Duke Medicine Connect

Teen Health Q&A: Turn Off the TV and Talk to Each Other

Wed, 28 Sep 2011 12:50:05 -0400

In this Q&A session, Richard Chung, MD, director of Duke’s adolescent medicine program, provides advice on some important teen health issues.

Is an annual exam enough, or should I bring my teen to the doctor more frequently?

For many adolescents, a yearly comprehensive examination in which their physical and mental well-being is fully assessed is adequate.

However, many adolescents come in for their annual examination with a laundry list of concerns that have accumulated over the course of the preceding year.

It would be better to seek care right when specific concerns arise during the year, because many issues can be resolved more effectively and efficiently if tackled earlier. Then the annual examination can focus on screening and routine health maintenance measures, which are crucial to preventive care.

What illnesses or conditions are teens least likely to seek treatment for, and how can I spot these conditions?

Contrary to the popular notion that all adolescents perceive themselves as invincible, the vast majority of them are quite concerned about their health and well-being.

However, many do not seek care despite feeling vulnerable.

Shame can be a powerful deterrent to seeking care for symptoms and concerns that might otherwise motivate a person to see a doctor. Teens are often ashamed about issues related to pubertal development, sexual health, and mental health.

These are common issues in adolescence, but many teens suffer in silence.

To ensure that illnesses are addressed early, good communication is crucial. Parents must try to engage their teenager in meaningful conversation at least once a day to demonstrate their care and concern and to get a sense of their teen’s general well-being.

It is challenging but definitely possible to gain insight into their lives through such conversations while also respecting their privacy.

Parents should explicitly affirm their teen’s privacy while also stating that no topic is out of bounds and that they will be supported regardless of what details they share. By setting such a standard, parents may be able to discover a teen’s distress early and help them seek care.

My teen is moody, and it seems to be getting worse. How can I tell if my teenager has an undiagnosed mental condition?

Significant mental illness is under-diagnosed, and one key factor may be the assumption that related symptoms are merely adolescent mood swings.

While healthy teens without illness do have strong and often fluctuating emotions, mental illnesses can present similarly or even in a more subtle form.

Parents should seek assistance from their physician when they or their teen have any concerns, especially if the symptoms are getting worse. For mental illness, which can be debilitating, it is difficult to overreact to suspicious symptoms.

My teen doesn’t like to talk about sensitive things. How can I speak to him about sexual issues?

Studies have shown that despite perceived awkwardness, adolescents do want to hear about sex from their parents. What they don’t want -- and what they fear will come out of such discussions -- is judgment and shame.

Discussing sexual issues effectively is challenging, even for physicians seeing adolescents in a medical office.

It’s all right to feel awkward. Most parents find the first mention of the topic most difficult, and follow-up conversations much easier. Parents should try to keep the initial discussion short and to the point, opening the door for subsequent dialogue.

Parents too often view discussion of sexuality as a one-time, intensive extravaganza (a.k.a. “the talk”). That approach is likely to be overwhelming and ineffective.

Whether via their friends, television, the Internet, or other avenues, adolescents are inundated daily with messages about sex and sexuality, many of which are distorted and unhealthy.

Given such a context, parents must realize the benefits of speaking effectively with their teen about sexual issues early and perhaps even regularly, and the serious risks of not doing so.

My teen doesn’t exercise at all. How can I get her to be more physically active?

All adolescents need a substantial amount of physical activity to maintain their health, whether or not they are overweight.

However, sedentary habits are commonplace among teens. A key first step is making physical activity easier to do. People adopt new behaviors when they both want to do those behaviors and believe those behaviors to be possible.

Starting with simple activities like walking is a good idea. Setting small and achievable goals early on can help an adolescent break sedentary habits and start momentum towards consistent exercise.

Exercising can take the form of dancing in one’s room, taking the stairs instead of the elevator, or even parking farther away from the shopping mall.

Taking a broad view of physical activity allows teens to accumulate a reasonable sum of activity over the course of the day, rather than planning discrete episodes of difficult and intimidating exercise.

After getting some momentum, they may be more agreeable to pushing themselves further.

Other ways to encourage activity and make sedentary habits harder to fall back into include parents exercising and staying fit, family physical activities, setting limits on screen time, and taking the TV out of the teen’s bedroom.

How can I encourage my teen to begin to take responsibility for his health?

This important aspect of adolescent development is sometimes overlooked by parents. As a result, many older teens and even young adults are not well equipped to effectively advocate for their health or seek care.

This is often an issue when young people struggle to transition from pediatric to adult care. It is helpful to establish the standard of caring for one’s body, even before adolescence. Gradually let the adolescent assume more responsibilities related to his or her health.

If a teen takes medications, transition responsibility for taking that medication to the teen over time.

Modeling by the teen’s parents also has a powerful influence. If parents have difficulty caring for their own health effectively, the adolescent may follow suit. On the other hand, positive efforts by a parent can set an important example

Kidney Stones: Add Water and a Dose of Personalized Care

Tue, 27 Sep 2011 13:08:38 -0400

The causes of kidney stone disease can vary widely from person to person. If you’ve had a single kidney stone, changes in diet are often all you need to prevent another stone from forming.

But if you’ve had more than one stone, or if there is a history of recurring stones in your family, Duke urologist Michael Lipkin, MD, says that a thorough medical evaluation is in order, to help identify your specific risk factors -- so that you can stop the stone-stone cycle.

“People who have recurring stones may need medication as well as diet changes,” Lipkin says, “but the right treatment can be very effective in preventing these painful episodes.”

Each person must discuss his or her unique circumstances with a doctor, but he says there are a few guidelines that will help most people.

Drink More Liquid

Water is a kidney’s best friend -- aim for 10 ounces, 10 times a day.

Eat Less Meat

Proteins from animals (including sea animals) increase uric acid in the urine, which increases the risk of stone formation -- and they decrease a substance called urinary citrate, which inhibits stone formation.

Choose Your Veggies Wisely

Veggies are good for everybody, but for people with stone disease some veggies are best left alone.

A substance called oxalate, which can contribute to stone formation, is present in certain plant-based foods such as rhubarb, parsley, spinach, and beets -- your doctor can tell you if you need to avoid oxalate-rich foods.

Snack on Calcium and Magnesium

These two minerals are good for inhibiting stone formation, because they lower the overall levels of oxalate in your urine.

Make sure that every day you’re getting at least 1,000 milligrams of calcium and 360 (for women) to 420 (for men) milligrams of magnesium -- and remember that the best source for these minerals is real food.

Mind the Stealthy Sodium

It’s true that excess sodium can increase the risk of stone formation, but the salt shaker is probably not your real enemy. Most sodium that Americans get comes from processed foods, restaurant food, and take-out food.

Try eating at home, and cooking from scratch when you can. Also avoid canned and pickled food, and go easy on the added salt, soy sauce, and teriyaki sauce.

Up Your Nose with a Rubber Hose: Balloon Sinuplasty

Tue, 27 Sep 2011 13:33:58 -0400

Alicia Pierce used to feel the sinus pressure in her teeth. Each spring, her lifelong allergies flared up and her chronic sinus problems took a turn for the worse. The pain and pounding migrated south from her forehead and nose down to her mouth.

It was awful.

Every few years since 1992, Pierce went in for surgery to open up sinuses so prone to infection that twice she suffered from methicillin-resistant Staphylococcus aureus (MRSA), a bacterial infection highly resistant to antibiotics.

In all, she had five surgeries and countless courses of antibiotics. Often, recovery from surgery was just as unpleasant as a sinus infection -- blood drained down her throat, and she needed several days to get over the effects of the anesthesia.

New Hope for Sinus Sufferers

Then, last March, with a raging sinus infection and her regular otolaryngologist out of town, Pierce met Donna Sharpe, MD, at Duke Otolaryngology of Durham. Sharpe cleaned out Pierce’s sinuses and discovered that her symptoms were off the charts.

Sharpe suggested balloon sinuplasty, an outpatient procedure performed under local anesthesia that could open up Pierce’s swollen sinuses without the side effects of previous surgeries.

