Gardasil & Increased Promiscuity? NOT an Issue

The Gardasil vaccine is back in the news. Gardasil is the vaccine recommended for both boys and girls to protect them against the Human Papillomavirus (HPV), which causes genital warts and cervical cancer) Yesterday, an article published in Pediatrics confirmed that girls who had received this vaccine did not, in fact, have any increased sexual promiscuity compared with their peers who did not receive the vaccine. Why was this study done? One reason for lower vaccination rates with this recommended vaccine (compared to other vaccines recommended in this age group) was parental concern that giving their preteen and teenage daughters this shot would appear to be giving "permission" to be more sexually active since they would be protected.

This study looked back at roughly 1400 girls over three and a half years. Almost one third of these girls received the Gardasil vaccine, while the other 2/3 did not. After the immunization, medical issues that can result from increased sexual activity- pregnancy and sexually transmitted diseases- were measured and compared between groups. Results? No significant difference in the two groups.

The results are not surprising, but I am happy to have this data to help reassure any parents who may have this concern. I have not yet found a teen who believes that the Gardasil vaccine somehow makes them bullet-proof in the sexual arena, although I have seen many who falsely believe condoms will do so- but that is a different discussion. If teens are aware of Gardasil, they know it is "for cancer". Only the rare teen (and parent, frankly) seems to realize that this vaccine also protects against genital warts- a disease that affects over a MILLION sexually active people each year in the United States; a disease that often destroys the self-image of young people just as they are trying to make critical life decisions. Genital warts make people feel "dirty" and "gross", and although we can treat warts to make new outbreaks resolve more quickly, we do not have a cure. And if you've ever had a wart frozen off your knee or finger, you know it hurts, so add painful plus embarrassing when that wart is in the genital area.

BOTTOM LINE: Gardasil is recommended as part of our routine vaccinations for both girls and boys to protect them from HPV-related cancers and genital warts. If your child is not yet vaccinated, talk with his or her doctor at the next visit.

New Study Offers Hope for Alzheimer Prevention

A glimmer of hope shines in the devastating world of Alzheimer's Disease (AD), as this week a study published in the Archives of Neurology journal reveals that a class of blood pressure medications (Angiotensin Receptor Blockers, known as ARBs) may reduce the risk of developing Alzheimer's.
Although the mechanism of Alzheimer's is not fully understood, we do know that abnormal deposits of amyloid (a protein) occur early in brain as an early stage in the disease process. This new study, the Impact of Angiotensin Receptor Blockers on Alzheimer Disease Neuropathology in a Large Brain Autopsy Series, looked post-humously at the brains of 890 people who had suffered from AD and high blood pressure, and found that those patients who took ARBs (for their blood pressure) had significantly LESS of these amyloid deposits built up.

The hope is that if we can find ways to prevent the build up of these amyloid deposits, then this will halt the progression of Alzheimer's both pathologically and clinically. Prior studies have shown    some clinical evidence that patients on ARB's for their blood pressure have a lower risk of developing AD, but this is the first study to show us the actual physical changes in the brain- very exciting news!

So, if you have a strong family history of Alzheimer's disease and/or are experiencing progressive memory loss, should you ask your doctor to prescribe you an ARB today? Well... yes and no. I would NOT prescribe an ARB for a patient in this situation who had normal blood pressure. However, if she had newly diagnosed high blood pressure, I would certainly consider starting her on an ARB (rather than a diuretic or beta-blocker, our other first-line medications), and I would be open to a discussion about changing her to an ARB if she had hypertension and was already being treated with another class of medications. Of course, when choosing a medication, there is a range of different issues- from side effects and drug interactions to cost (and health insurance preferences), but potential "side"benefits such as this are absolutely part of the decision process.

BOTTOM LINE: Alzheimer's research is critical to help us find a cure for this debilitating disease, and this new study offers encouragement that ARB's may play a role in slowing the development of AD.

Breaking News: Fish Oil Supplements "Out"?

Today the Journal of the American Medical Association (JAMA) published a study about the Association Between Omega-3 Fatty Acid Supplementation and the Risk of Major Cardiovascular Disease Events. The popular media has picked this up and many headlines are focusing on removing these fish oil supplements from your medicine cabinet- is that the take-home message? Maybe not...

