In practice in WA since 1987 I’ve tried to obey the letter and spirit of the law requiring pre and post testing counseling for patients receiving HIV testing, and have grumbled that this state law pushed into place by the gay-rights lobby at a time when little effective treatment was available and serious concerns about confidentiality and discrimination were major concerns.  Now that highly effective treatment for HIV is available the advantages of early HIV diagnosis would seem to make any barriers to testing for HIV counterproductive. An easy to use, affordable, reasonably accurate HIV test is a big change to the current status-quo, where considerable emphasis is placed on protection of the patient via counseling regarding results, and places more value on more widespread testing, early diagnosis and opportunities for prevention of spread of HIV.

Tests have been available for years for use by individuals to obtain their own specimen and mail it away to a test facility for confidential testing without accessing a physician or medical care provider.  These have not been widely used.  If the home oral swab rapid test comes to market it is very likely to be much more widely used. I fully agree with the FDA advisory panel that the benefits of this test will outweigh its risks. Still we should not ignore the risks.  I see the benefits and risks as outlined below:

Benefits                                                                               Risks

More HIV positive patients identified                     Rare false positives may lead to poor decisions

Prevention of some cases of HIV                           Rare false negatives may lead to not getting blood test

Low financial barrier to HIV testing                       Some patients may not get appropriate test results counseling

Convenience of HIV testing                                   What unintended consequences to expect

I anticipate that in mass market use the false positive rate and the uninterpretable results rate will be higher than the extremely low rates in the test populations used in the initial studies, but even so I expect the use of a readily available home saliva HIV test will be one more step toward earlier diagnosis and slowing of the rate of spread of HIV in the U.S.

1. West Virginia (18.4)                      >30%                               25% (tie for 8^th highest)
2. Tennessee (16.9)                          >30%                              25% (tie for 8^th highest)
3. Alabama (16.9)                             >30%                              25% (tie for 8^th highest)
4. Kentucky (16.5)                             30%                               29% (alone w/top rate)
5. Arkansas (16.4)                            >30%                              26% (6 way for 2^nd)
6. South Carolina (16.3)                     25%-29%                        24% (4-way tie for 12^th)
7. Mississippi (15.9)                            >30%                             26% (6-way tie for 2^nd)
8. Iowa (15.3)                                  25%-29%                        22% (3-way tie for 17^th)
9. Missouri (15)                                 >30%                              26% (6-way tie for 2^nd)

For reference there are nine states with 2009 rates of obesity > 30% of which 7 are here in the top 9 most medicated states. The national average rate of smoking is 21% and all 9 of the states with the highest rates of medication use are in the top 17 states for rates of smoking.

I cannot access the SDI data to see what the rates of obesity are in the states with the lowest incidence of obesity are  but here are some other health related statistics and their relationship to a relative lower obesity rate.

1)      Colorado is alone as the only state in the US with a 2009 rate of obesity at <20%.   Why doesn’t Colorado rank at the very top for the lowest for death rates in adults?  Possibly because of a smoking rate of 20% (tie for 28^th highest leaving it pretty good but with  a death rate of 709/100,00 (11^th best).

2)      The fifteen states with obesity rates from 20-25% (the best except for Colorado) are listed below in alphabetical order:

                                                      Death rate (rank)                             Smoking Rate (rank)

a)      Alaska                               742 (2oth)                           24% (Tie for 12^th highest)

b)      California                         660 (4^th)                                15% (50^th highest, i.e. 2^nd lowest)

c)       Connecticut                   691 (8^TH)                               18% (tie for 38^th highest)

d)      Hawaii                               590 (1^st)                                16% (49^th, i.e. 3^rd lowest)

e)      Idaho                                 723 (16^th)                             18% (tie for 38^th highest)

f)       Minnesota                        675 (5^th)                                17% (tie for 44^th highest)

g)      Montana                           786 (33^rd )                            20% (tie for 29^th highest)

h)      New Jersey                     717 (14^th)                             18% (tie for 38^th highest)

i)        New York                        676 (6^th)                                19% (tie for 32^nd highest)

j)        Oregon                              748 (22^nd)                             18% (tie for 38^th highest)

k)      Rhode Island                   749 (23^rd)                             20% (tie for 28^th highest)

l)        Utah                                    659 (3^rd)                               11% (51^st highest, i.e. lowest)

m)    Vermont:                           721 (15^th)                             18% (tie for 38^th highest)

n)      Virginia                              762 (25^th)                             19% (tie for 32^th highest)

o)      Wyoming                           773 (29^th)                             21% (tie for 21^st highest)

Looking at this data you may note that 4 of the 5 states with the lowest death rates are in the 15 states with the lowest rates of obesity, and that none of them are worse than the 44^th highest smoking rates. (only Arizona is missing, in the next 25%-29% obesity rate and at a tie for 21^st in rate of smoking)  You may also note that the only two states in the top 15 for lower obesity rates ranking in the bottom half for death rates have smoking rates ranking at 21^st and 29^th.

Contrast this with the five states with the highest death rates:

1. West Virginia with >30% obesity and 25% smoking rate (tie for 8^th highest)
2. Mississippi with > 30% obesity and 26% smoking rate (tie for 2^nd highest)
3. Oklahoma with >30% obesity and 26% smoking rate (tie for 2^nd highest)
4. Alabama with > 30% obesity and 25% smoking rates (tie for 8^th highest)
5. Louisiana with >30% obesity and 26% smoking rate (tie for 2^nd highest)

In contrast the states with the lowest death rates have the opposite statistics for obesity and smoking rates:

1. Hawaii with 20-24% obesity and 16% smoking rate (3^rd lowest).
2. Arizona is the exception in these states with 25-29% obesity and a smoking rate of 21% (right at the national average and ranking in a 6 way tie for 20^th highest in the U.S.
3. Utah with in the 20-20% obesity and the lowest smoking rate in the U.S. at 11%.
4. California with 20-24% obesity and 16% smoking, second only to Utah.
5. Minnesota with 20-24% obesity and in a tie for 4^th lowest smoking rates at 17%.

It appears that states where citizens choose not to smoke and trend to be less obese have both lower rates of medication use and lower death rates. My guess is that the observation of lower death rates and lower rates of medication use are the result of lower rates of diabetes, hypertension, COPD, cardiovascular disease in these same states.   Yes these other health markers also trend directly with obesity and smoking rates.

So what can you as an individual learn from this?  Get fit, avoid obesity and don’t smoke.  No surprises here.

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Belly Fat is Bad for Our Health

Just How Fat are Americans?

CDC Widgets  - Go Here to calculate your own BMI and see other cool calculators

Some states have taken measures to reduce tobacco use, you can use this CDC widget to see how your state is doing, and what other states have done.

Essentially all of the evidence used to support the belief that gum disease is a risk factor or a cause of atherosclerosis was from observational studies.  In an observational study it is observed that condition A is present more often in people with condition B than in persons without condition B.  Many studies showed that patients who had heart attacks are more likely to have bad oral health than patients who have not had heart attacks.  This is far different from saying that gum disease causes heart attacks.  In an extensive evaluation of all of the studies showing a relationship between gum disease and cardiovascular disease a panel including both dentists and physicians concluded that the evidence simply does not support the conclusion that there is a causative relationship. The problem appears to be that several other risk factors for cardiovascular disease are also put patients at risk for gum disease.  These include tobacco use and low socioeconomic status, as well as age and diabetes mellitus.  In a controlled study these confounding variables would be considered and “controlled” for in any analysis.  In an observational study this is much more difficult to take into account

The association of periodontal disease and atherosclerosis was so in synch with our bedside observations that it was intuitive to accept the association as dogma. For me at least it never occurred to seriously question the relationship. This was in part because of the widespread acceptance of the test hsCRP (highly sensitive C-reactive protein), a test for low-grade systemic inflammation as an independent risk factor for coronary disease.  It was easy to infer that because periodontal disease is a chronic inflammatory condition, can lead to bacteremia, and is a potential cause of systemic inflammatory marker elevation, that is “just made sense” that it is a cardiovascular risk factor.