It was a smash success.

“I feel great,” says Pierce, a 46-year-old mother. “I’ve had no problems. I would recommend it to anyone.”

In a specially outfitted procedure room at her office, Sharpe performed Pierce’s balloon sinuplasty on May 25, three weeks after performing the first such outpatient procedure in North Carolina.

For many patients, compared to traditional sinus surgery outpatient, balloon sinuplasty is gentle and easy as a breeze.

New Technology in a Relaxed Setting

With the lights turned down low and relaxing music playing softly, the patient lies back in a reclining chair.

Sharpe inserts a flexible catheter into her patient’s nostril. Using a nearby video monitor along with a previous CT scan of the patient’s sinuses, Sharpe carefully guides the tiny catheter into an inflamed and mucus-filled sinus.

She follows that with a lighted guide wire that illuminates the hollow cavity. A spot on the patient’s head glows like a firefly, confirming that Sharpe has reached her target.

The physician inserts a small balloon, similar to those used for cardiac angioplasty, along the wire inside the catheter. Once the balloon is properly positioned, Sharpe inflates it, dilating the sinus opening.

As she removes the deflated balloon, the sinus drains. The patient feels a decrease in pain and pressure, and the procedure is over. In many cases, that’s it.

As needed, Sharpe will irrigate the sinus to flush out stubborn mucus or other material, but often, the relief is immediate. The patient is pain-free, breathing well, and ready for normal activity right away.

No incision, little or no bleeding, and a success rate exceeding 90 percent.

“It’s a pretty awesome technology,” Sharpe says.

Outpatient Balloon Sinuplasty Is Not for Everyone

Despite its success rate and examples like Pierce, outpatient balloon sinuplasty is not for all chronic sinusitis sufferers.

Patients must possess the anatomy to allow access via the catheter (blockages such as a deviated septum or sinus polyps are disqualifiers). They also need the temperament to tolerate surgical work inside their head under local anesthesia.

Sharpe performed balloon sinuplasty for three years in an operating room on patients under general anesthesia, which is still an option for people who are qualified for the procedure but too anxious to sit still for it.

During that time, she spoke often to colleagues about the possibility of doing the procedure on an outpatient basis. Then technology caught up: California physician and inventor Josh Makower, a sinusitis sufferer himself who created the technique, helped refine the equipment for use in an outpatient setting.

Revolutionizing Patient Care

Sharpe says the technology is a revolution in patient care.

“It’s similar to the change in cardiology 25 years ago,” she says, “when many people no longer needed to have their chests opened up to unblock their arteries.”

Balloon sinuplasty also has become more accessible now that it’s less invasive. Approved by the Food and Drug Administration as well as the Centers for Medicare and Medicaid Services, the outpatient procedure costs about one-tenth as much as it does in an operating room.

Patients leave Sharpe’s office ready to return to their day, free of sinus pain for the first time in weeks or months.

Carter Thompson, who was the first person in the state to receive outpatient balloon sinuplasty (also in Sharpe’s office), experienced immediate relief much like Pierce did.

Thompson went home after her procedure, cleaned her house, and entertained guests that night.

“It’s surreal. I don’t know what to do with myself,” Thompson joked about her new life without sinusitis. She has found special pleasure in enjoying activities that were out of the question before, such as walking outside on a humid summer day.

“Dr. Sharpe has helped me tremendously.”

Cardiac Arrest: Know Your Role

Tue, 27 Sep 2011 13:29:52 -0400

Cardiac arrests happen. A lot. Every minute, an American dies of a cardiac arrest.

We all know that it would be best to act on the abundant prevention advice available and avoid, to begin with, the heart disease that is the most common cause of cardiac arrest.

But changing the habits of a nation takes a long time, so health professionals such as Duke cardiologist James Jollis, MD, are working to spread a few new, common-sense guidelines for the public -- as well as innovative but simple techniques for emergency personnel -- that could save thousands of lives a year.

The key, Jollis says, is everyone knowing their role.

Bystanders

New research has prompted new CPR guidelines from the American Heart Association which recommend chest compression-only CPR instead of the old practice of compressions and rescue breathing.

If you see someone collapse and become unresponsive, sometimes gasping for air, take four simple steps right away:

Call 911
Locate an automated external defibrillator (AED) if possible
Begin chest compressions
Apply the AED when available

Kneeling over the victim with arms straight, press hard and fast in the center of the chest at a rate of about 100 compressions per minute.

“Keep compressing the chest until they wake up, an AED is applied, or someone takes over,” Jollis says. If a victim receives bystander CPR, they are twice as likely to survive, yet only one in five persons suffering cardiac arrest in North Carolina receive bystander CPR.

If you are in a public place that has an automated external defibrillator (AED), ask someone to retrieve it or get it yourself if it is nearby. Office buildings, churches, schools, libraries, stadiums, airports, and shopping malls commonly have these devices mounted conspicuously.

All you have to do is open the box and follow the instructions. The device won’t shock the person administering the treatment. Certain U.S. cities and communities that have trained large numbers of people in CPR have bystander assistance rates better than 60 percent.

To increase North Carolina’s rate, Jollis and others are currently working on a program to teach CPR to every eighth-grader in the state, by training teachers to teach the technique to students.

Other efforts include teaching CPR to all heart attack victims and their families on discharge from the hospital, and to all employees of every medical center in the state -- accountants, administrators, and cafeteria workers alike.

Emergency Response

Emergency medical services (EMS) personnel and first responders (firefighters and police) have increasing responsibility under new guidelines.

Because most cardiac arrest victims receive neither bystander CPR nor defibrillation, it is crucial that emergency personnel arrive as quickly as possible to give lifesaving services. For a patient who has suffered cardiac arrest, even one minute can make the difference between life and death.

Research has shown that therapeutic hypothermia -- the intentional cooling of a resuscitated but unresponsive person’s body to 90 to 93 degrees Fahrenheit -- can minimize the brain inflammation and subsequent brain damage that often occurs when blood flow is restricted by cardiac arrest.

Emergency personnel can induce hypothermia with a simple IV of cooled saline solution. Some EMS units keep these bags in an ambulance refrigerator, while smaller EMS outfits just keep saline in a beverage cooler on ice.

Hospitals

The ideal scenario for a cardiac arrest victim is that bystanders save their life, EMS prevents further damage and transports victims quickly, and all of the state’s 122 hospitals are ready to deliver care to correct the underlying problem and to help the patient recover.

The reality is that not all hospitals have postcardiac arrest protocols in place to begin with. Duke and other major medical centers in North Carolina are working with smaller hospitals to establish a plan that will allow any hospital to provide advanced care in an informed manner.

They’re also focusing on informing patients as part of recovery care: educating both patient and family about the changes in the patient’s life lessens the chance that the patient will experience a second cardiac arrest.

Eating Disorders: Talking Is Good Medicine

Tue, 27 Sep 2011 13:55:03 -0400

Nancy Zucker, PhD

“You suddenly go, I’m watching her die, I’m literally watching her die, and you think I can’t do anything about it.”

This is how Jim Brown [the family’s names have been changed] described his realization that his 11-year-old daughter had an eating disorder, and that he had to try anything and everything to save his daughter’s life.

He and his wife, Sarah, turned to Nancy Zucker, PhD, director of the Duke Center for Eating Disorders, for help.

Parents' Self-Care Promotes Daughter's Healing

Once their daughter was in treatment, Zucker suggested the Browns participate in a parent support group. The support group allowed them to see that their family was not alone in the fight against an eating disorder -- and that to help their daughter recover, Sarah and Jim would also have to learn to take time for themselves.

“Self-care means making a mental decision to care for yourself, because you understand that it will help your child recover,” says Zucker. “It requires physically taking time to do things that help you feel more relaxed and less stressed or anxious.”

Jim Brown says it wasn’t easy to accept that idea. “There are times as a parent you almost feel guilty for engaging in self-care,” he says. “You go, ‘Look, if she is suffering, I need to be suffering.’ It’s almost a martyr complex.”