There are a few separate issues to discuss. First of all, note that the reason there was a study to begin with is that it has long been established that populations with primarily fatty fish-based diets have lower rates of heart disease. Being Americans looking for a quick fix, we'd rather pop a pill than change our behavior, so rather than add fish to our diets, we look to taking a capsule filled with fish oil. Supplement studies, however, have not been as robust in demonstrating the same heart benefits as simply changing your diet. This study was a meta-analysis that examined over 3600 previous studies, ultimately including 20 of them that met criteria to eliminate bias and make them truly "evidence based". This included nearly 70,000 patients and their rates of heart attack, stroke, and death. Ultimately, fish oil supplements by themselves were NOT shown to lower the risk of death, heart attack or stroke. Do omega-3 supplements lower triglycerides? Yes- but if you are focusing on patient outcomes and not simply lab numbers, the benefits are not there.

Are there other reasons to consider taking fish oil supplements? Probably so, although I will continue to argue that you are better off adding salmon, tuna, trout or sardines to your diet several times per week. Beyond lowering triglycerides, Omega 3 Fatty Acids have been been recommended for potential benefit against numerous cancers, inflammatory bowel disease, dry eyes, rheumatoid arthritis and even dementia. If you are NOT willing to add fish to your routine diet, then taking fish oil supplements for any of these reasons may be beneficial, and there appear to be no serious negative effects (except for a shrinking wallet.)

BOTTOM LINE: If you are taking fish oil supplements to improve your cardiovascular health, you may be improving your lab values but not decreasing your risk of heart attack or stroke- go for a jog or go fishing (and eat your catch) instead. 

HPV: Not Just for Genitals...

A recent study published in JAMA has created a buzz about the Human Papilloma Virus- HPV- again, but this time, the focus is on the mouth. Researches have noted that despite a significant decrease in smoking, head and neck cancer rates are not falling in proportion. It turns out that not only does HPV cause cancers in the genital area (cervical, penile, anal, etc.), but HPV also plays a significant role in causing head and neck cancers.

The study is titled "Prevalence of Oral HPV Infection in the United States, 2009-2010." Over 5000 people (ages 14-69) participated in the study, and it turns out that roughly 7% of them had HPV detected in their mouths. (They swished mouthwash in their mouths for 30 seconds, then this liquid was DNA analyzed for the the presence of different HPV strains.) Men had a higher rate- 10% in men vs. 3.6% in women, and infection was much less common in those people with no history of any type of sexual contact (less than 1% in "virgins" vs. 7.5% in others.) The good news is that the primary cancer causing strain- type 16- was only present at a 1% prevalence rate across the board. (Let's step aside and note here that with HPV, certain strains cause warts, and others cause cancers, so not all strains are equally medically dangerous.) How does the HPV even reach the mouth? Mostly through oral sex. Use barriers (condoms) for ALL sexual intimacy, please. 'Nuff said.

So, will the HPV vaccines (Gardasil and Cevarix) protect against head and neck cancers, too? We certainly hope so! As we get more "herd immunity" (which means more people are vaccinated than not, and so live disease is passed less and less) we hope to see not only a decrease in genital cancers, but hopefully a parallel decline in oral cancers, too.

BOTTOM LINE: HPV is COMMON, both "top" and "bottoms"...let's use our knowledge to prevent the cancers HPV can cause! For me, this is yet another good reason to immunize against HPV.

TVs and TIRED KIDS (and Parents)

Televisions have become so commonplace that we often barely notice their presence. Many families leave the tv on for most of the day, more like background noise than anything else. A article recently published in PEDIATRICS addresses the use of television in preschool aged kids, 3-5 years old. The roughly 600 children in the study showed an increase in sleep problems associated with evening media use (television and computers), especially when that tv was located in the child's bedroom. Additionally, the study found that watching violent programs increased sleep problems, regardless of the time of day that the program was viewed.