I hope this 20 year walk down the path of least resistance is one I and others will remember when presented with an observational study purporting to show a relationship. Although I tell patients frequently that just because one factor precedes or coexists with another that it does not automatically follow that one causes the other, I too am obviously guilty of falling into this trap.

Sometimes as a medical community we are criticized for insisting on controlled, randomized, blinded studies to prove efficacy of our treatments, tests and procedures. It can be an expensive, time consuming and sometimes frustratingly tedious process.  Still, without solid scientific controlled studies we will be at risk of taking what seems to make sense as factual.  Bleeding sick patients was accepted as dogma in centuries prior to use of the scientific method, and we need to beware believing everything we see.

This book nicely discusses the issues of overdiagnosis in both chronic disease and in cancers.  The long-held assumption that all malignancies left untreated progress, spread and lead to death is simply not true.  We are learning that many types of cancer have unpredictable courses.  Prostate cancer is the most notorious of these, with good evidence showing that most prostate cancers are ones patients live with asymptomatically whether they know about them or not and die of something else without ever having symptoms of the prostate cancer. This is the primary issue behind the recent USPSTF “D” recommendation against routine PSA screening in asymptomatic men. There is strong evidence that some percentage of renal cell cancers, some types of breast cancer and thyroid cancers not infrequently regress or remain indolent and never lead to symptoms.

The recent evidence suggesting frequent overdiagnosis in breast cancer is very disturbing. An April 3 article in the Annals of Internal Medicine in a large retrospective review in Norway infers a 15-25% incidence of overdiagnosis in women found to have breast cancer on mammographic screening. They used every other year screening, and suggest that for every 2500 women screened 6-10 cases of overdiagnosis occurred, 20 women were diagnosed with breast cancer that was not overdiagnosis, and 1 death related to breast cancer was prevented.  We have strongly encouraged women to get annual mammograms for years. Personal anecdotal experience can make us even more confident that we are doing the right thing.  I have had many patients diagnosed with early breast cancer by mammogram over the last 20+ years, and until recently had not had any women over age 40 that I can recall diagnosed with advanced stage breast cancer who had been getting their annual mammograms.  It was very intuitive and tempting for me to believe that I was saving many lives and preventing much morbidity by aggressively pursuing early breast cancer diagnosis.  I know that I have put many women through emotionally stressful and uncomfortable additional testing, biopsies, and breast cancer treatment.  It is concerning to think that I may be subjecting some of these women to overdiagnosis and unnecessary treatment, but until we as a society actively address the issue of overdiagnosis and try to find ways to figure out which early cancers found on screening can be managed with active surveillance and which need curative treatment we are left with the inevitable overdiagnosis dilemma. This will  involve asking a cohort of women with various very early cancers to be observed for progression prior to intervention.  Whether this is going to be acceptable is not clear.  We need to do the same thing for men with early prostate cancer.  We are following lots of men with prostate cancer, but as far as I know not in a formal study that will give us help in knowing which cancers can be safely followed.  For now I’m doing nothing different except keeping my eyes wide open to further research and recommendations.

Much of what we do in medicine today is aimed at early diagnosis of asymptomatic disease, and overdiagnosis is a very valid concern any time we are screening for asymptomatic disease. The recent changes in criterion for hypertension, diabetes and hypercholesterolemia are leading us to the preventative treatment of many diseases that are of themselves asymptomatic.  The whole issue of overdiagnosis is going to be fascinating to follow over the next decade or two.

You may also enjoy:  PSA Controversy Continues

Eat: I too often see patients in acute grief with superimposed upper abdominal pain that I am certain is from gastric hyperacidity and not eating. Simply forcing yourself to eat can go a long way towards getting through a period of grief without complicating peptic ulcers or gastritis. I tell patients that they don’t have to be hungry, don’t have to feel like eating, and don’t even have to eat an extremely healthy diet. They just have to force themselves to chew and swallow a reasonable amount of food three times a day. Tradition in many communities, religions and cultures bears out the importance of eating. It is a nearly universal custom for family, friends and relatives to bring meals to the bereaved.

Sleep: Sleep is very difficult for many people in times of great stress or grief. In my opinion this is one of the most important times for physicians to prescribe sleep aides. It is tough to maintain your sanity and move through the rituals, responsibilities and duties expected when you are reasonably rested. In a sleep deprived state this is nearly impossible. Don’t be afraid to ask your physician for help if sleep is a problem after a major loss.

Carry On: This is my way of saying that forcing yourself to participate in at least some of your usual daily activities is very helpful in regaining some sense of normalcy. If you stay home all day, only see others who are also grieving, and don’t force yourself to carry on with your usual life activities it is too easy to become all-consumed by your grief. If you exercise normally continue to exercise. If you go to church continue to go to church. If you are in a service club, a book club, a bowling league, or other routine activity try to get back into that activity reasonably quickly. It can really help as a distraction and start to lead to a feeling that life can and must go on after the loss.

There is much more to managing grief, and I’m certainly no psychologist. Still, the advice to eat, sleep and carry is a good base on which to base your recovery.

Fits great

Wrong Hand to Fit

The way most drugs work in the body is that they attach to a receptor site. If the receptor site is shaped in way that the left or right handed molecule fits well, and the other shape does not fit well, the one that fits well is going to the active drug. Think of this like hands and a glove. Your right hand fits nicely into a right-handed glove. Your left hand does not easily fit. The same is true for your left hand and a left-handed glove.

For other things like your head, any hat the right size fits because our heads are symmetric (relatively), with no isomeric variations.

In some cases the less active isomer is truly inactive. In other cases it appears that the “pure” active isomer has advantages as a medication. The not-so-surprising observation that drug companies somehow seem to discover that one isomer of their blockbuster drug is really the active isomer just before the patent expires on the original isomer mix leads some of us to be skeptical about the benefits of isomers. Still the trend toward isomers as medications seems to be real, so it is useful to understand what an isomer is, and why sometimes it may not be worth the added expense of buying the brand name isomer when the isomeric mix product is an inexpensive generic. Here are a few of the more popular isomers used as medication with a little Dr. Pullen commentary:

Lexapro vs citalopram: Lexapro was brought to market by Forest Laboratories just prior to the patent expiration of Celexa, the racemic citalopram product. The argument that Lexapro has less side effects and works faster is much harder to define than with a product like Nexium where more objective endpoints like ulcer healing, gastric pH, etc are available, but in my experience most patients to equally well on generic $4./month citalopram vs. Lexapro at $138.24/ month (Costco pricing). With the approval of Teva to exclusively market generic Lexapro for 6 months their price will be somewhat lower than brand name Lexapro, but in 6 months expect much lower prices from competitors. If the price approaches the $4. cost of citalopram generic Lexapro is likely to be very commonly used.