The parent support group helped the Browns realize that taking time to do things that helped them manage their fear, stress, and anxiety would enhance their ability to help their daughter.

Jim says, “Nancy’s group was good in that it was like having a doctor tell you, ‘You’ve got a job to do, and for you to do this job you’ve got to be strong.’ It was somebody independent of you saying, ‘That’s the right thing to do.’”

Zucker notes that the act of self-care can be easier than it sounds.

“You do it one step at a time,” she says, “and it can start as simply as by going for a five-minute walk or leafing through a fun magazine.”

She encourages parents to take time alone and also to seek support from others, whether that means lunch with a friend or a date with your partner.

“It means making your health a priority and not letting anything get in the way -- because taking time to care for yourself helps you take care of your child.”

Fearing a relapse is the hardest part of his daughter’s recovery, says Jim Brown. However, he knows there are many parents who watch their children suffer, feeling helpless.

To other parents Jim says, “Seek help. Don’t just try to do this by yourself.”

Some 11 million people in the United States suffer from an eating disorder. The Duke Center for Eating Disorders specializes in the outpatient management of anorexia nervosa, bulimia nervosa, binge eating disorder, and other forms of eating disorders.

Weight No Longer

Tue, 27 Sep 2011 15:43:07 -0400

Recently, the Duke Center for Metabolic and Weight Loss Surgery surveyed applicants to their weight loss surgery program about their past attempts to lose weight.

They learned that by dieting, these 1,600 people had lost a total of 248,475 pounds. And then they gained it back. And lots more. Over 325,750 pounds, in fact.

“As anyone who has dieted has probably discovered, the problem is not losing weight,” says Duke bariatric surgeon Dana Portenier, MD, “but keeping it off.”

For some people with severe obesity, weight loss surgery is a life-changing experience that improves their health as well as their self-esteem.

Depending on the procedure, weight loss surgery can help people lose between 40 and 80 percent of excess weight. People who would consider weight loss surgery would have a body mass index (BMI) of 35 or over.

Someone with a body mass index of more than 40, or with a BMI between 35 and 40 with two significant medical problems related to obesity, would be considered a good candidate for surgery.

But weight loss surgery is only the beginning of the journey. Portenier answers a few questions to help put this tool in perspective:

If I get bariatric surgery, will I still be able to have Thanksgiving dinner with my family?

Absolutely. You’ll be able to enjoy the same holidays with your family that you did before the surgery -- the only thing that will change is your choices.

You’ll be eating more in moderation, and we’ve seen that after the surgery our patients naturally start to gravitate toward more healthy food choices. They report high levels of satisfaction with small quantities of healthy foods -- and they’re able to focus more on time with loved ones than on food.

I’m afraid of having elective surgery. What do you tell patients to make them feel safe?

If your BMI is high enough to make you a candidate for weight loss surgery, then it’s actually more dangerous for you not to have the surgery.

A 2004 study showed that health care costs for morbidly obese patients who diet alone are 45 percent higher than those who have weight loss surgery. Severe obesity affects nearly every organ system in the body, and the long-term health consequences of obesity cannot be overstated.

Hands down, severe obesity is simply more dangerous than weight loss surgery for most patients.

This is major surgery and you should know all the risks involved, but it’s important to note that mortality and complication rates of weight loss surgery -- when performed by experienced bariatric surgeons -- are much less than for comparable surgeries, such as colon surgery, hip replacement, and pancreatic surgery.

So while this surgery should never be taken lightly, the evidence shows that it is safe.

My BMI is 35 but I don’t know if I’m a good candidate -- how can I know it will work for me?

If you tend to gain and lose weight cyclically -- meaning you lose, then gain back, then lose, then gain back -- weight loss surgery could be a very effective tool to help you end that cycle and keep weight off permanently.

At Duke, we work with each of our patients to determine whether weight loss surgery is the right tool for him or her. Patients meet with physicians, psychologists, and nutritionists before surgery to make sure that they are set up for success after the surgery.

What happens after the surgery? How long does it take to recover, and how will I know what I can and can’t eat?

We tell our patients that they’ll need to take three weeks off of work after the surgery.

It may be that you are back in action before that, but we believe that this should be a “selfish” time -- it is a momentous lifestyle change, and we want you to have plenty of time to learn how to integrate your new self into your old life.

As for knowing what to eat, we will be with you every step of the way. We develop a lifetime relationship with our patients. They spend lots of time with our specialists before their surgery to get prepared, and after the surgery we check in with them at regular intervals.

Our behavior and nutrition specialists are dedicated to helping you thrive in your new lifestyle.

Weight loss surgery is an excellent tool, but it is only a tool -- the most important factor in your progress is you. Surgery is only the beginning of the journey.

Fertility Treatments: Q&A with Thomas Price, MD

Wed, 28 Sep 2011 13:14:57 -0400

Sometimes the road to a baby bump can be bumpy. How do you know if you need fertility treatments or just more patience? Reproductive endocrinologist Thomas Price, MD, answers this question and more.

When is it time to see a fertility specialist?

If you are younger than 35, try for a year to get pregnant before considering fertility treatments. If you are 35 or older, try for six months.

Of course, these guidelines are for those who don’t have obvious problems, such as very irregular periods or a history of pelvic inflammatory disease.

As we all know, the older you get the lower your chances of pregnancy become. After age 40, chances of successful pregnancy are low. But I’ve heard of women having children well into their forties and even older.

Stories of older women, especially celebrities, having children in their late forties tend to get a lot of attention. The part of the story that doesn’t always come out is that they very likely became pregnant with the help of an egg donor.

Even with in vitro fertilization (IVF), the chances of a woman becoming pregnant after her early forties with her own eggs are very low. In fact, we typically don’t offer in vitro fertilization with a woman’s own eggs after age 44.

Are there still options after this age?

We offer treatment with an egg donor up to age 50.

Egg donation is extremely successful in our program. At our clinic, between 50 and 60 percent of couples will take home a baby on the first try with egg donation.

What are some of the most common causes of infertility?

In women, the most common causes of infertility are ovulation problems -- not making an egg. Again, this is something that becomes more challenging as a woman gets older.

Poorly functioning fallopian tubes can also be an issue. Tubes can be damaged or scarred by disease. Endometriosis or problems with the uterus also can cause infertility. Low sperm count or poor sperm quality in males can also make pregnancy difficult.

What treatments are available?

Some of the options include medications, surgery, and IVF. But there is no one best treatment. Every woman and couple is different.

How does IVF work?

We use hormones to stimulate the production of eggs in a woman’s ovaries.

The eggs are retrieved from the ovaries, fertilized in the lab, and then put back into a woman. Then, we hope that implantation occurs and the woman becomes pregnant.

IVF bypasses the fallopian tubes that might be damaged. It also increases fertilization rates when there are problems with low sperm count.

How important is the lab at a fertility center?

The lab is incredibly important. In fact, the lab may be the most important factor in a successful in vitro fertilization procedure.

There are no labs out there that are better than Duke’s. Our state-of-the-art air filtration unit is extremely important to the success of growing embryos.

Is there a resource that compares success rates of fertility centers?
Yes. The Society for Assisted Reproductive Technology publishes the IVF success rates of clinics nationally.

I’m afraid of learning that an expensive procedure is my only option for becoming pregnant.

This is a common misconception.

Many people have the impression that we only do the fancy stuff like IVF. The fact is many couples get pregnant with simple treatments that are not expensive. For example, simple ovulation problems can be treated with inexpensive oral medication.

My insurance does not cover IVF. How does Duke help put fertility treatment within my reach?

Duke is a member of Advanced Reproductive Care, a corporation that helps people finance fertility treatment. They offer all sorts of packages, financing options, and a 100 percent refund guarantee program.

I’m also very proud that through the Pay It Forward Fertility Foundation, Duke Fertility Center gives several grants a year to couples who cannot afford fertility treatments.