Interestingly, the average reported screen daily screen time was a little over an hour, with roughly 14 minutes occurring in the evening. Remember that these were 3-5 year old preschoolers, and the information was obtained from parents filling out media diaries and sleep questionnaires. If this information was accurate, then please note that even kids watching LESS than the recommended maximum of two hours per day were still affected. Nearly one in five parents reported sleep disturbance in their child. (As an aside, please note, parents, that the medical community strongly recommends NO TELEVISIONS in kids' bedrooms!)

We are learning more and more about the impact of computer screens on our brains, and consistently finding that screen evening screen use impairs the quality of sleep. For children, adolescents and adults alike, we need to go back to "the good old days" of READING or relaxing in a warm bath before bed...but remember to read from a BOOK, not an electronic reader!

BOTTOM LINE: Media screen viewing, especially in the evenings before bed, impair your quality of sleep. If you have daytime fatigue, focus on LIMITING your screen time!

Dodge This Bullet...HPV

Yesterday I mentioned that the New England Journal of Medicine recently published a study regarding HPV vaccine efficacy in boys. Today I'd like to explain the study. The title is "Efficacy of Quadrivalent HPV Vaccine against HPV Infection and Disease in Males". "Quadrivalent" refers to the fact that the vaccine targets four strains of the Human Papilloma Virus: strains 6 & 11, that cause 90% of genital warts, and strains 16 & 18, which cause the majority of cervical cancers (roughly 70%).
I'll start by saying that yes, the study was partially funded by Merck, the manufacturer of the vaccine. That being said, I do not feel it negates the study, although obviously it introduces some bias. They took over 4000 boys/young men age 16-26, from 18 countries, and gave half a placebo vaccine series, and half real. The study was double blind (no one knew what they were giving or getting), and randomized (which raises the quality of the study.) Some of the participants were fully screened initially to determine if they already HAD any HPV strains, and others were not. Note that in "real life medicine", we have no way to test people ahead of time to see if they have already contracted HPV.

In the young men with unknown prior HPV status, the vaccine had an efficacy of 60%. In those known to be HPV negative initially, the efficacy was 90%. It is not surprising that the vaccine would appear to work better in those that did not already have some strain of HPV, and this supports the reasons to vaccinate youth BEFORE they are sexually active. I thought it was interesting that they ended up with 1% of the placebo subjects developing genital warts- the same as in the general population. I am encouraged that the incidence in those vaccinated dropped to 0.1%.

The devil is always in the details, and how people pull out statistics. I could note, for example, that 3 patients in the placebo group received gun shot wounds, while only one in the vaccine group did- but obviously the vaccine did not prevent gun shot wounds! The good news here is that true adverse events were minimal and of uncertain relationship to the vaccine.

BOTTOM LINE: HPV vaccination can significantly reduce the incidence of genital warts in young men as well as young ladies, with minimal side effects.

Did U 4Get? Medication Reminders

Ah, texting- the new language of our youth! As we embrace technology, I believe there will be many beneficial uses of the tiny screens upon which our culture is becoming increasingly dependent. There are multiple "apps" out there, for example, that help people track behavioral changes such as exercise, or count days without junk food (or soda, or alcohol, or cigarettes or candy bars!) In my practice, I have seen these simple electronic tools really help my patients improve their health.

Along those lines, there is an interesting study recently published in the medical journal Obstetrics and Gynecology, entitled Using daily text-message reminders to improve adherence with oral contraceptives: a randomized controlled trial. This was a small, short study with just less than one hundred young, high school female graduates followed over three months. The women were randomized to receive a daily text message reminding them to take their birth control pill, and their compliance was both self-recorded and externally monitored.

The results surprised me, frankly. I would have thought simply participating in such a study, none-the-less receiving a DAILY reminder would have yielded near perfect compliance. Unfortunately, what was seen was that BOTH groups missed a significant number of pills each month (4.9+/-3.0 for the text-message group and 4.6+/-3.5 for the control group.) It's possible the difference in the groups was small because women in both groups used additional reminders such as alarms on their cell phones.

The other disappointment is that the girls' self-reporting of missed pills was markedly below their true number of missed pills, which strongly suggests that they could be underestimating their true risk of becoming pregnant if they are sexually active.

