Preventive Care Recommendations at Your Fingertips

Preventive medicine is a rapidly growing field.  Testing that detects diseases in early stages, treatments that prevent diseases before they occur, and behaviors that make diseases less likely all hold the promise to keep us healthy and let us live longer.  Unfortunately the field is also increasingly marred by tests and services that are recommended to patients without any scientific evidence that they work, or worse, despite much evidence that they are useless.

That’s why I’ve long been a disciple of the U.S. Preventive Services Task Force (USPSTF).  The USPSTF is an independent panel of experts in primary care and prevention that systematically reviews the scientific evidence and develops recommendations for all kinds of clinical preventive services.  They are the most objective and least biased national recommendations panel, because (unlike many professional organizations) they have no incentive to encourage or discourage the use of any service.  (That’s why I included them on my Web Resources page.)  So whenever a patient asked “Should I have an annual chest X ray” or “What tests should I have to check for ovarian cancer?” I always relied on their recommendations.

So I was delighted when my patient, Mr. Timo Kissel (thanks!), pointed me to a new feature that makes the USPSTF recommendations much easier to use by both patients and doctors.  They have a new tool called the Electronic Preventive Service Selector (ePSS) which can be used on the web or downloaded to a PDA.  The user enters his/her age, gender, use of tobacco, whether she is pregnant, and whether she/he is sexually active, and the website displays the recommendations tailored specifically for that person.  Try it yourself.  Go to the “Search for Recommendations” screen and enter your information.  Find out what you should do to stay healthy, and what unnecessary testing you should avoid.  (Be sure to look at the definitions of what the A, B, C, D and I grades mean.)

Some of the recommendations may surprise you and are counter to the practice habits of many doctors.  For example, screening for prostate cancer with a PSA blood test or a rectal exam is still controversial, and there is insufficient evidence to recommend for or against such testing.  Also, doing any kind of tests (like stress tests or CT scans) to look for heart disease in patients with no risk factors or symptoms of heart disease is known to be ineffective.

If you have the time, search around through the recommendations.  I’ll be happy to answer any of your questions that come up.

Tangential Miscellany:

I’m donating platelets again tomorrow.  My new readers may have missed the last time I wrote about blood donation.  I may bug you occasionally about donating blood.  It’s important.

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An Oral Antibiotic Reduces the Symptoms of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a very common chronic condition.  The most common symptoms of IBS are crampy abdominal pain, painful diarrhea or constipation, and abdominal bloating.  The cause of IBS is unknown.  Many of my patients suffer from it.  The National Institute of Diabetes and Digestive and Kidney Diseases has an informative website about the symptoms, diagnosis and treatment of IBS.

Last month the Annals of Internal Medicine published an important article about this common problem by a research team led by Dr. Mark Pimentel, a gastroenterologist at Cedars-Sinai Medical Center.  The study randomized 87 patients with IBS into two groups.  One group received rifaximin (an oral antibiotic that is not absorbed by the gut into the rest of the body) for 10 days.  The other group received placebo.

The group receiving the antibiotic had less IBS symptoms, and the improvement lasted for 10 weeks, long after the last antibiotic pill was taken.  Rifaximin is fairly safe and side effects were rare and not severe.

Rifaximin is by no means a cure of IBS, but for those whose symptoms are very bothersome, this study may represent an important advance.

Tangential Miscellany:

The Cedars-Sinai Medical Staff Pulse interviewed me about my practice.

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CDC Advisory Committee Recommends Vaccine to Prevent Shingles

Six weeks ago I wrote about Zostavax, a vaccine that prevents shingles.  At that time I suggested waiting to see if the CDC was going to recommend it.  Last week the CDC Advisory Committee on Immunization Practices (ACIP) recommended that all adults over 60 who have had chicken pox receive the vaccine.  The press release about the ACIP’s recommendation is here.  The Medical Letter review of Zostavax reported that shingles causes a very strong immune response, and once an adult has shingles, it is very unlikely she will ever have it again.  So they do not think the vaccine is helpful in adults who have already had shingles.