Even though it may be a few years before I’m ready to have a baby, are there things I could be doing now to prepare my body?

I’m glad you asked! All women should start taking folic acid a couple of months before becoming pregnant.

Also, make sure you have all your vaccinations up to date, quit smoking, seek treatment for any diseases, and optimize your weight. Being either under- or overweight can adversely affect your fertility

Sleep Apnea: When a Snore Is More

Wed, 28 Sep 2011 13:35:23 -0400

Sleep apnea is as common as type 2 diabetes, and most people who have sleep apnea haven’t been diagnosed -- which puts them at risk for more than just sleepiness.

Having sleep apnea increases the odds that you’ll develop high blood pressure, heart disease, memory problems, weight gain, impotency, and headaches.

And then there are the dangers that do come along with plain old sleepiness: poor functioning at work and at home, decreased decision-making skills, and a serious risk for impaired driving.

A 2008 study showed that people with sleep apnea double their chances of being in a car accident and are three to five times more likely to be in a severe accident that causes injury.

What You Should Know About This Common Condition

The risk myths

Being older, being obese, and being a man are three major risk factors for sleep apnea that many people may already be aware of, says Duke neurologist Rodney Radtke, MD.

But it’s important to know that women can also develop the disorder, especially after menopause. A woman’s symptoms might be less obvious than a man’s.

If you’re not obese, you may think your snoring is just garden-variety snoring. But Radtke says fully one-third of sleep apnea patients are not obese.

For women and men, whether fat or thin, sleep troubles of any kind that persist longer than a few months should be addressed with a doctor.

When to see a doctor

Duke neurologist Paul Peterson, MD, says that if either you or your partner notices the following signs, it’s time to see a physician:

Daytime drowsiness that causes you to fall asleep while you’re working, watching television, or even driving
Pauses in your breathing during sleep (your bed partner may notice them first)
Snoring loud enough to disturb the sleep of others or yourself
Shortness of breath that awakens you from sleep

Waking up with a dry mouth, morning headaches, and, occasionally, insomnia may also be symptoms.

What’s the treatment?

Some people with a mild degree of sleep apnea can be helped with lifestyle change -- which is easier said than done, but it’s also completely non-invasive and, obviously, the cheapest option.

For mild cases, one or more of the following may help:

Sleeping on one’s side
Avoiding alcohol and sleeping pills
Weight loss

For more serious cases, or when lifestyle change isn’t working, the most common tool used to treat sleep apnea is a continuous positive airway pressure (CPAP) machine. This device blows air into the mouth and nose in order to keep the airway open.

Radtke -- who himself uses the device to treat his own sleep apnea -- says it’s just one of several very effective options that are available for patients with sleep apnea.

Five Myths About Live Kidney Donation

Tue, 27 Sep 2011 15:36:19 -0400

Matthew Ellis, MD

Live organ donation is truly a gift of a lifetime, but Matthew Ellis, MD, medical director of Duke’s kidney transplant program, says many people don’t realize that they can give this gift of life without endangering their own.

Duke performs about 120 kidney transplants every year, and a third are from living donors.

Here are five common misconceptions that potential kidney donors may have:

I have to be related to someone to donate a kidney to him or her.

New anti-rejection medications make it possible to donate to distant relatives, even friends. But wanting to donate doesn’t mean you’re automatically qualified to do so.

Duke’s transplant team takes prospective donors through a careful physical and psychological screening process -- much of which can be done remotely for donors who live far away -- to make sure the donor can undergo the surgery with no ill effects, physical or otherwise.

The surgery is difficult, expensive, and I’ll need to take a lot of time off.

Today’s kidney donation surgery usually takes only a few hours, and it requires only a few small incisions and two or three days in the hospital.

“We say it usually takes three weeks to get back to almost all of your normal activities, and about six to eight weeks to feel completely back to normal,” says Leslie Hicks, RN, Duke’s kidney transplant coordinator.

All hospital expenses are paid for by the recipient’s medical coverage -- only costs of travel, time off work, and a few post-surgery medications aren’t covered, and there are several organizations that may help cover those costs for donors who cannot.

After the surgery, my life will be different, and it might limit what I can do.

Careful screening of donors means that only people who are in very good health will be selected -- and for those people, the risks of future complications are very low.

Women of childbearing age can still have healthy pregnancies after donating, and the risk for future kidney disease is not affected by the donation of a single kidney.

“Your health care needs after the surgery are essentially the same as before the surgery,” says Ellis.

Kidney donors will need regular blood and urine tests to monitor kidney function, and they need to watch their blood pressure, so they must visit their regular physician every year but, Hicks points out, that’s something all of us should do anyway.

If my intended recipient and I aren’t a match, the process ends there.

Thanks to the new paired kidney donation program, if you and your loved one are not a compatible match, you can be put into a database that multiple hospitals use to search for other incompatible donor and recipient pairs who might fit your criteria -- meaning the other donor gives your loved one a kidney, and you give yours to their loved one.

Duke doesn’t accept “Good Samaritan” kidney donations.

Duke is now accepting altruistic donors -- those who are willing to donate a kidney to a recipient in need, even if that person is a stranger.

Nearly 90,000 people in the United States are waiting for a kidney donation. To learn more about organ donation, visit unos.org or kidney.org.

Atrial Fibrillation: Does Your Heart Flutter, Flop, or Fly?

Wed, 23 Mar 2011 12:34:21 -0400

What keeps your heart beating, every second of every day, throughout your life?

Your pacemaker. (Yes, you have one.)

The sinus node, a group of cells near the upper right chamber in your heart, is your natural pacemaker. It creates the electrical impulses that start every beat of your heart . . . with . . . nice . . . even . . . spaces . . . between . . . each.

In some people, sometimes, that nice, even rhythm can go chaotic. Atrial fibrillation (AFib) occurs when the upper chambers of the heart (the atria) beat fast and irregularly.

Running Mice, Flopping Fish

Duke AFib specialists Tristram Bahnson, MD, Patrick Hranitzky, MD, and Tim Donahue, MD, have heard many colorful descriptions from patients of what AFib feels like: a mouse running or a fish flopping in the chest, a fluttering or racing heart, a fullness in the throat.

Most people with AFib -- but not all -- will also have fatigue, chest pain, or dizziness.

“AFib is the most common of the abnormal heart rhythms,” says Bahnson, who is also director of the Duke Center for Atrial Fibrillation. “Up to one in 10 people will have it.”

Anyone, at any age, can get AFib, says Hranitzky, but there is a strong correlation between getting older and getting the disorder. “AFib in a young person is typically due to a genetic predisposition,” he says.

Physicians Tristram Bahnson, Patrick Hranitzky, and Tim Donahue say AFib can be treated— and the sooner, the better.“In the older population, over 65 years old, AFib is most likely caused by environmental factors. That is, the fibers in the atria stiffen with age, leading to chaotic electrical activity.”

In addition to growing old, other culprits commonly associated with AFib include high blood pressure, heart valve disease, thyroid problems, and sleep apnea. “As many as half of people with sleep apnea will get atrial fibrillation,” says Bahnson.

Why Worry?

Some people with AFib will have extreme fatigue or exercise intolerance, and some will not.

Some will have frequent symptoms, and some will have only occasional flutters.

For this reason, some people may not realize they have the disorder. But even the occasional racing heart should be reported to your doctor, says Hranitzky.

“Frequent symptoms may warrant an EKG [electrocardiogram],” he says. “If the symptoms are infrequent, monitoring may not be necessary, but a consultation with your family doctor is needed.”

The most pressing danger of not getting AFib treated is stroke -- people who have AFib are at a much higher risk of stroke than people who don’t.

But once the AFib is diagnosed, the stroke risk can be lessened with anticoagulants (blood thinners).

And there’s a second risk, says Donahue, who treats patients at Durham Regional Hospital. “When the heart races for long periods of time, that can lead to heart failure, and this can happen in a matter of weeks.”

Heart failure occurs when the heart is damaged enough that it can’t adequately do its job of pumping blood through the body.