Nexium vs Omeprazole: Nexium has been a blockbuster drug for AstraZenica for years. This was a brilliant marketing move, by AstraZenica, again just prior to Prilosec (the original brand name for omeprazole) going generic. In order to market a “better” drug, Nexium was marketed as a 40 mg esomepraxole (left handed isomer) and compared to the 20 mg dose of omeprazole. It was shown to be very slightly faster acting. Now that you understand isomers does it surprise anyone that by taking the active isomer or omeprazole and using 4 times the dose of esomeprazole that is in racemic omeprazole the it is slightly faster acting? Not me. Is it worth the cost premium (Costco omeprazole 20 mg = $11.75/ 30 capsules vs. Nexium 40 mg = $202.75 / 30 capsules). Probably never.

Albuterol vs Xopenex: Unlike the prior two isomers, Xopenex is the R isomer not the S isomer of albuterol. There are some patients where the racemic mixture in albuterol causes more cardiac stimulation like racing heartrate than the R-albuterol isomer in Xopenex. This makes Xopenex preferable for some patients, but most patients do just fine on albuterol.

There are lots of other drugs sold as isomers, but this is enough to give you examples, and hopefully enough reason to be skeptical of claims of superiority for isomers sold as new expensive branded drugs.

For an NFL fan arguably the best thing that could happen to your team is to sign Peyton Manning and have him perform at or near his pre-injury level.  The corollary is that one of the worst things to happen to your team would be to take a huge salary cap hit to get a Peyton Manning with such weak throwing arm that even with his experience and determination he is unable to excel or that he is re-injured and unable to play. The opportunity to get a superbowl champion, 4-time MVP, and future hall of fame quarterback who suddenly has become available to lead your team to a championship makes it easy to overlook the nature of spinal nerve injuries and cervical spine surgery.

The excitement and media heyday surrounding Peyton Manning neck surgery and his recent free agency prompted me to post about the nature of weakness from spinal nerve injury, and what can be expected in terms of recovery of strength and function.  The real issues come down to two questions:

1. Is the nerve injury he has sustained to his cervical nerve root significant enough to cause irreversible weakness that will render him unable to perform at a level close to his previous superstar status. How much more recovery of strength can he expect.
2. Is he going to be able to hold up to the trauma he will be subject to as an NFL quarterback?

Let’s look at these one at a time.

How much of Manning’s arm weakness can he recover?:   The real key to how successful Mr. Manning is going to be in his comeback hinges on the degree of chronic nerve injury he has sustained.  Most of the time once a spinal nerve had been injured leading to muscle weakness, if the weakness persists for very long the damage is permanent.  It is not clear how long Manning had been having weakness prior to his single-level fusion procedure, but it is certainly concerning that he had undergone at least 2 prior microdiscectomy procedures and that with a player as valuable to his team and generally competitive as Manning it seems unlikely that he chose to stop playing and have surgery at the first sign of weakness.

So what is the chance of a full recovery of motor function, i.e. strength, for Manning and how is this likely to affect his effectiveness as at throwing a football?  I expect it to be more significant than may be widely appreciated. I cannot find it reported anywhere just which cervical level Manning had fused, so I don’t know which cervical nerve root is damaged.  The most common cervical levels for disc injury are the C5-6 and the C6-7 levels.  The cervical discs and nerves are labeled for the two vertebrae they are between.  There are 7 cervical vertebrae, so the C6 nerve root exits

Brachial Plexus Diagram

between the C5 and the C6 vertebrae, and the C7 nerve root exits between the C6 and the C7 vertebrae.  The anatomy is further complicated because the nerves to each muscle in the shoulder and arm get stimulation from several spinal nerve roots.  This is because the cervical nerves come together in a complicated conglomeration of nerves called the brachial plexus.  The nerve roots enter the plexus and fibers from several nerve roots joint to exit the plexus as peripheral nerves.  Each muscle gets stimulation from one of these peripheral nerves.  Key muscles in the throwing process include the triceps, the pectoralis major and minor, the latissimus dorsi, the deltoid, the biceps, the biceps radialis, and others.  Each of these muscles in innervated by a specific peripheral nerve, and most of these receive varying amounts of innervations from the C5, 6, 7 and 8 nerve roots.

Certainly Manning has had access to the best available therapy to try to regain muscle strength.  Still muscles just don’t work without nerve stimulation.  This is called trophy, or trophic stimulation.  Muscles that lose their innervations undergo atrophy (no trophy) and become smaller and lose their function.  (think of polio and spinal cord injury victims) No amount of exercise, therapy or effort can make a muscle without innervations work. So if Manning still has arm weakness six months after his fusion surgery it is likely he will be left with at least some degree of muscle weakness.  Six months post surgery he is not likely to get much more strength back.  Certainly therapy can help other muscles become stronger and assume some of the roll of the muscles that have lost strength, but for Manning to function at a level required of a top level NFL quarterback I predict he will need to be able to throw the a football at very close to his prior strength.

How Vulnerable Is Manning To Recurrent of Further Injury?: How serious are the concerns that Peyton Manning will be at risk of additional levels of disc injury due to already existing disc injuries and the additional stress on the disc levels adjacent to a fusion.  I expect that the fusion is going to hold up pretty well, and not itself be highly vulnerable to becoming unstable.  The issue is really whether he develops disc herniations at the levels above and below the fusion, and whether he develops narrowing of the spinal canal (spinal stenosis) related to scar tissue or exuberant bone growth in the area of the fusion or at adjacent disc levels. NFL quarterbacks are sacked an average of twice a game, an although Manning is very experienced and may be able to minimize the number or sacks and hits he receives, undoubtedly he will be hit and his neck will be put in harm’s way in the course of an NFL season.  I anticipate that these are going to be future issues for Manning, but that they are not likely to be the reason he is or is not successful in his short term comeback.

I anticipate that Peyton Manning’s success or lack of success at his comeback is going to hinge on how much arm strength he has remaining.  This will be apparent to fans by the time the season comes, and he really has had enough time to strengthen his muscles by now.  Teams expecting him to become a great deal stronger than he is right now are likely to be disappointed.

This same issue occurs with everything from surgeries to chiropractic care.  I remember in medical school that one student in our class was traumatized by the sudden death of his patient right in the middle of his first time alone with a patient for a physical exam.  Did he do something to cause her death?  Almost certainly not, but still he was likely pretty anxious the next few times he did a physical exam.

The natural course of many self-limited illnesses makes post hoc ergo propter hoc relationships very common. If you have a sinus infection that is going to last 10 days, but you see the doctor on day 8 and get an antibiotic, are told the medication should help within 2-3 days, when you recover in 2 days it is natural to credit the recovery to the antibiotic.   If you get a headache the day after you start a new medicine, or a rash when you have been on the medication for a few days then post hoc.  The relationship is assumed.

This issue is discussed very nicely in a recent article in Forbes by Henry Miller:

The Data on Drugs’ Side Effects Must be Reliable

As a medical resident at a major cancer center some years ago, I was responsible for administering a 4 a.m. intravenous dose of a drug that was part of the patient’s treatment protocol. I stood by the patient’s bedside, groggily flicking and tapping the syringe to get the last tiny air bubble out of the drug before injecting it.

Just as I was about to push the plunger to administer the drug, the patient died — just stopped breathing and expired. There was a “do not resuscitate” order, so sadly, that was that. The time was 4:01 a.m.

