Friday, May 27, 2011

The Shingles Shot

One diagnosis that I never like to make is shingles. Shingles is a rash that is confined to a dermatome, an area of skin that is controlled by one nerve. The rash can be quite painful; in fact, sometimes the pain starts even before the characteristic rash can be seen. In some very unlucky patients, the pain lasts long after the rash has healed – post-herpetic neuralgia.

There is a vaccine to help prevent shingles, or at least lessen any outbreak. In a clinical trial involving thousands of adults 60 years old or older, Zostavax® reduced the risk of shingles by about half (51%) and the risk of post-herpetic neuralgia by 67%. While the vaccine was most effective in people 60-69 years old it also provided some protection for older groups. No serious problems have been identified with the vaccine.
This is a one-time immunization. Research suggests that the shingles vaccine is effective for at least six years, but may last much longer. Even if a patient has had shingles, Zostavax can help prevent future recurrence. Ongoing studies are being conducted to determine exactly how long the vaccine protects against shingles.
Almost anyone 60 years of age or older should get the shingles vaccine, regardless of whether they recall having had chickenpox or not. Studies show that more than 99% of Americans ages 40 and older have had chickenpox, even if they don’t remember getting the disease. Certain people, primarily those with impaired immune systems, should defer.
The FDA has recently widened the scope of approval to patients ages 50-59. In a statement, the FDA said that among the newly approved 50 to 59 age group, about 200,000 people contract shingles each year. According to Karen Midthun, MD, director of the FDA’s Center for Biologics Evaluation and Research, “The likelihood of shingles increases with age. The availability of Zostavax to a younger age group provides an additional opportunity to prevent this often painful and debilitating disease.”

Monday, May 23, 2011

Cardiovascular Disease and NSAIDs

Even since rofexocib (Vioxx ®) was voluntarily recalled, physicians are increasingly more wary about the use of NSAIDs (non-steroidal anti-inflammatory drugs) in patients with heart disease. A new study published in Circulation suggests that any NSAID use should be limited in patients with cardiovascular disease.

In patients who have already had a heart attack, the use of NSAIDs is associated with increased risk of another heart attack and death. The increased risk was not only present at the start of treatment, but persisted the entire time the patient was taking a NSAID. The highest risk was with diclofenac (Volaren ®); ibuprofen (Motrin ®, Advil ®) showed an increased risk after use for more than one week. Naproxen (Naprosyn ®, Aleve ®) was not associated with an increased risk of death or MI for the entire treatment duration, but was associated with more gastrointestinal bleeding risk.

This was a large study of more than 80,000 patients from Denmark. The authors concluded that there is no safe therapeutic window for NSAID treatment.

This is another opportunity to remind patients that all medications are important, including over the counter products. Patients will sometimes neglect to mention seemingly trivial products and physicians are not always diligent in updating medication lists. Patients should be sure to apprise all treating physicians of all medical problems, even though it might seem irrelevant to the current situation.

Circulation. 2011;123:2226-2235

Sunday, May 15, 2011

How Can I Reduce My Cancer Risk?

There was a very nice update this month from the Yale Cancer Center (
about reducing cancer risks. Patients may seek genetic counseling based on a clustering of cancers in their family. Only about 10% of cancers are due to a hereditary cause; about 50% of cancers are preventable through lifestyle modifications. Clusters in families may be due to shared lifestyle and environmental factors.

Tobacco use increases the risk in many, many types of cancer. This includes cigarette, cigar, pipe, chewing tobacco and second-hand smoke. The National Cancer Institute has a free information service with smoking cessation counselors available to answer questions (1-877-448-7848). Another environmental issue is sun and tanning bed exposure: sun protection should be used year-round.

Obesity may account for about 14% of cancer deaths in men and about 20% in women. There is increasing evidence that decreased physical activity increases the risk of a number of cancers and this effect is independent of body weight. There is also some indication that physical activity may be also associated with a lower risk of recurrence.

Excessive alcohol use has been shown to increase the risk of multiple cancers. There are data to suggest that even moderate alcohol use may increase cancer risk, off-setting the potential benefits of decreased heart disease risk.

About 17% of all cancers are due to infections. Known viruses that cause cancers include HPV, Hepatitis B, Hepatitis C and HIV. Most of these infections are spread through sexual contact. Vaccines are available for HPV and Hepatitis B.

Many people are unaware of these modifiable risk factors. Lifestyle changes can lessen the future risk of developing cancer and help prevent a recurrence. 

Sunday, May 8, 2011

Diabetes in Connecticut

Diabetes has become an epidemic in the United States. One in ten adults has diabetes and another three in ten has ‘pre-diabetes,’ with blood sugars that are chronically elevated but don’t quite meet the criteria for the diagnosis of diabetes. The number of adults with diabetes may double by 2025 and the cost to treat diabetes may exceed the entire Medicare budget for 2010 ($514 billion). These data are from the US Centers for Disease Control and Prevention.

Using this new information from the CDC, the Institute for Alternative Futures diabetes model estimates that the number of Connecticut residents living with diabetes (diagnosed and undiagnosed) will increase 62% by 2025 from 294,900 to 477,300. The resulting medical and societal cost of diabetes will be $4.7 billion – a 68% increase from 2010. The entire report is rather sobering:

I have started testing all of my overweight patients for diabetes. Delaying or preventing the onset of diabetes can have a dramatic reduction in complications and premature death. The test that I find least helpful is the fasting blood sugar. Far more indicative is evaluating the rise in blood sugar two hours after a meal or measuring the hemoglobin A1c  (the average blood sugar for the previous eight weeks). Another clue that diabetes is lurking is elevated triglycerides with low HDL cholesterol (the ‘good’ cholesterol).

There is a wealth of information available on taking steps to lessen one’s risk of diabetes. A good place to start is with The Centers for Disease Control and Prevention: Know your own numbers - ask your physician for a copy of your last set of blood tests.

Monday, May 2, 2011

Lessons from Texas

This weekend I attended a dynamite conference about improving the treatment of diabetes in the Latino population. The presenters, from the University of Texas Southwestern Medical Center, discussed tailoring medical care to a population that is steadily growing. Even as the conference focused on the Latino populations, there is much that can be applied to the general population.

We as physicians can, and must take the first steps to improve the quality of health care services to diverse populations. We need to recognize and respect gender preferences within certain religious groups and we need to respect our patients’ efforts to communicate in a second language. We also need to understand the strong influence of recommendations from family and friends.

No matter the language, common terms may be different enough to engender misunderstanding. If a physician asks a patient to take insulin with “dinner,” does that mean the main meal at midday or the evening meal? The course director, Jaime Davidson, MD, tells the story of prescribing a medication once daily. Dr. Davidson wanted the patient to take the medication one time per day; however, once is ‘eleven’ in Spanish.  After three days, the patient had used all his medication for the month. This is a dramatic example, but miscommunications can happen at any time.

Our perception of a ‘healthy meal’ is heavily influenced by our preferences and cultural background. If our grandparents never ate broccoli, and our parents never ate broccoli, how likely is it that we will be serving broccoli to our children? This may sound silly, but we once had a babysitter who was speechless when served eggplant – her parents had always threatened the kids with eggplant for dinner if they were bad!

One of the thrills of primary care medicine is that we never know who will next come through the door with what problem – sensitivity to cultural differences can help improve care to all our patients.