BOTTOM LINE: While technology may be able to help us towards healthy lifestyles, daily text medication reminders may not be an effective tool (at least in this setting.) Physicians need to emphasize (and patients need to implement!) strict compliance with oral contraceptive pills.

Now CALCIUM is Dangerous??

Have you heard about the latest study that showed CALCIUM supplements may increase your risk of heart attacks? What's next, finding out Vitamin C makes you sick? Okay, I'm being facetious here, but let's talk about this news from a couple different angles.
First of all, here is what the study from the BMJ (British Medical Journal) says. They looked at a bunch of studies with a total of roughly 12,000 patients and assessed whether those people who took calcium supplements of 500mg or more (without Vitamin D) had more or less heart attacks compared with those who took placebo pills. There were a total of 296 people who suffered heart attacks- 166 on calcium supplements, and 130 on placebo pills. Does this mean placebos CAUSED 140 heart attacks? NO. Does it mean that calcium supplementation by itself CAUSED heart attacks? No- but it does show "an association" with heart attacks, one that may or may not be present if you add Vitamin D, which plays a role in calcium absorption, bone health, and cardiac protection.
There is NO association of heart attacks with increased purely dietary calcium intake (meaning high calcium intake through eating dairy and other calcium-containing foods). What does this tell me? Once again, we are spending a zillion dollars to PROVE THAT GETTING OUR NUTRITION FROM WHOLE FOODS, RATHER THAN SUPPLEMENTAL PILLS, IS BETTER FOR OUR HEALTH.
We've got to stop looking for a quick fix, and start improving our diets (MORE fruits and veggies, less of everything else) and increasing our exercise. Common sense AND scientific studies have proven this over and over.
In the meanwhile, realize that medicine is constantly evolving. What we preach as doctrine today may be heresy tomorrow. Look at what we have recommended for positioning of newborn babies in the last couple decades as an example- first we said on their stomachs (so they don't choke if they spit up), then their sides, and now their backs. Each time, we are SURE we have the answer. Remember that doctors used to recommend smoking to relax- how crazy is THAT?
BOTTOM LINE: Calcium supplements are unlikely to be your greatest risk factor for heart disease- talk with your doctor about your total health picture before you decide whether or not to take ANY supplement!

Finally, Good News if You've had a Miscarriage

Here is another medical topic that you probably think is uncommon until it affects you or someone you love- miscarriage. Despite the fact that statistics show somewhere between 5-10% (or higher) of all conceptions miscarry, you don't hear about it. 80% of miscarriages take place in the first trimester, and most of those occur very early-before eight weeks.

What I'd like to share, though, is a new study that brings some good news. Doctors have traditionally told patients who have a miscarriage to wait six months before trying to conceive again. A study published in the British Medical Journal (BMJ) looked at over 30,000 women who had miscarried, then had a subsequent pregnancy. Happily, women who conceived their next pregnancy within six months actually BETTER medical outcomes (less recurrent miscarriages, fewer ectopic pregnancies, and even less c-sections, low birth weight babies or pre-term deliveries) than women who's next pregnancy began six to twelve months after their miscarriage.

Why is this news important? Well, if you've had a miscarriage, I don't have to explain. The significance is not that you should rush to get pregnant again, but more that there is NO NEED TO WAIT. Many women (and men) have anxiously waited to get pregnant the first time, only to miscarry and then be told to wait for half a year before trying to conceive. That's tough for any age, but if you are already in your late 30s (and therefore already have an increased risk of complications associated with having kids), waiting six months is not only emotionally draining, but increases your other risks as you "age". (Mind you, I have MANY friends who had babies even in our early forties, so I'm not judging, here!)

By the way, please recognize that miscarriage can be very emotionally painful- express sympathy but try to avoid phrases like "what happened?" that the mom may hear as "what did YOU do?" We think most early miscarriages are due to chromosome issues, not from something the mom did, didn't do, ate, drank or otherwise initiated.

BOTTOM LINE: New medical evidence shows that there is no physical need to wait six months after a miscarriage before trying to conceive again, so go right ahead whenever you are emotionally ready!