Had I more quickly removed the air bubbles and administered the drug at exactly 4 a.m., the patient would have died within seconds of receiving it. As a result, the investigators on the treatment protocol, the maker of the drug, federal regulators and I would all have suspected that the drug was the proximate cause of death.  Read more

This post hoc issue plays havoc with everything from medication side effects reporting to patient’s expectations for treatment. I think it is an import concept to keep in mind when we try make sense of what we observe in live and medicine.

Why don’t I do a better job?  I suspect it is a combination of factors.  I think the first is that this is rarely high on a patients list of topics they want to discuss at an office visit.  It is easy to put off this discussion when seemingly more pressing issues are the patient’s expressed reason for the office visit.  Even at physical exam visits, or in the medical coding lingo “preventative care” or “health maintenance” visits, it is alluring to focus on topics that lead to a longer or healthier life rather than a better death experience.  Here is the list of the physician-related barriers to completion of an advance directive listed in the AFP article:

• Discomfort with the topic.
• Lack of institutional support.
• Lack of reimbursement.
• Lack of time.
•  Waiting for the patient to initiate the discussion.

In my case it is certainly not discomfort with the subject, and I am not intentionally waiting for the patient to bring up the subject, but lack of time and reimbursement undoubtedly play a role.

In addition most patients really don’t need my help in working through this decision process if they address the issue before there is a crisis. Although there are cultural, personal and ethnic variables that shape our decision making, most of my patients can  really quite quickly and easily work through the process of completion of both a very functional living will and a durable power of attorney without my assistance.  So why doesn’t everyone just do it themselves?  Here are the barriers listed in the AFP article that are patient related:

• Fear of burdening others, i.e. family or friends.
• Health Literacy
• Lack of interest or knowledge of the subject.
• Spiritual, cultural or racial traditions.
• Waiting for their physician to initiate the discussion.

So how can you just “Do it yourself?” It’s really easy.  Obvoiusly since you are reading this article you have access to the internet, and everything you need is just a few clicks away.  I encourage you, if you have not already completed these documents, to DO IT NOW:

1. Down load your state’s Advance Directives at the caringinfo.org site.  This is really easy and you can get everything you need by selecting your state from the list here.
2. Many states have a form called a POLST form.  This stands for physician orders for live sustaining treatment.  If you use a search engine like Google, and you type in your state + POLST form you will easily find a form to download if your state has a POLST form.  You can get the Washington State form to download easily at WA POLST download.  Many physician offices have these available, just ask your doctor.
3. For some people a form to help you ascertain your values on this subject and to make your values clear to the individual you choose to have your medical power of attorney is helpful.  The University of New Mexico  Institute for Ethics has published online a non-copyright protected form for you to download.  Some patients will find it helpful to attach this to their advance directive as guidance to their proxy in making decisions in line with their values.

There you have it.  You have no more valid excuses to keep you from completing your own advance directive and living will.  Once you complete it be sure to not keep it a secret.  Give a copy to your physician, to the person you choose as your DPA, and keep a copy handy at your home.   Don’t be a victim of your own procrastination or discomfort with this topic.  If you find it helpful ask questions on the subject up with your personal physician.  Be sure to let them know you have these documents completed.

In my best cheer-leading mantra:  You can do it!  Go – Go – Go!

I see patients, parents, grandparents, siblings, friends and lovers concerned about suicide in the office from time to time.  Other times I am the one concerned about suicide in patients I think may be at risk.  Suicide is I a big and growing concern in the U.S. these days and I thought this would be a good time to write about this topic to share some statistical information and some thoughts. I hope to stimulate a forum for comments and sharing of thoughts in the comments below.

First some thoughts:

• I think of suicide as the ultimate in selfish behavior most of the time. The purported victim leaves behind many other victims of their act. Family, loved ones, friends, associates and their whole community are left to grieve, often filled with guilt over the lost soul. Don’t ever think of suicide as leaving the world better off without out your presence, you will leave far more sadness and grief behind that if you live.
• Never be afraid to ask anyone if suicide is a concern.  They may lie and say no, but often people with suicidal intent will admit their concern if directly and empathetically asked.
• If you have concerns about suicide for yourself or someone else ask for help. There are 24-hour crisis lines available, your physician, pastor, or other professional is obliged and usually happy to try to help.
• Never think of a half-hearted suicide attempt as a way to find help.  Miscalculations or other mishaps can make a suicidal gesture (not really meaning to kill yourself, but really asking for help) into a successful suicide all too often.

Is suicide the epitome of selfishness?  I was initially taken aback when a person I completely respect told me how angry he was about a colleague who had committed suicide, telling me how selfish he though the person had been.  I had not thought of suicide as a selfish act previously, but have thought a good deal about it since.

I see patients, parents, grandparents, siblings, friends and lovers concerned about suicide in the office from time to time.  Other times I am the one concerned about suicide in patients I think may be at risk.  Suicide is I a big and growing concern in the U.S. these days and I thought this would be a good time to write about this topic to share some statistical information and some thoughts. I hope to stimulate a forum for comments and sharing of thoughts in the comments below.

First some thoughts:

• I think of suicide as the ultimate in selfish behavior most of the time. The purported victim leaves behind many other victims of their act. Family, loved ones, friends, associates and their whole community are left to grieve, often filled with guilt over the lost soul. Don’t ever think of suicide as leaving the world better off without out your presence, you will leave far more sadness and grief behind that if you live.
• Never be afraid to ask anyone if suicide is a concern.  They may lie and say no, but often people with suicidal intent will admit their concern if directly and empathetically asked.
• If you have concerns about suicide for yourself or someone else ask for help. There are 24-hour crisis lines available, your physician, pastor, or other professional is obliged and usually happy to try to help.
• Never think of a half-hearted suicide attempt as a way to find help.  Miscalculations or other mishaps can make a suicidal gesture (not really meaning to kill yourself, but really asking for help) into a successful suicide all too often.

Next some statistics that I find interesting and informative:

• N 2007 suicide was the 10^th leading cause of death in the U.S.
• Although persons of all ages may commit suicide young men and the elderly are by far at highest risk. The incidence of suicide in adolescents ages 15-19 is 6.9/100,000, in young adults 20-24 is 12.7/100,000 and in adults 65 and older 14.3/100,000. In the age range 15-19 males are 5x as likely as females, and in 20-24 males are 6x as likely as females to die of suicide.
• Access to firearms is a major risk for successful suicide.  Children in homes with firearms are 10x as likely to die of suicide as children in homes without firearms.
• Both men and women die of firearms related suicide but males are especially at risk. 56% of male suicides involve firearms vs. 30% of females.  Males are also more likely to die of suffocation than females at 24 vs.21%.
• Females are far more likely to die of poisoning at 40% vs. 13% than males.
• Gay young men are especially at risk for suicide.  See comments below.

Risk factors for suicide include:

• Prior suicide attempts
• Mental health problems
• Drug or alcohol abuse
• Separation or divorce
• Physical or sexual abuse
• Being young and gay.  Several studies show higher risks of suicide in gay male adolescents.  Risk estimates range from 2-10x. (1,2)
• Returning veterans of the recent Iraq and Afghanistan wars are at risk.

So what can we do to keep suicide from affecting those near us?  I suggest a few things. 

• If you choose to have firearms in your home, take rigorous precautions to keep them away from adolescents.  Recognize this as a major risk factor.
• Even if you do not suspect any concern, make the topic a regular subject to bring up with your child.  Be sure they understand that suicide is not acceptable, and that you are very willing to help them in any way if suicide becomes remotely a concern.
• Take any suicidal hints or references very seriously.
• Keep prescription and non-prescription medications well away from youth.  Buy non-prescription drugs in small quantities or keep larger quantities locked away.
• Never think of suicide as beneficial to others. It is strictly a selfish exit from life, and leave behind others to struggle with your loss as well as all of their own problems.  It makes nothing better.