Therefore I’m recommending Zostavax to all patients over 60 who have had chicken pox but not shingles.  It’s a single shot, and the duration of efficacy is still unknown, meaning it’s possible that the protection will wane after a few years.  We don’t keep the vaccine in stock.  We order each dose as patients request it, and Merck ships it to us within two days of our order.

If you’d like to be vaccinated, please call the office to find out the price and schedule an appointment.

Tangential Miscellany:

In response to my post about the importance of daily weighing to maintain weight loss, Matthew Lehrer informed me about a software program that he has found very helpful in losing weight.  CalorieKing is a program that helps you track your eating and exercise and makes recommendations to help you achieve success.  It also has a PDA version so you can enter your food when eating away from home.  I would love to hear about anyone else’s experiences with it.

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Influenza Vaccination

Flu season is almost upon us.  As far as I can tell from the flu activity monitoring of the CDC and the L.A. Department of Public Health Acute Communicable Disease Control site L.A. County has not yet reported any significant numbers of flu cases.

So now is a good time to review the CDC recommendations for flu vaccination and decide if you should have the flu vaccine.  The following groups of people should be vaccinated:

People at high risk for complications from the flu, including:
Children aged 6 months until their 5th birthday,
Pregnant women,
People 50 years of age and older, and
People of any age with certain chronic medical conditions;
People who live in nursing homes and other long term care facilities.

People who live with or care for those at high risk for complications from flu, including:
Household contacts of persons at high risk for complications from the flu (see above)
Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)
Healthcare workers.

The following groups of people should not be vaccinated:

People who have a severe allergy to chicken eggs.
People who have had a severe reaction to an influenza vaccination in the past.
People who developed Guillain-Barr syndrome (GBS) within 6 weeks of getting an influenza vaccine previously.
Influenza vaccine is not approved for use in children less than 6 months of age.
People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen.

The Medical Letter recommends the vaccine for anyone who doesn’t have any of the above contraindications.  We expect our delivery of flu vaccine in the next few weeks.  In the meantime, if you find the vaccine at another convenient location (a pharmacy, etc.) get it.

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Keeping the Weight Off

I’ve written before that quitting smoking is the hardest thing I ask my patients to do.  Losing weight is the second hardest.  Many patients struggle for years with their weight, and frequently after successfully losing weight, slowly regain it.

Last week’s New England Journal of Medicine had an important article about keeping weight off:  A Self-Regulation Program for Maintenance of Weight Loss.  The study enrolled people who had already lost at least 10% of their body weight in the last 2 years.  On average, they had lost 42.5 lbs.  They were randomized to three groups.  The control group received only quarterly newsletters.  The two intervention groups were counseled to weigh themselves daily and to self-regulate their diet and exercise in order to return their weight to normal if it increased.  The intervention groups met weekly.  One group met face-to-face, and the other met over the internet.

The sobering results are that, while the intervention group did much better, all three groups gained weight.  The face-to-face group gained an average of 5.5 lbs, the internet group an average of 10.4 lbs, and the control group an average of 10.8 lbs.  So daily self-weighing, self-regulation of diet and exercise in response to weight changes, and weekly face-to-face meetings to reinforce and support the self-regulation training seems to have done best.

I’ve always asked patients to weigh themselves weekly, thinking that daily weighing would increase anxiety without adding useful information.  This is clearly not the case.  A daily habit is probably much easier to maintain than a weekly one.  The authors note in their conclusion

Although concern has been expressed about possible adverse effects of regular self-weighing, there is little evidence to support this concern and no evidence of adverse consequences of the interventions in our trial.

This is a good reminder that regardless of how people lose weight, ongoing intervention is required to prevent regaining the weight.  Daily self-weighing and weekly face-to-face meetings worked best, which is similar to the strategy used by Weight Watchers, a weight loss and weight maintenance program I’ve recommended to many patients.

