptoms and even signal the onset of a major depressive disorder. The flashes may also be a clinical sign for underlying cardio vascular disease as well as a risk factor for poor bone heath. Although “natural”, hot flashes are not great to experience and ultimately may correlate with poor overall health.
What we do know is that the peak incidence of hot flashes occurs approximately 1 year after menopause in 80% of women in the US, but (and this is what is so surprising) the overall duration of hot flushes is unclear.

(Sorry that this intro is so long, but now I’ll get to a recent attempt to answer the “how long will this last” question…) A study published in the May issue of Obstetrics and Gynecology tried to assess the duration of menopausal hot flashes and associated risk factors.

The “flushing and flashing” women that were followed were part of The Penn (Pennsylvania) Ovarian Aging Study of 435 women (half white and half African American) that were monitored for 13 years. Hot flushes (they use this term instead of “flash”) were evaluated at 9 -month and 12-month intervals though in-person interviews. At enrollment, the participants’ ages were 35 to 47 (mean age 42.2) and 91% were still premenopausal. The most common age at onset of moderate-to-severe hot flushes was 45-49(35%); 30% were between 40-44years, 21% were older than age 50and 14% were younger than 40 years. Age at the onset was inversely associated with duration of hot flashes. In other words, the younger the women were, the longer they suffered. This totaled 11.57 years for those whose onset of hot flushes occurred before the age of 40; and decreased with onset at older ages: 11.25 years for those whose flushes started at 40 to 44 years; 8.1 years with onset ages 45-59 and 3.8 years duration with onset at 50 years of age or older.

Other independent predictors of the duration of the flushes were race (African Americans had a longer duration) and body mass (thin women also had a longer duration.) It’s thought that obese women convert hormones produced by their adrenals to estrogen-like hormones in their abundant fat and hence have production of estrogen that “saves them” from many years of flushes. It’s interesting that in this study smoking, alcohol use and number of children the women bore had no association with the duration of their hot flushes. (Although in general, the data has shown that smokers enter the menopause at an earlier age than non smokers, simply because the toxins in cigarettes kill off the follicles in the ovaries….my comment in this article against smoking!).

In the discussion portion of the article, the author’s state that “the median duration of moderate-to-severe hot flushes was 10.2 years, well beyond the duration considered in clinical guidelines. When women who reported mild hot flushes were included, the median duration increased to 11.6 years.”

Before all you women who begin to have menopausal symptoms in your early 50′s freak that these will continue unabated into your 60′s, I have to point out that the majority of the women in this study were younger than 50 when they reported moderate-to-sever hot flushes. (Most were 45 to 49.) Hot flush duration was approximately 8 years for this group compared to less than 4 years when onset occurred at ages 50 years or older.

Bottom line: The earlier you begin to have hot flashes (even if you are still getting your period) the longer you can expect them to continue during menopause. Now that you have this information, discuss therapies with your doctor.

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.

I’m currently at 39,000 feet on my way to NY to have a fun weekend with my daughter. I slipped a few medical journals into my carry-on to review so that I could find an article to share in my weekly newsletter. The seat is cramped, the cabin is crowded, most of my fellow passengers are sleeping….I passed over articles on multiple therapies for tuberculosis (too much coughing going on around me), sepsis and organ failure, as well as AIDs – defining cancers (too depressing)…Each subject is critical to the progress of medicine and I did read up on them, but for this newsletter I selected an article in JAMA titled ” Genital Shedding of Herpes Simplex Among Symptomatic and Asymptomatic Persons with HSV-2 Infection”.
So here it is…answering the question: do individuals who don’t know they have genital herpes shed the virus (and hence can spread it to a partner) to the same extent as those that have recurrent lesions (and are aware of their diagnosis)?

A quick herpes review: Genital herpes (HSV-2) is unfortunately, extremely prevalent. Over half a billion people worldwide have the virus and it is estimated that 23.6 million persons aged 15 to 49 become infected annually. In the US, 16% of adults have had it as evidenced by the fact that they have antibodies to HSV-2, but only 10 to 25 % of persons with this “everlasting infection” know that they harbor it. As a result, individuals who don’t know they have had herpes spread most of the HSV-2 infections. The risk of sexual transmission doesn’t correlate with recognition of symptoms but is correlated with silent viral mucosal shedding (and obviously, sexual contact with a partner).

Researchers at the University of Washington enrolled participants who were 18 and older in this herpes study for the published study. They advertised for participants through word of mouth at the university, newspaper ads (and promises of payment), tested many and in the end found 498 individuals who had antibodies to herpes 2. They then divided them into 2 groups: those who were symptomatic (had a clinical history of genital herpes) and those who were not (never knew that they had a lesion, their diagnosis was made with the herpes antibody blood test). Each person then self-collected swabs of their genital secretions for at least 30 days. (The swabs were examined by quantitative polymerase chain reaction for HSV DNA…I had to add that for the purists.)

The results showed that those who had symptomatic genital lesions were twice as likely to shed the virus and 3 times more likely to develop lesions than those who were, on initial testing, asymptomatic. However in those with no symptoms, genital HSV shedding did occur on 10% of days, and almost all of it was subclinical (i.e. the person did not recognize a lesion). There was a similar shedding rate between men and women; which means that men can have sub-clinical shedding on normal appearing genital skin. (There goes the adage, look before you engage…)
What they also found was that many of those who were initially asymptomatic begin to recognize recurrent herpes once they had received the diagnosis through their blood tests. They may have felt that what they had in the past was just a mild irritation or itch and ignored it, now they didn’t.

I have frequently been the doctor who sees a patient with “something down there” and either through direct culture and/or a blood test have made the diagnosis of herpes. Often the first statement posed by my now horrified patient is “he never told me”, or “was he with someone else?” Neither may be correct…the partner may not have known that he (or she) had acquired herpes in the past, or the woman with the “new” herpes infection may have had it all along and only now has become aware of a clinical lesion. (Perhaps brought on by illness, stress or diminished immunity.)

It certainly would be helpful to have universal herpes 2- antibody testing. But this is not currently a part of “routine” blood tests, nor is it financially feasible. The best protection will continue to be the use of condoms. For those who have been diagnosed with herpes, daily prophylactic use of the antiviral medications such as Valtrex or acyclovir should decrease shedding as well as recurrent lesions. So far that’s the best advice that’s offered by the experts. Somewhat depressing at 39,000 feet (or for that matter at sea level)!

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