I’d love to hear comments from readers. Leave a comment below.

Weakness that I don’t think of as being asthenia on the other hand is usually used to describe a loss of muscle strength that is localized or if generalized is not associated with overall wasting or other symptoms of advanced disease. Weakness can be associated with neuromuscular disease like a nerve root impingement, a stroke or other brain lesion and other causes that lead to true loss of power in one or more muscles, or can be more a perceived weakness where patients feel they need to exert more force than normal, but on testing muscle strength is normal. Disorders like chronic fatigue syndrome and depression can lead to perceived weakness

A specific disorder called myasthenia gravis is a condition where strength at rest is normal, but with repeated use muscle strength decreases. It is due to an autoimmune disorder where antibodies against the post-synaptic acetylcholine receptors at the neuromuscular junction are blocked.

Numerous medications have asthenia as a potential side effect. The HIV drug Ritonavir which functions as a protease inhibitor has been associated with asthenia. This has to be somewhat of a dilemma as progression of HIV itself is a potential cause of asthenia. Chronic opioid use for pain management has been linked to asthenia in some individuals. Alcoholism is a common cause of asthenia, as are other types of drug abuse. The list of potential medication causes of asthenia is long, and medication use always needs to be considered in a patient presenting with undiagnosed asthenia.

Still in my practice, admittedly a suburban practice where neglected disease is relatively uncommon and HIV is not a major part of my practice, advanced age, end stages of serious illnesses, and cancer are the most common causes of asthenia. As patients become very old it is common for them to lose strength and body mass and whether this is asthenia or not may be up for debate. Asthenia associated with weight loss is a fairly common presentation of undiagnosed cancer. Asthenia is fairly common with end stage cirrhosis and liver failure, with very severe congestive heart failure and with COPD as respiratory failure approaches. In most cases unless a diagnosis can be made with good treatment options asthenia is a serious if not ominous symptom.

I have to say I rarely describe a patient as having asthenia, but when I do it is with the intent of trying really hard to find an underlying cause that can be treated or at least discovered, because asthenia in my mind is usually something that needs to be figured out.

I think of benign neglect in my office primarily in dealing with patients who are more likely to benefit from not investigating or treating a condition or complaint than by actively managing the condition.  A good example is a woman in her mid 80’s with mild dementia and multiple chronic medical conditions, maybe longstanding diabetes and who has had a coronary bypass surgery 12 years ago who asks if she should have a mammogram. In this case her life expectancy is relatively short, maybe 2-5 years, and the benefit of an early diagnosis of breast cancer is minimal.  In addition the diagnosis is going to force difficult decisions to be made.  Is no treatment, minor treatment, or moderately aggressive treatment best for her situation?  Is she competent to make the choice herself?  The dilemma expands.  Maybe the best approach is to not test for the condition in the first place. In her case most of the time it is an easy consensus to choose not to do the mammogram.

Benign neglect can also apply to situations where leaving relatively harmless conditions alone is better than aggressive treatment.  Examples I see are molluscum contagiosum, where the lesions usually resolve with no therapy in a year or so vs. painful ablative therapy that is far from uniformly successful on the child with the lesions. Another example is with seborrheic keratoses ( the brownish waxy pasted on lesions so common on our skin as we age)  or small lipomas (benign fatty tumors) of the skin.  These generally don’t go away, and often very slowly grow, but usually never bother the patient except cosmetically.  If the y need to be removed later it is not especially more difficult on larger lesions. If patients are comfortable ignoring these, then benign neglect is a great option. Benign neglect is a key to successful parenting too.  It is more widely called ignoring, and involves not rising to the lure of a child’s minor misbehavior.  Often the misbehavior is an attention gaining behavior, and ignoring the behavior will more likely lead to dissipation of it than confrontation or punishment. Examples in early childhood are temper tantrums, and in teens door slamming or a minor cursing. Bringing attention to the behavior may be just the attention the child consciously or subconsciously desired, and the benign neglect of ignoring can be effective at reducing the behavior.

It’s important to understand what you are doing when you choose benign neglect as the best tactic. It is not appropriate when it simply makes your life easier. In order to be truly benign the choice must in it total consequences have a neutral or better impact.  Most of the time when I choose benign neglect I anticipate the likelihood of negative consequences of active intervention to outweigh the likelihood of negative consequences of choosing no active intervention. Benign neglect is an important part of good primary care, yet needs to be used consciously and carefully.

I often am asked by patients if they should come see me or if they should just go directly to the specialist they feel is going to be able to definitively address their concern. I don’t mean to sound pompous here, but often patients are way off base in choosing the specialist best suited to their problem. Seeing a specialist in an arena of healthcare different from your problem has several risks.  These include significant delay in receiving appropriate care, incurring the expense of extensive testing in their area of interest prior to reaching the specialist appropriate to your circumstances, overdiagnosis, and missing related or unrelated problems that a family physician may recognize but a sub-specialist may not notice.  Let’s go through these in more detail:

• Delay in Receiving Appropriate Care:  This can be the result of various causes.  The one most concerning to me is when a patient makes a self-diagnosis and sees a specialist in that field.  Often symptoms that seem related to one area expertise are caused by a disorder not apparent to the patient.  Epigastric pain and nausea may be the result of heartburn and a gastroenterologist may be suited to evaluate and treat the pain.  On the other hand it may be related to coronary ischemia and need urgent intervention.  Seeing a gastroenterologist is not only not going to help, but may delay care, either because of a longer time to get an appointment for evaluation or because specialists often extensively evaluate issues in their area of concern prior to referral to another specialist. The time to have a trial of a medication for acid reflux and have an endoscopic exam of the esophagus and stomach may be detrimental to the care of a patient with coronary disease.
• Incurring Expensive Testing:  When a patient sees a family physician they are likely evaluated for the most serious or most likely problems causing their symptoms. The list of potential concerns often extends across several areas of sub-specialty interest. By looking at the most serious and most likely issues first a family physician is more likely to avoid expensive tests for very unlikely problems. An example might be a patient with groin pain.  If this patient sees a family doctor, they will probably be evaluated by history and physical exam for things like inguinal hernia, urologic causes like kidney stone and infection,  hip pathology, in women ovarian-gynecologic issues including ectopic pregnancy, gastrointestinal causes and neurologic causes.  If they see a urologist  they are likely to have extensive evaluation for urologic problems, and may get a correct diagnosis of a kidney stone or UTI.  If their problem very likely a gynecologic problem, they are still likely to have extensive evaluation for the urologic issues because no specialist wants to miss a diagnosis in their field of expertise no matter how low the likelihood may be. This holds true for most specialists.  If you see a sub-specialist you are very likely to have an extensive evaluation for problems in their scope of practice whether or not they think you likely have a problem in their realm.  A family physician is more likely to go through a process of looking for problems they consider important and likely, and put off extensive evaluation for very unlikely diagnoses. The cost savings of the latter approach  can be huge.
• Overdiagnosis:  I’ll be brief here, but if you have imaging like an MRI, CT scan, ultrasound or even many lab tests abnormalities are often noted that can lead to extensive testing which has its own risks, or diagnosis of a problem that does not now nor will ever bother you. The latter is called overdiagnosis.  See a prior post on overdiagnosis for more information on this topic.  Overdiagnosis may lead to medication side effects, risks of unnecessary procedures, and emotional distress.
• Missing related or unrelated Problems:  A specialist while highly trained in their scope of practice may not be focused on related or unrelated important health care issues.  If you see a cardiologist it is unlikely that they are going to recognize that you are due for a mammogram and urge you to get a preventative care visit for this and other preventative services you are due. If you see a dermatologist it is unlikely you will bring up your “Oh doctor, by the way I am having these odd numbness and weakness symptoms,” that may lead your family physician to consider a TIA and make interventions to prevent stroke.  The list of similar situations is nearly endless.