Mastering the Rhythm

The first line of defense against AFib is usually medication.

“Normally we’ll prescribe benign medication like beta–blockers -- medications that slow the heart rate -- in addition to aspirin or some form of blood thinner, such as warfarin [Coumadin] to reduce stroke risk,” says Hranitzky.

For many people, these medications will be enough to get rid of most, if not all, symptoms and restore quality of life. For those who do not get relief, there are more options, including pacemakers and, more recently, a minimally invasive surgical procedure called catheter ablation.

“Ablation is a game-changer,” says Donahue. “It allows us to cure AFib completely in some patients.”

In the procedure, long and flexible tubes (catheters) are inserted in the veins, usually in the groin, and are threaded up to the heart through the blood vessels.

Instruments on the catheters are used to cauterize (burn) regions of the heart that are responsible for disrupting the heart rhythm. The cauterizing creates scar tissue, which disrupts the electrical activity that causes the abnormal rhythm.

Because the procedure is minimally invasive, complications from catheter ablation for AFib are rarely serious. But it’s still an evolving procedure that is now offered at only a limited number of centers in North Carolina.

Duke physicians have documented some of the lowest complication rates for patients who undergo catheter ablation compared with other centers in North Carolina and around the world.

Take Heart

The consensus among Duke experts is that virtually all AFib patients can be successfully treated.

“But it’s very important to get treated early,” says Bahnson. “Successful therapy is improved by early intervention. Plus, it is very important to have your stroke risk assessed early.”

The Duke Center for Atrial Fibrillation

The Duke Center for AFib offers an unusual breadth of experience for patients.

In addition to a wide array of treatment options, the center recognizes the other conditions common among AFib patients such as sleep apnea or heart failure, and collaborates with other Duke experts to treat them.

“Duke is unique in that our treatment strategies are varied, we have a large spectrum of treatment options, and we recognize that it is important to individualize care,” says Bahnson.

Find a Convenient Location Near You

Duke AFib experts treat patients at:

Duke University Hospital
Duke Raleigh Hospital (dukeraleighhospital.org)
Durham Regional Hospital (durhamregional.org)

For more information, call 888-ASK-DUKE (888-275-3853).

Tinnitus: A Treatment of Tunes?

Wed, 23 Mar 2011 11:02:10 -0400

You know that droning sound a refrigerator makes? That, or something similar, is what the 50 million Americans with tinnitus must endure.

According to the American Tinnitus Association, 12 million of those Americans seek medical help for the condition; for two million, it’s severe enough to cause family problems, job problems, sleep problems, or even depression as a result.

Often caused by exposure to loud noise, tinnitus is becoming more common, especially among veterans. Users of portable music players are also at risk, but so are those who undergo certain chemotherapies or experience stress, head and neck trauma, or even sinus infections.

Musical Treatment, Promising Results

To treat tinnitus, hearing specialists often turn to specialized hearing aids to make the condition more manageable. But Duke audiologist Rebecca Price says there is a new technique that may help some patients with tinnitus: the Neuromonics Tinnitus Treatment Program.

“While tinnitus may begin as the result of damage to the hearing mechanism,” says Price, “it is our brain’s response that causes an increased perception of internal sound. This new program addresses not only the damage to the person’s hearing, but also the brain’s role in the disorder.”

In the first phase of this six- to nine-month program, soothing music is embedded with sound that is customized to a particular patient’s hearing loss and to the sound that’s bothering the patient.

The patient uses an MP3 player to passively listen to this music for at least two hours per day for about two months, during which time his or her brain learns to ignore the sound created by the tinnitus.

Why music? “Because music spans a broad range of sound frequencies, it allows us to control how the patient experiences the tinnitus and helps the brain learn to interpret the sound differently,” says Price.

“The therapeutic benefit of music is also key. Relaxing music stimulates the brain in a positive way, and patients find music much more pleasant than white noise.”

During the next four to six months, the music is altered and specific sound is removed from the music, allowing the patient to be re-exposed to the original sound of the tinnitus.

“The second phase of treatment is where active rewiring of the brain takes place and the brain is trained to attach a more neutral response to the tinnitus,” says Price. “The hope is that the patient will come to ignore the sound -- or at least find it much less bothersome.”

At Duke, 30 patients have undergone treatment to date; while there is no cure for tinnitus, patients who have undergone neuromonics treatment have noted a reduction in tinnitus awareness and disturbance and an improved quality of life.

“Neuromonics is not a treatment program for everybody with tinnitus,” says Price, “but the results so far are promising.”

To learn more about neuromonics treatment for tinnitus, call 888-ASK-DUKE (888-275-3853).

Hammer Toe: The Case for Sensible Shoes

Wed, 23 Mar 2011 10:50:15 -0400

A pair of stylish, high-heeled shoes can make some women feel glamorous and sexy, but those beautiful shoes can also cause an unsexy-looking and -sounding foot deformity: hammer toe.

High heels and pointed shoes force the toes down into the shoe or into a point. When toes don’t have enough room to lie flat, a hammer toe can develop, usually with a bunion.

Anyone with a family history of hammer toe is also more likely to develop the condition.

Conservative Treatment

Duke orthopaedic surgeon Selene G. Parekh, MD, says there are several treatment options, starting with physical therapy for mild cases.

Selene Parekh says a new treatment for hammertoe gets patients on their feet faster.You can stretch the muscles and tendons to relieve the cramping and to straighten your toes. If your toe is also rubbing up against the underside of your shoe, you can also use small pads, found in most drugstores, to cover and protect the toe.

“As far as conservative treatments options, though, that’s it,” Parekh says.

Sophisticated Surgery

For more advanced cases, the traditional approach is a surgery in which the surgeon removes some bone and inserts a pin into the toe. For four to six weeks, the pin keeps the previously bent toe immobilized while its bones fuse.

Though the surgery is effective, the patient has a pin sticking out of her toe -- and when she begins walking, if she isn’t careful, the pin itself can get caught on things or hit the ground.

A newer technique involves inserting the SmartToe implant into the toe instead of a pin. The bones fuse around the implant, which is permanent. “Think of the device as something similar to a pin but completely inside your bone,” Parekh says.

“One of the big benefits of implants is that you don’t have something sticking out of your toe.” While recovery lasts just as long as with the traditional surgery, the SmartToe allows patients to get back on their feet and walking faster than with the traditional pin, sometimes within days.

Be Good to Your Feet and Seek Relief

Parekh says it’s a good idea to seek medical attention if you have toe pain with or without shoes. Or, if shoes you used to find comfortable are no longer comfortable, see a foot expert or an orthopaedic surgeon who can discuss your options with you.

“I’ve had patients who have 200 or 300 pairs of shoes and are very emphatic and serious when they say there is no way they’re getting rid of their shoes,” he says. “And that’s okay. We can work with them, with everyone understanding that we will eventually have to do surgery.”

Other patients say they don’t care what shoes they wear. They just want to relieve the pain and walk comfortably again.

“After taking care of so many patients, one thing I can say is if your foot and ankle hurt, you will feel miserable,” Parekh says. “It really is worth taking care of your feet to prevent any long-term problems.”

Hammer toe is actually a slight misnomer. Hammertoe specifically refers to deformities of the second, third, fourth, or fifth toes. The toe is bent at the middle joint, causing it to resemble a hammer. Many people also use the term to refer to all such deformities, but a multiple-jointed deformity is more accurately called a claw toe.

The Sweet 'N Low-Down on Artificial Sweeteners

Wed, 23 Mar 2011 10:43:24 -0400

Little blue, yellow, and pink packets on the table -- which one should you choose?

Artificial sweeteners can help reduce caloric intake by providing a high level of sweetness with few to no calories.

But many people have questions about whether artificial sweeteners are safe, whether they truly help with weight loss, or even if these artificial “foods” can contribute to overeating. Which little packet should a health-conscious consumer choose?

Safety First

Like all other food additives, artificial sweeteners must undergo a rigorous approval process based on the results of animal or human studies.