So if you’re trying to lose weight or you’ve lost weight and don’t want to gain it back, dust off your scale, get into a regular exercise program, and think about joining a weight loss program.  If you’d like a weight loss coach who can meet with you personally, or a personal trainer to help you exercise, let me know.

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A Habit of Giving

Most of us think of ourselves as people who go out of our way to do the right thing, especially if it helps those less fortunate than ourselves.  We donate to charities; we volunteer our time; we tell our friends about worthy causes.  Nevertheless I was surprised to find that I had forgotten about a much-needed gift that most of us can give:  blood.  A few weeks ago I was embarrassed to find out it had been six months since my last blood donation.

Though my last donation was to the Red Cross, I found out since then that the Red Cross charges hospitals for the blood they collect.  I don’t object to this.  After all, the Red Cross has operating costs and they do not make a profit.  Still, I thought it would be much more efficient and helpful to donate directly to a hospital.  So two weeks ago I donated at the Cedars-Sinai Blood Donor Facility.  I learned a lot about how fragile our blood supply is and how grateful the hospital is to their regular donors.  Platelets have a very short shelf life, so they are in constant demand.  I was asked to donate platelets and plasma, and I did.  The nurses were great.  They knew all the regular donors by name and treated them like family.  I was struck by the life saving commitment the regular donors had made.

If you would like to donate a life-saving gift to a stranger you’ll never meet, please look at the Blood Donor Facility website for contact information and for guidelines about who can donate.  If no local hospital is convenient for you, look at the American Red Cross blood donation website for their locations.

Thank you very much.

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An Interaction between Aspirin and Ibuprofen

About a month ago the FDA released a warning about an interaction between very commonly used medications:  aspirin and ibuprofen.

Many patients have been instructed to take low dose aspirin (81 mg daily) for heart attack or stroke prevention.  Aspirin prevents heart attacks and strokes by binding to an enzyme in platelets called cyclooxegenase (COX) and preventing its normal function.  COX is essential for platelet function, so aspirin prevents platelets from aggregating into small blood clots, which is an essential step in heart attacks and some strokes.  For the same reason, aspirin increases the risk of bleeding, since it inhibits normal blood clotting.

Patients on low dose aspirin sometimes need pain relief or anti-inflammatory medication, for example for a headache or a muscle sprain.  Doctors frequently prescribe ibuprofen (which is the medicine in Motrin and Advil), since it is a more effective pain medication than aspirin, and since additional aspirin will further increase bleeding risk.

The FDA alert cautions us that since ibuprofen also binds COX, though much more briefly than aspirin, taking the two together could prevent aspirin from binding, and potentially diminish aspirin’s effectiveness in heart attack and stroke prevention.  The alert suggests that in patients taking daily low dose aspirin who also need ibuprofen, the ibuprofen should be taken least 8 hours before or at least 30 minutes after the aspirin to minimize any interaction.

Another alternative is to use a pain reliever in an entirely different family, like acetaminophen (Tylenol).  This would eliminate any interaction with aspirin, but usually gives less pain relief than ibuprofen and has no anti-inflammatory properties.

I’m grateful to my colleague, Dr. Yaron Elad, for pointing me to this story.  It’s sobering that even with medications that have been around for many years and are used very commonly, we’re still learning new reasons to be cautious.

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The CDC Recommends Routine HIV Screening for All Teens and Adults

Last week the Centers for Disease Control and Prevention released new recommendations for all physicians for HIV testing.  The new recommendations were generated in response to the fact that of the approximately 1 million Americans infected with HIV, about one quarter have not been tested and are unaware of their infection.  These patients can not take advantage of the many therapies available for HIV infection, and may unknowingly transmit HIV to others.  The CDC hopes that if all patients with HIV can be diagnosed, they can receive appropriate treatment and counseling, potentially slowing the spread of infection.  They also hope that routine testing will remove any stigma associated with testing, so that those who are infected can be tested whether or not they report high-risk behaviors to their physician.  You can read the CDC’s questions and answers about the new recommendations for the general public here.