I feel pretty strongly that the first point of care for most health concerns should be either your family physician or the emergency department for life threatening emergencies. The scope of practice of your family physician gives you the best chance of efficient, timely and effective care.

In the meaningful use arena the problem is in how the regulators define meaningful use.  At our office we have had an EMR since 1997, and take expend considerable effort to make very meaningful use of the information. We have a virtual disease management registry so that we can improve our efforts to assure our diabetic, hypertensive and hyperlipidemic patients stay on track to maintain good control of their health. We make attempts to get patients in for preventative care visits. We use printed prescriptions to reduce errors with hand written prescriptions.  Unfortunately in order to demonstrate the government definition of meaningful use, and qualify for a financial reward for meaningful use from Medicare, I need to do some other things with the EMR.  These involve taking time during patient visits to generate documents to pass out to patients at the end of the visit.  To a bureaucrat these may seem important, and maybe they are, but to me they mean I have to spend 2-3 minutes of each visit assuring that the patient’s gets a printed medication list and problem list, and then typing a visit summary and directions to give the patient.  This means that the note for the patient encounter has to be complete or nearly complete while they are in the exam room.  On a busy day I in the past have chosen to complete these at the end of the half-day so that later patients do not need to wait as long for me to get to their visit.  For some visits I agree that these are important. For other visits they are just extra work that either takes time away from direct patient – physician interaction or puts me behind in my schedule and late for the next appointment and every subsequent appointment that half day.

In the case of pain management I have done the mandatory 4 hours of additional education on the use of pain medications.  That was the easy part.  Now I need to document at each visit that I am abiding by the state regulations.  The concept of these is right on target, but the details of the regulations is onerous. Now for every office visit with patients on chronic opioid pain management we need to use specific tools to assess the individual patient for depression, opioid abuse risk, degree of pain control, level of functionality and be sure that every 6 months we have a new 20 point pain medication agreement explained, signed and documented in the chart.  After this if there is any time left we can actually assess the problem causing the pain and see if there is anything to do to help with that.

These new regulations are on top of the complicated set of rules for what we need to document in order to show to the insurance company that they should pay me and what I need to document to give our lawyers enough information to defend me if I am sued.  Oh, I also want to make a note that serves to help me or anyone else provide good continuity of care.

If I sound cynical it is not accidental. I feel like the newest regulations have gone over the top, and now every day I spend more time documenting care than I do providing care.  It’s silly, and I predict that these efforts will turn out to be counterproductive.  Patient satisfaction and actual quality of care will be lower as a direct result of government regulations designed to improve quality of care. There you have it, my experiences from my first 6 weeks of daily work under the 2012 Washington state chronic pain management regulations and the Medicare meaningful use incentive program.

As president Reagan famously said, “The most terrifying nine words in the English language are: ‘I’m from the government and I’m here to help .’ ”

In the years since Lenore’s death CF has been found to be caused by a mutation in the cystic fibrosis trans-membrane conductance regulator  (CFTR) gene that regulates ion transportation (ions like chloride hence the traditional sweat chloride test for CF) and therefore fluid flow within cells. One specific mutation is the G551D mutation (substitution of aspartic acid for glygine at position 551), and the new drug Kalydeco specifically targets the abnormal protein in these specific CF patients. Kalydeco helps the defective protein work more normally, and so reduces the abnormalities in CF patients with this specific mutation.

Unfortunately only about 1 in 25 CF patients have this specific mutation in the CFTR genetic code. The rest have some combination of the other at least 1000 known mutations. The most common CFTR mutation is called F508del (a 3 nucleotide deletion at location 508 leading to a missing phenylalanine amino acid “F”) and about 1 in 30 Caucasians have this specific mutation in the CFTR gene. Kalydeco is not effective in patients who are homozygous for the F508del mutation.  This homozygous F508del mutation is the most common genetic code in CF patients. IN the 4% of CF patients with at least one copy of the G551D mutation Kalydeco has been shown to be effective in reducing CF symptoms, and is an exciting breakthrough.

Patients with the G155D mutation produce a protein that is able to make it to the cell membrane, where Kalydeco allows it to function much more normally.  In patients with the F508del mutation the protein fails to fold in a way that allows it to move to the cell membrane, and so a drug like Kalydeco cannot function.  Scientists are working on possible medications that could allow the migration of the other defective genes to the cell membrane where use in combination with Kalydeco could potentially be effective.

It is exciting not just for the 1200 U.S. patients with this specific type of CF, but also because it is an example of how genetic research, gene analysis in genetic disorders, and great basic science can lead to novel therapy for genetic disorders.

The rapid approval of Kalydeco is a great example of the new expedited FDA approval process for drugs that have the potential to be novel or breakthrough products where there is currently no effective therapy, or the drug is a major advance in therapy.  It took only 3 months for Kalydeco to get FDA approval, even faster than the promised fast-track approval promised for special circumstance drugs.

The catch in this whole process is the incredible anticipated cost of Kalydeco.  In a Wall Street Journal article the estimated annual cost of Kalydeco is reported to be $294,000.  Since the anticipated number of patients eligible to receive this orphan drug is so small, and because of the novel and documented improvements demonstrated in patients using Kalydeco it is expected that insurers will pay for the cost of the medication. If all 1200 eligible patients take Kalydeco the annual cost at this price would be $353 million annually.  Still this price is not Guinness world record. Two more expensive drugs are Soliris for a rare condition parosysmal nocturnal hemoglobinuria at $409K annually and Elaprase for the rare genetic disorder Hunter Syndrome , a polysaccharide storage disorder, at $375K annually. These are examples of orphan drugs with very limited markets where the cost of development is shared by very few patients.

I look forward to seeing more examples of genetic research leading to personalized medications for individuals.

Screening for prostate cancer has been all over the news recently, with the USPSTF proposed recommendation against routine PSA screening, and is a classic example of the risks of screening tests. The strongest argument against PSA screening is overdiagnosis and exposure of men to invasive prostate biopsies, and potentially dangerous therapy for prostate cancers that will never become clinically significant in some unknown but likely high percentage of cases. One of the primary reasons I don’t anticipate a dramatic reduction in PSA testing in primary care is because it is perceived by physicians that they are much less likely to be sued for complications of care caused by overdiagnosis of prostate cancer than if a patient is diagnosed with advanced prostate cancer and who has not been offered PSA screening. I suspect at least some physicians are going to be afraid to do the right thing even if they are convinced that the evidence supports not doing PSA screening.