The FDA assigns a maximum acceptable daily intake, or ADI, for each sweetener. The ADI is an average level that an individual can safely consume daily.

ADIs have a large built-in safety factor: they are 1/100th of the amount that is considered safe for human consumption. In most cases, the ADI is a level far greater than what most individuals would consume under normal conditions.

For example, the ADI for sucralose would be the amount of artificial sweetener found in six cans of diet soda.

Just like other food ingredients, it is possible that certain people may have an adverse reaction to one or more artificial sweeteners. Also, people who have the rare genetic condition known as phenylketonuria, or PKU, must avoid aspartame due to its content of phenylalanine.

But for most people, if you enjoy using a packet or two of artificial sweetener in your morning coffee, tea, or oatmeal, it’s safe for you to continue.

The Hunger Beast

How do artificial sweeteners affect weight loss and hunger?

Some research had previously suggested consumption of artificially sweetened foods and beverages might actually trigger overeating and hunger in certain individuals.

However, most scientific evidence currently available indicate that artificial sweeteners do not impact appetite, hunger, or fullness.

A study released in the August 2010 issue of the journal Appetite found that zero-calorie sweeteners did not prompt overeating. The study compared the effect of stevia, aspartame, and table sugar on hunger and satiety levels.

Subjects were given a stevia-, aspartame-, or sugar-sweetened snack 20 minutes before a meal. At meals, participants were instructed to consume as much or as little as they liked.

The researchers found that subjects who consumed the artificially sweetened snacks did not compensate by eating more at their lunch or dinner meal as compared to those who consumed the sugar-sweetened snacks.

A 2009 review of 224 studies on the subject of artificial sweeteners and calorie intake (published in the American Journal of Clinical Nutrition) found no mechanism by which artificial sweeteners promote increased caloric intake.

Can artificial sweeteners promote weight loss?

While sometimes a controversial question, Duke Diet & Fitness Center dietitian Elisabetta Politi says that when artificially sweetened foods and beverages are substituted for high calorie sugar-sweetened foods, weight loss may occur, but she cautions to keep in mind this is only one variable that can contribute to weight loss.

“The position of the Duke Diet & Fitness Center on artificial sweeteners is that they can be consumed in moderation as part of an overall healthy, well-balanced diet,” she says.

“For people who are looking to decrease their caloric intake, replacing a sugar-sweetened food or beverage with an artificially sweetened one may indeed be helpful in reducing caloric intake.” However, she cautions to keep in mind that artificial sweeteners may be found in foods that are not always the most nutritionally sound.

Also, consider the company that artificially sweetened foods or beverages keep. “In other words, do you have that diet soda with a burger and fries, or does it accompany a healthy meal?” Politi says.

“We say you can choose whichever color packet you like, but make sure that the rest of your plate has lots of fresh, healthy foods.”

LASIK: How Safe Is it?

Wed, 23 Mar 2011 12:20:16 -0400

Chances are, you know someone who has had LASIK surgery, or you may have considered the procedure yourself.

Despite the allure of ditching daily eyewear, the decision to undergo this elective surgery is one most people understandably deliberate on for quite a while. So we asked Terry Kim, MD, professor of ophthalmology at the Duke Eye Center, just how safe LASIK really is.

I’ve heard LASIK described as quick, easy, and painless. Is it?

Make no mistake -- LASIK is surgery, and anyone who implies otherwise is not forthcoming.

“Like any surgery, the experience of the surgeon is the most important factor in achieving the best results.” —Terry Kim, MDThe surgeon creates a flap in the cornea, and a laser is used to reshape the underlying cornea. The surgery takes less than half an hour, and patients feel pressure, but no pain.

However, that does not mean it is a simple procedure that just anyone can perform. Like any surgery, the experience of the surgeon is the most
important factor in achieving the best results.

In addition to the experience of the surgeon, what other factors are important?

A number of factors are crucial to success with LASIK surgery. It starts with a thorough preoperative exam by a qualified surgeon and staff to ensure you are a good candidate.

The quality of the surgical tools, such as the laser, is also very important. We believe that having dedicated, on-site laser machines in a controlled operating room environment, where temperature and humidity are constantly monitored, contributes to better outcomes in our patients.

We also have two different excimer laser platforms so that we can customize the procedure to each patient’s eye measurements and ensure the best vision possible.

How common are complications?

The complication rate for LASIK surgery is very low, making it one of the safest surgical procedures around.

We perform a full comprehensive examination to identify any factors such as dry eyes and thin corneas that may increase the risk for complications.

At Duke, our rate of complications is extremely low, with the majority of them occurring less than 1 percent of the time, and our rates of enhancement [the need for additional laser adjustments] are under 2 percent.

Who really shouldn’t have the surgery?

Good question -- there are people who are not good candidates for LASIK surgery. In fact, I generally turn down roughly 20 percent of the prospective patients who come in for an evaluation.

Some of the more common reasons include high refractive errors [nearsightedness or farsightedness], dry eyes, thin or abnormally shaped corneas, cataracts, and retinal problems from diabetes.

The good news is that if you do not qualify for LASIK, Duke offers an array of alternative surgical procedures, such as PRK or LASEK, corneal implants, phakic intraocular lenses, and cataract surgery with presbyopia- or astigmatism-correcting intraocular lenses.

What’s the bottom line for anyone considering LASIK?

LASIK is not for everybody, but those who are good candidates can experience a vision-changing and life-changing experience.

As with any surgery, people should do their homework beforehand, and choose a surgeon and facility they have every confidence in.

Want to Know More?

Duke’s surgeons and staff have been delivering LASIK care for over 15 years and have performed more than 20,000 LASIK procedures.

To make an appointment to determine if you are an appropriate candidate for LASIK, call 888-ASK-DUKE (888-275-3853).

Fancy Footie Work: Keeping Young Soccer Players Healthy

Wed, 23 Mar 2011 13:55:36 -0400

Whether you’re a superstar or just starting out, avoiding injuries on the soccer field begins with information.

Parents of young soccer players can take valuable lessons from current trends in soccer injuries, to keep their kids in the game and out of the urgent care waiting room.

Avoiding Overuse Injuries

There’s been a rise in overuse injuries among kids who start playing competitive soccer at a young age and play year-round, says Duke sports medicine expert David Berkoff, MD.

“When kids are growing and their muscles are catching up and developing, their bodies can develop weakness or imbalances,” he says.

His advice? If your child experiences pain several days in a row, get him or her to a doctor to be evaluated. And make sure your young player gets an off-season that includes a physical assessment.

Since soccer injury rates rise after age 12, injury prevention programs become important once soccer players reach middle school. “But is it practical for every player to go through these?” asks physician assistant John Lohnes, another soccer specialist at Duke.

“Will they ever realistically have the time and coaching expertise to devote to injury prevention? Like any program, it only works if you do it.”

Physical therapist Kelly Hess, who directs Duke’s soccer outreach program, says the team preaches the injury prevention gospel as loudly as they can. “Kids are not as worried about injury prevention,” she says.

“They want to get stronger and faster to be better soccer players, but we’re trying to teach athletes and their parents that injury prevention helps with speed and agility as well as minimizing injuries. But it takes more than one week at a camp to apply the principles taught. You need to do a lot of work on your own to see results.”

Get Soccer Fit

Hess offers some exercise suggestions for young soccer players looking to prime their bodies to play and avoid injury.

Young Upstarts

If your child has just begun playing soccer, he or she should first develop coordination and body control. Skipping, jumping rope, playing hopscotch, or doing grapevine patterns can sharpen both.

Young Professionals

Older, more serious soccer players benefit from more specific training.

For core strength needed to stabilize the body, do planks and side planks.
For glutes and quadriceps strength to stabilize your knees, do squats, but make sure you have perfect form.
To strengthen hip abductors which help hips rotate to prevent the knees from collapsing inward, do side leg raises lying down, side steps with an exercise band around your knees, squats with a band around your knees, or clamshell exercises.
To strengthen hamstrings and minimize the risk of ACL injuries, do Nordic hamstring curls and hamstring curls on a ball or machine.