The recommendations include testing all patients aged 13 to 64 once during any health encounter, whether it be in an emergency department, at their private physician, or at a public clinic.  After that initial screening, patients at high risk of HIV should be tested at least annually.

Persons likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and MSM [men who have had sex with men] or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

Everyone else can be tested as frequently or as rarely as clinical judgment dictates.

So even if it’s entirely inconceivable that you have HIV, the next time I draw your blood for any other reason I’ll ask you if I can add an HIV test.  (Obviously, you can decline.)  I’ll be happy to answer your questions about the test and what a negative or positive result means.

I’ll be very curious to see what impact these new guidelines have on the rate of new HIV infections in the next few years.

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A Vaccine to Prevent Shingles

Zostavax, a vaccine to prevent shingles, has recently been approved by the FDA and reviewed by The Medical Letter.

Shingles (also called herpes zoster) is a very painful illness involving blisters that occur in a stripe-like pattern on one side of the body.  Shingles can only happen in people who have had chicken pox.  The virus that causes chicken pox, varicella zoster virus (VZV), stays in the in sensory nerve cells of the infected person forever.  As decades pass after the initial illness, our natural immunity slowly fades, and enables VZV to reactivate, causing shingles.  Typically the blisters in shingles resolve after a couple of weeks.  In some people, however, the pain persists for months or even years.  This persistent pain is called postherpetic neuralgia (PHN).  PHN can be debilitating and happens most frequently in older patients.  It occurs to about a third of patients with shingles over 60.  Usually the immune response to an episode of shingles is quite strong, and it is unusual for patients with normal immune systems to have shingles again.

The Singles Prevention Study randomized over 38 thousand adults 60 years of age and older who have had chicken pox to receive either Zostavax or placebo.  They were followed for about three years.  Shingles occurred in 315 vaccine recipients and 642 placebo recipients.  PHN developed in 27 vaccine recipients and in 80 placebo recipients.  That means that 59 people have to be vaccinated to prevent one case of shingles over three years, and 364 people have to be vaccinated to prevent one case of PHN.

The vaccine is indicated for adults 60 or older who have had chicken pox and are not immunocompromised.  I would not recommend it to anyone who has already had shingles.  The biggest unknown factor is the duration of effectiveness, which would determine how frequently it would need to be readministered.

The CDC has not yet made a formal recommendation about Zostavax, but they are expected to do so in the next few months, so I’ll be keeping an eye on their vaccine-preventable diseases page.  In the meantime, shingles is treatable with antiviral medication, and the treatment works best if started within three days of onset of the rash.  So if you get a painful rash, don’t delay seeing your doctor.

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Throw Away Your Bagged Spinach

The Associate Press reports in this article that 50 people have become ill this week and one has died because of food contaminated with a dangerous strain of E. coli.  The FDA suspects fresh bagged spinach as a possible cause and is advising all Americans not to eat any.

The death occurred in Wisconsin, where 20 people were reported ill, 11 of them in Milwaukee. The outbreak has sickened others – eight of them seriously – in Connecticut, Idaho, Indiana, Michigan, New Mexico, Oregon and Utah. In California, state health officials said they were investigating a possible case there.

The full text of the FDA warning contains the typical symptoms of illness due to this strain of E. coli:

E. coli O157:H7 causes diarrhea, often with bloody stools. Although most healthy adults can recover completely within a week, some people can develop a form of kidney failure called Hemolytic Uremic Syndrome (HUS). HUS is most likely to occur in young children and the elderly. The condition can lead to serious kidney damage and even death. To date, 50 cases of illness have been reported to the Centers for Disease Control and Prevention, including 8 cases of HUS and one death.

So throw away your bagged spinach, and if you feel ill after eating some, please see your doctor.

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