Far less emotional and dramatic are consequences of defensive medicine precipitated by the ordering of imaging tests. It is commonplace for a physician to order an MRI of a patient’s knee early in the course of management of a knee injury.  In an NEJM study of randomly chosen men without a complaint of knee pain the incidence of finding a meniscus tear on knee MRI was 31%.  A finding of adrenal masses on abdominal CT scan is very common.  In one study the incidence of an adrenal mass finding on abdominal CT in patients without a known malignancy was 5%. In this same study of 973 consecutive patients of the 973 zero were found to be malignant.  This is exactly my experience, i.e. I’ve never had one of these turn out to be a cancer. Yet once an adrenal mass is found it is almost always recommended as a part of the radiologists report to have it reevaluated at least one, often twice or more to assure “stability.” It is unusual for a primary care physician not to order these follow up tests, more defensive medicine.  The risk of radiation exposure from abdominal CT scanning is not insignificant.

Treatment of sore throat, acute short-duration sinusitis, otitis media and acute bronchitis with antibiotics is very common.  It may be defensive medicine or just taking the path of least resistance, but there are very real risks of antibiotic therapy and almost all the evidence and expert opinion argues against the use of antibiotics in these conditions. With the increasing incidence of Clostridium difficiele infections, and increasingly virulent and antibiotic resistant C. diff as well as the other risks of side effects of specific antibiotics their use is far from risk free.

Nearly every new highly sensitive imaging technique is also very good at finding incidental variations of normal and abnormalities for which radiologists are reluctant to recommend no further evaluation, This is defensive medicine on the part of radiologists, as well as good business on their part in our fee-for-service environment.  What business person of sound mind is going to put themselves at legal risk and at the same time recommend against a test that is in their financial interest.  The risk to patients is more than just the risk of further radiation.  Often the tests also lead to invasive tests or treatments, all of which have their own risks.

Many blood tests have the same risks, including tests like CA-125 for ovarian cancer, of course PSA, but also things as simple as a CBC. A CBC with a low white blood cell count is usually either normal or the result of a recent viral illness. Still it usually leads to a follow up test to assure a return to normal. If it persists low it may lead to referral to a hematologist who often orders a bone marrow evaluation.  These are not only moderately painful but can have uncommon serious complications.

Essentially every test or procedure we do entails some risk. Ordering tests for defensive medicine reasons when the chances of finding clinically important and helpful results is fairly low makes the chances of finding false positives or overdiagnosis and leading to complications that would never have happened if the testing had not been done relatively higher. The cost of defensive medicine is not just in dollars.

The exact mechanism of action of Latisse is not clearly understood but it appears to be a prostaglandin receptor binder . Prostaglandin receptors are present in here and is thought that prostaglandin receptors are somehow involved in the development and regrowth of hair follicles.

Latisse® is a prescription only product that is designed to be applied once daily to the base of the upper eyelashes with a single use a sterile applicator. Despite the intention to make Latisse® prescription only,  much like other drugs for which patients might wish to use but don’t want to get a prescription to see a physician about Latisse® is widely available online without direct physician supervision. This is unfortunate because the teeth can have very annoying and potentially permanent side effects. These include a plum shade discoloration of the eyelid, macular edema which can be very serious even lead to blindness, a condition called punctate epithelial keratitis which can lead to significant itching and irritation of the eyes, as well as dry eye, eyelid swelling and injection of the conjunctival blood vessels making the eye seem reddish or pink. In addition though not mentioned in the product insert there are reports of Latisse® leading to darkening of the iris.

Although Latisse is a prescription only product it’s very easy to purchase this drug online without a prescription. The top of the Google search list for pilot case online is a site where you simply submit a medical form history and a “patient marks licensed physician will carefully ensure Latisse is a safe  option free you to use before we send your order.” They even advertise a discount for Valentine’s Day few by two more bottles. The retail price@drugstore.com for one bottle for peace is $115.99, but several online sources appear to be selling Latisse for between $70 and $85 per bottle. A bottle will last one month if applied as directed to both upper lids and even the manufacturer notes that Latisse only works as long as you continue to use it. Whether longer thicker eyelashes are worth approximately hundred dollars a month plus the risk of serious side disorders that could even affect vision and cosmetic or annoying eyelid problems is for each individual to decide.

Resource: Latisse side effects

There are several interesting things about this recommendation. First the quadrivalent Gardasil vaccine is chosen over the alternative bivalent vaccine (Cervarix). The obvious reason for this is because the quadrivalent vaccine gives immunity against the type 6 and 11 HPV that cause up to 90% of genital warts. As a family physician and a parent of a male child this alone would be enough reason for me to immunize my son against HPV. Despite this significant benefit of the vaccine, most of the data considered in this decision-making was based on risk reduction of the more serious consequences of HPV 16 and 18 infection. These can include anal intraepithelial neoplasia, various epithelial head and neck cancers, and penile cancer.

The MMWR article discusses the burden of cancer disease in males related to HPV infection. The article states that of the approximately 22,000 HPV 16 and 18 associated cancers in the US each year approximately 7000 are in males. Many of these are oropharyngeal and anal cancers. The incidence of new cases of genital warts each year in the US among sexually active males is estimated at a quarter million.

The MMWR article also addresses the efficacy of the quadrivalent vaccine in inducing adequate immunity. The efficacy in inducing antibodies against all four strains of genital warts was almost 90% in one large study. The reduction in the incidence of genital developing warts in the population who received at least one dose of vaccine was estimated at 68%. A subset of men in this study group who were immunized who have sex with other men was looked at separately.  Their risk for developing anal epithelial neoplasia related to HPV 6 and 11 was reduced by approximately 50%. It seems reasonable to assume that the incidence of straight men getting this immunization will be less likely to carry the HPV 16-18 strains and put their female partners at risk for cervical dysplasia and cervical cancer.

Safety of HPV Vaccine for Boys: The safety data for the HPV for vaccine is very strong. The most common adverse events were mild or at most moderate, and were usually injection site swelling, with many fewer cases of headache and fever. Approximately 40,000,000 doses of HPC for vaccine have been used the United States in the first five years since licensure and no increase in incidence of any serious consequences have been noted. Don’t believe the ranting of fanatics who badmouth this along with many other safe and effective vaccines. Fainting after getting the shot seems to be the most serious adverse outcome and doesn’t seem to be any higher than with any other shot.

Cost of HPV Vaccine for Boys:  At approximately $130./ dose, and $390./ 3 shot series, this is a real concern. Probably the strongest argument against routine HPV for vaccine of males is its cost. Any discussion of the benefits of immunization of males depends greatly on the incidence of immunizations of females. The rate of immunization of females in the US remains much lower than ideal with an estimated 47% of females age 13 through 17 having received at least one dose and only 32% having received all three doses. If a very high percent of females was immunized the risk of males who have female sexual partners acquiring genital warts would be considerably lower. Given the high current prevalence of the HPV virus it seems reasonable to assume that for some time now heterosexual young men will continue to have a significant chance of acquiring HPV virus. The estimates of the cost of per quality adjusted your of life in men vary from $20,000 to under $50,000 based on varying assumptions but unquestionably the cost of HPV vaccination of young men routinely is going to be high.

Why Give HPV Vaccine for Boys So Young?: Parents may ask why immunize my 11-12-year-old boy who I’m quite certain is ingrained have sex for many years. The answer is several fold. The first is that the highest efficacy for prevention of genital warts is in pre-sexual persons. The second is that children immunized between ages nine and 15 had higher antibody titers and therefore presumably better immunity than those vaccinated from age 16 through 26. The bottom line is that boys vaccinated prior to first sexual contact and purred age 15 have the best chance of immunity to genital warts and avoiding contracting them.