Ask an Expert

Consistency is essential, but Hess cautions that using proper form is even more crucial. If you’re unsure whether you’re doing an exercise correctly, seek assistance from a physical therapist.

Contact Kelly Hess, Duke Sports Medicine soccer outreach coordinator, at 919-314-7670 or kelly.hess@duke.edu to schedule an appointment with a soccer sports medicine specialist.

The Estrogen Epic Continues

Tue, 05 Oct 2010 15:39:09 -0400

When menopause symptoms strike, what is a woman to do?

“Everyone should take estrogen!” “No one should take estrogen!”

Charles Hammond, MD, chair emeritus of Duke’s Department of Obstetrics and Gynecology, says that in the course of his career, he’s seen the medical opinion on estrogen replacement swing from one extreme to the other, and back again -- at least twice. And frankly, he doesn’t expect the debate to end anytime soon.

That doesn’t do much to comfort women who are facing menopause and its often life-altering, sometimes debilitating symptoms.

Women quit hormone replacement therapy in droves following the July 2002 closing of the Women’s Health Initiative (WHI) studies -- the largest study to date of estrogen replacement in postmenopausal women -- which showed that the therapy created a small but measurable increase in breast cancer risk, and did not provide any protection against heart disease or dementia.

Nearly a decade later, the tainted reputation of estrogen therapy has left a gaping hole in the therapeutic options for women struggling with symptoms of menopause. But HRT (hormone replacement therapy) still has a place in helping some women, Duke experts say -- as long as it is prescribed appropriately.

Why? Why Not?

For women whose menopausal symptoms are mild, the question of taking estrogen is not much of a question these days -- according to the best scientific evidence available, the benefits are not compelling enough to offset the risks.

But for women whose symptoms interfere with their normal daily life and diminish their quality of life, Hammond says physicians must walk the fine line between the risks of action and the consequences of inaction.

“The primary reason to prescribe estrogen for a woman is menopausal symptoms,” says Hammond -- hot flashes, vaginal and urinary changes, and psychological or mental effects ranging from depression to a frustratingly nondescript haze that is usually labeled “cognitive dysfunction.”

None of these symptoms are life-threatening, but they can have a long-term -- and really unpleasant -- impact on a woman’s quality of life. Some women experience vaginal changes that make sexual intercourse quite painful -- sometimes impossible, even with lubricants.

As for hot flashes, Hammond says, “people tend to chuckle about hot flashes, with this image of Aunt Fannie sitting on the porch with her hand fanning.” But they’re not funny at all for women who experience such strong and frequent flushing that they can’t get restful sleep, can’t concentrate at work, and avoid social activities.

Sexual and urinary dysfunction affect as many as 50 percent of menopausal women, says Hammond, and without treatment these symptoms can get worse over time. About 75 percent of women have hot flashes -- among those women, two thirds will see a lessening of their symptoms after a few years. But a quarter of all women experience severe, persistent hot flashes that can go on for decades.

Although every natural remedy under the sun has been touted at one point or another for soothing hot flashes, nothing’s been proven to have more than about a 20 percent effectiveness rate -- in other words, not much more than a placebo effect.

For these symptoms, estrogen remains the hands-down most effective way to diminish or even reverse both hot flashes and vaginal symptoms.

Think Little and Brief

But what if estrogen might increase a woman’s chances of developing cancer later on?

Hammond says that while researchers will continue to debate the role and risks ascribed to estrogen in women’s health and disease, most physicians and health organizations recommend prescribing estrogen at the lowest possible effective dose to women whose symptoms are significant, and to keep them on the hormone for as brief a time as possible.

“There are two forces at work in this debate,” Hammond says. “One is a population of symptomatic women, whose quality of life is suffering. The other is the fact that we all want a treatment that doesn’t have any side effects or any risk. And in terms of hormone replacement therapies, that just doesn’t exist right now. And quality of life is important, so trying to bring these two things together is the goal.”

Life After Estrogen

For now, while HRT may still be prescribed for women with severe menopausal symptoms, long-term use of the therapy is no longer the norm.

“We now recommend that women take HRT for only a few years, then stop and see whether symptoms return,” says Duke internal medicine physician Lori Bastian, MD. “If that happens, we’ll try other interventions.”

Because a “cold turkey” approach may aggravate symptoms, Bastian suggests that women taper off HRT gradually. In the post-HRT world order, what other means can women use to ease their path through “the change”?

Antidepressants such as Paxil and Effexor have shown benefit in some women for easing psychological effects and even hot flashes.

Soy, with its wealth of estrogen-like substances called isoflavones, continues to earn kudos for its proven power to ease menopausal symptoms. Even though it’s a natural product, soy should be taken in moderate amounts -- excessive use of soy may stimulate diseases such as fibrocystic breast disease, breast cancer, uterine fibroids, or endometriosis.

Regular exercise, including weight-bearing, resistance, and aerobic components, can be especially important to maintain (or begin, if you aren’t exercising already) during menopause and beyond. Exercise helps protect bone mass, lowers the risk of cardiovascular disease, and releases endorphins that help ease mood swings.

Calcium and vitamin D are key to help prevent bone loss. Aim for about 1,000 to 1,500 milligrams of calcium a day from all sources, including calcium supplements; excess amounts (more than 2,500 milligrams per day) can cause harmful effects. Because the body requires vitamin D to metabolize calcium, 15 minutes of sunlight daily or vitamin D supplements (at least 1,000 milligrams) are also recommended.

Bastian also recommends that women coping with menopausal symptoms avoid alcohol, which may trigger hot flashes, and give up smoking -- the nicotine in tobacco suppresses estrogen metabolism and can worsen menopausal symptoms.

For easing stress, time-honored techniques such as deep breathing and yoga can be very effective indeed -- and blissfully free of side effects.

Women, Estrogen, and Heart Health

Tue, 05 Oct 2010 15:40:16 -0400

One of the main issues surrounding menopause is that it coincides with a steady increase in heart disease among women -- it is often said that women have a “protection” from heart disease that they lose, seemingly along with their estrogen, around the time they undergo menopause.

But Duke cardiologist Kristin Newby, MD, notes that the exact link between the two has not been proven. “it could be that estrogen is an innocent bystander to a process that we haven’t discovered yet,” she says.

“In some ways I think we do a disservice by perpetuating the idea that women have this almost magical protection against heart disease up until menopause,” says Newby.

While estrogen debates may continue indefinitely, there is no controversy about the fact that women and men alike are developing heart disease at earlier ages than ever before -- and that women should adopt heart-healthy behaviors including healthy diet, regular exercise, stress management, and regular well visits to a doctor, in their twenties.

What’s a “Bioidentical Estrogen?”

Bioidentical hormone replacement can be a confusing term, because it can be applied to any non-estrogen substance (often available without a prescription) that is meant to relieve the symptoms of menopause.

These substances are often promoted as panaceas that provide the benefits of estrogen replacement without the risks, but a variety of groups -- including the American College of Obstetricians and Gynecologists (ACOG), the American Medical Association, and the Food and Drug Administration -- have released advisories that bioidentical hormone therapies may be no different from estrogen replacement therapies, in terms of risk.

Duke gynecologist Charles Hammond, MD, says that one of the major safety concerns of bioidentical hormone replacement therapy is that there is no regulation of the manufacture and marketing of these formulas.

“And there’s not one shred of good scientific research that shows these products are any safer or any better than estrogen."

"In fact, there have been a number of papers showing that they sometimes don’t contain the ingredients they say they do. so on the down side they may carry the same risk as estrogen, and on the ‘plus side’ they may not be worth a thing, because you don’t know what’s actually in it.”

Concussions: What to Do After

Mon, 04 Oct 2010 12:55:27 -0400

Although most people recover fully within seven to 10 days after a concussion, how quickly they improve depends very much on how well they take care of themselves after the injury.