So what should you do for your boy?  My recommendation is that you get your son immunized a relatively young age, certainly before age 15 but ideally with his pre-sixth-grade immunizations around age 12. Why so early? Why not is really the better question. The immunity seems to be long-lasting and getting the vaccine for your child while you still have considerable influence over their receiving the vaccine, while you’re still confident that their pre-sexual, and while they’re in the routine of getting other immunizations just seems to make the most sense to me. So is HPV for boys a good choice? My  recommendation:  A strong yes.

Leave a comment and join the discussion.

Oxycontin has a reputation as probably the most abused of the prescription opioids because of its lack of acetaminophen, its high percentage of rapid release oxycodone, and its lack of properties preventing crushing the pills which eliminates the extended release properties and makes it possible to inhale, inject or smoke the drug.  Sometimes known as Hillbilly Heroin, Oxycontin is among the leading causes of prescription drug overdose deaths and opioid addiction in the U.S.

If Zohydro receives FDA approval as a single ingredient, high dose hydrocodone product there is little doubt that it will join Oxycontin as a major drug of abuse.  Proponents of non-acetaminophen opioid pain medications are correct when they state that acetaminophen has its own problems, and especially when too many pain pills are taken to get pain relief the daily acetaminophen dosage can exceed the 4000 mg / day maximum safe dose.  Serious and even fatal acetaminophen liver damage can result.  Still single ingredient opioid products are so prone to diversion, addiction, and abuse that I anticipate that Zohydro, if approved, will quickly become a major drug of abuse.

One thing physicians have on our side now is the Oxycontin experience.  We will be much more skeptical of allowing escalating Zohydro doseage and addiction become commonplace. Still I am not looking forward to one more drug with few advantages and much abuse potential coming to market.

Oxycontin is available in doses of 10, 15, 20,30, 40, 60 and 80 mg tablets.  Using the recommended opioid Morphine Equivalent Dosage calculator available for download at the Agency Medical Directors site, 30 mg of morphine is equivalent to 30 mg of hydrocodone but to only 20 mg of oxycodone (i.e. oxycodone is 1.5 x as potent on a mg for mg basis than hydrocodone).  Using these equivalency ratios it would be expected that Zohydro might become available in doses up to 120 mg per pill.  This would make it highly popular as a drug of abuse, as current hydrocodone products all contain acetaminophen, and maximum hydrocodone dosing even with products with 10 mg hydrocodone and 325 mg acetaminophen are 12 tablets daily, making 120 mg of hydrocodone the maximum daily hydrocodone dosage.

Let’s look at the evidence for transmission of the various STDs by oral-genital contact.

HIV:  Human Immunodeficiency Virus, the cause of AIDS, is the STD many fear most.  It can be transmitted when a body fluid containing the virus gains access to another person’s mucous membranes or bloodstream.   Unquestionably HIV is transmitted by anal and vaginal intercourse.  There are at least a few cases where it is believed that the HIV virus was transmitted to the receptive partner after oral sex with ejaculation.  Oral sex without ejaculation into the mouth is theoretically possible, but is felt to be extraordinarily unlikely. The risk of contracting HIV from a single incidence of anal intercourse with with ejaculation and no condom use with an HIV infected male has been estimated at 1:100.  Extensive study has been done in trying to find out what the incidence of contracting HIV from oral sex with ejaculation with an HIV infected male, but these studies all have confounding variables.  The real problem is that all of these studies have been in gay male populations, and a low percentage of the men had only oral sex.   On second and subsequent interviews many times the history changed, and made other routes of transmission more likely.  In one study it was estimated that there were zero cases of conversion in a population after over 35,000 incidences of oral sex.  All said, although it is possible to contact HIV from oral sex, the chances are very low. Low enough that if oral sex is a behavior that replaces anal intercourse in gay men the benefit of avoiding the high risk behavior likely greatly outweighs the risks of oral sex in this situation.

Herpes Simplex:  This may be the most common STD transmitted by oral sex.  Up to 70% of teens are estimate d to have been infected with the herpes simplex 1 virus, the cause of >90% of oral herpes cases.  Many others, and many of the same people also have been infected with the herpes simplex 2 virus, the cause of >90% of genital herpes.  The problem with herpes simplex is that despite popular belief, an infected person can shed the herpes virus at times when they have no symptoms or visible evidence of infection. It is believed to be  fairly common to transmit the herpes simplex virus either from the mouth to the genitalia, or from the genitalia to the mouth during oral sex.  The incidence of HSV transmission by oral sex is not well studied.

Gonorrhea:  Gonorrhea, caused by the bacteria Nisseria gonococcus, is an STD that typically causes painful urination and  a discharge of pus from the urethra in men.  In women it can be asymptomatic, can cause a vaginal or cervical discharge, or can cause more serious infection of the fallopian tubes and or ovaries, called Pelvic Inflammatory Disease (PID).  Gonorrhea can also infect the throat or tonsils.  The route of this infection appears to be oral sex, generally receptive oral sex with the penis in the mouth.  It is less clear whether cunnilingus can transmit gonorrhea although it is felt that this is very rare if it ever happens.  Men likely only contact gonococcus from vaginal or anal intercourse or from an infected partner during receptive oral sex.

Chlamydia:  There is less data about transmission of Chlamydia by oral sex.  It is generally felt to be possible to transmit Chlamydia both as the person performing and the person receiving fellatio.  The incidence of this is just not known.

Syphilis:  Syphilis is fairly uncommon in the US, but transmission of syphilis during oral sex is relatively easy, and is felt to be a relatively common cause of transmission, possibly up to 15% of cases in some areas of the US.

HPV:  HPV is probably the most prevalent STD in the world today. The HPV virus can be transmitted to the throat or mouth during oral sex.  The incidence of this is poorly understood, but there is an increasing rate of HPV positive head and neck cancers in the last 30 years.  Many experts feel that this correlates to increasing acceptance of oral sex.  Oral cancer has historically been primarily a disease of older adults with a long history of smoking and drinking, or in younger persons who use oral tobacco.  In recent years the incidence in younger non-tobacco users has increased, and many of these cancers are HPV positive on testing.

Hepatitis:  There is debate whether hepatitis B can be transmitted by oral sex, but if possible it is felt to be very unlikely.   Hepatitis A can clearly be transmitted by oral-anal sex, and is much more common in the gay male population than in the heterosexual population.

In summary oral sex is not safe sex, but it is far less risky than either vaginal or anal intercourse regarding STD transmission.  In addition the risk of pregnancy in heterosexual oral sex is near zero.   Avoiding receiving ejaculate in the mouth greatly lowers the risk of transmission of HIV, though probably not the risk of herpes, gonorrhea, or HPV.  Condom use for men, or use of a dental dam in women seems effective in markedly reducing the risk of most STDs with oral sex, but may not be common practice.

Psychological Issues:  Oral sex is clearly an intimate act.  Most psychologists agree that sex, either oral sex or sexual intercourse, brings a relationship to a different level.  How this type of intimacy affects a relationship, the self esteem of the participants, and future feelings about relationships and intimacy are subjects worthy of consideration, but I know of no research into this topic.

So, “How safe is oral sex?”  What do you want to tell your children about oral sex as a part of their sex education? You can decide now based on the discussion above and whether it involves men having sex with other men (MSM)  vs. heterosexual oral sex.  One risk of labeling oral sex a high-risk behavior in MSM is that it may leave gay men feeling that its risk is equal to anal intercourse, which is far from the truth.  If oral sex is an alternative to anal intercourse for MSM then it greatly reduces the risk of HIV transmission.