Duke neurologist Joel Morgenlander, MD, and neurosurgeon Gerald Grant, MD, say that these tips are helpful to follow after a concussion -- whether you’re a kid or an adult:

Get plenty of sleep at night, and rest during the day. Keep a regular schedule -- no late nights, no sleepovers for kids.
Avoid activities that are physically demanding, require a lot of concentration, or are mentally or emotionally stressful.
Avoid multitasking -- whether that’s watching TV while fixing dinner or fielding multiple messages on your smart phone.
Your reaction times may be slower, so ask your physician when you can safely drive a car, ride a bike, or operate major equipment.
Consider returning to work or school gradually -- start with half-days if possible.
Take only drugs that your health care professional has approved.
Adults: no alcohol
Kids: no video games

After Your Concussion

It’s a good idea to let employers, teachers, coaches, and family members know what’s happened, so they can understand and help you deal with any challenges that arise, whether it’s patience with mild forgetfulness or accommodating the need to take frequent rest breaks.

Mental and physical rest is very important -- in today’s multitasking world, true rest can be a true challenge, but it’s essential to the brain’s recovery.

All in the Game

You don’t have to lose consciousness to have a concussion. If a concussion is sports-related, the injured player should always be evaluated by a health professional.

After a concussion, you should stay off the field -- don’t even practice -- until you are cleared to return to play.

Duke sports injury clinics, located in five Duke Urgent Care centers in the Triangle, can evaluate potential concussions -- as well as tend to other bumps, strains, bruises, and strains.

Energy Drinks: Think Before You Drink

Mon, 04 Oct 2010 14:20:14 -0400

"Red Bull gives you wings,” asserts one TV spot. Some energy drinks sport suggestive names like Amp and Battery, others are more matter-of-fact, such as 5-Hour Energy, which comes in “shots.”

But whether they promise a boost or a buzz, what energy drinks deliver is no great shakes, according to exercise physiologist and dietitian Kara Mitchell, RD, who coordinates both the fitness and nutrition programs at Duke Health & Fitness Center.

“The central ingredients in most of these drinks are caffeine and sugar,” says Mitchell.

Forget those B vitamins some drinks tout as their secret weapon. “There is zero research supporting that these will boost energy -- it’s just the caffeine.”

The herbal ingredient guarana, commonly added to energy drinks, also contains caffeine.

Jitter Juice

A typical cup of coffee has 80 to 135 milligrams of caffeine, but some energy drinks contain two or three times that amount.

When you consider that most fans don’t stop at one little bullet can, but consume several a day, you can understand why energy drinks make nutrition experts a little nervous.

“A little caffeine is not that bad for most people, but you just don’t need that amount in your diet,” says Mitchell, who notes that heavy caffeine consumption increases irritability, raises blood pressure, and heightens the risk of irregular heart rhythms.

“You may also be masking issues like fatigue, not getting enough sleep, that really need to be addressed.”

Bittersweet News

Those seeking to enhance a workout may opt for sports drinks like Gatorade or Powerade.

They’re a safer alternative to energy drinks because they aren’t caffeinated, says Mitchell, but she recommends sticking to the lower-calorie versions and she notes that most people simply don’t need them.

“Sports drinks are meant for athletes to replenish electrolytes. If you’re sweating longer than an hour, these might be a good resource. Some enjoy the drink because it offers hydration with flavor. I have few concerns with people drinking these kinds of beverages, but you should be aware of the sugar and calorie content in the beverage you choose.”

Water + Hype = Expensive Water

Similarly, vitamin-fortified waters (like the aptly named Vitaminwater), also known as “enhanced waters,” are little cause for alarm, especially if the taste encourages you to stay hydrated.

“These may add some flavor,” notes Mitchell, “but they’re no different or better than drinking water and taking a multivitamin.”

One major difference is cost: pennies for the water and multivitamin combo versus nearly two dollars for a 20-ounce bottle of Vitaminwater.

The greatest “enhancement” here is to the company’s bottom line -- and if you opt for the full-calorie version (100 to 125 calories per 20-ounce bottle, compared to 140 calories for a 12-ounce can of Coke), your waistline.

Protein Power Takes a Powder

Protein drinks purport to boost energy and even shore up muscle, but these claims are hard for a fitness and nutrition expert to swallow.

Mitchell explains, “Protein is a source of energy, but it’s the last one; you’re going to burn carbohydrates first."

"Protein does play a role in tissue maintenance, helping the body repair the damage to muscle fibers that occurs during exertion, which is what improves strength and endurance. What gets confused is someone thinking they need to consume more protein in order to build muscle. More calories mean more fat, not muscle.”

If you really feel you need more protein in your diet, you’re better off consuming it in foods like lean meats and legumes. But most people eat plenty of protein, she notes.

“Rarely do I see anyone who needs to increase their protein intake. Most of us eat too much, while we underconsume fruits and vegetables.”

Learn how not to be fooled by food labels at Duke Medicine’s Teer House -- a great educational venue offering nutrition classes.

Gut Check: Test Your Gastro Knowledge

Mon, 04 Oct 2010 14:31:56 -0400

Test your knowledge of a range of common GI complaints. Duke gastroenterologist Rahul Shimpi, MD, helps digest the information.

1. True or false? Diet plays an important role in gastrointestinal complaints.

Often true -- but not always. “though I’m not convinced there’s a dietary link with all things digestive,” says Shimpi, “there are definitely food intolerances like lactose behind a lot of GI symptoms."

"I have patients keep a food diary to see if they can link consumption to their discomfort. Diet definitely plays a role in functional dyspepsia (indigestion), where eating lower-fat foods and smaller, more frequent meals helps.”

2. Celiac disease means the body cannot tolerate:

A. Dairy
B. Beans
C. Protein
D. Gluten

D. Gluten is a specific protein in wheat, barley, and rye that provokes an inflammatory response in people with celiac disease, damaging the lining of the small intestine and causing a range of possible symptoms, not all of them digestive.

Once considered a rare childhood disorder, “celiac disease may affect far more people than we once thought,” notes Shimpi. “Here again, keeping a food diary can be helpful -- and even if a doctor hasn’t been able to pinpoint celiac through testing, if you have relief from symptoms when you refrain from eating wheat, for example, there’s no harm in avoiding these foods.”

3. True or false? Ulcers are brought on by stress or spicy foods.

False. “Most peptic ulcers are now thought to be caused by the bacterium H. pylori or by overuse of aspirin and pain relievers known as NSAIDs, which include ibuprofen and naproxen,” says Shimpi.

Smoking and alcohol use make matters worse, and symptoms may worsen with stress and certain foods, although it is not thought anymore that these factors actually cause ulcers.

4. Which of the following is not true of irritable bowel syndrome (IBS)?

A. It may be triggered by certain foods.
B. It’s related to stress.
C. It’s more of a psychological condition than a physical one.

C. is untrue, though many physicians once believed that IBS was psychosomatic. IBS is a functional bowel disorder, and it is diagnosed by ruling out other conditions that share its symptoms: abdominal pain or discomfort related to frequent diarrhea or constipation.

Stress is a factor GI specialists address in addition to treating the physical symptoms of IBS -- and that goes for other digestive conditions, as well.

“Gastroenterologists do not discount the role stress plays in gastrointestinal health,” notes Shimpi. “We refer people to stress management services, and, not infrequently, we prescribe medications aimed at reducing anxiety and depression.”

5. To relieve constipation, you should:

A. Eat more fiber.
B. Increase your intake of fluids.
C. Increase physical activity.
D. Take laxatives.

All of these will help bring on a bowel movement, but try fiber, fluids, and activity first. “plenty of water, plenty of fiber, and moderate exercise are good for your gut,” says Shimpi.

“Inactivity slows your gut. The benefits of exercise are underappreciated -- at least anecdotally we know that people who exercise tend to feel better and have fewer GI symptoms. Generally speaking, laxatives are okay for occasional use. Constipation that requires regular use of laxatives should be evaluated by a physician.”

6. According to the American Gastroenterological Association, approximately one-third of the U.S. population has gastroesophageal reflux disease (GERD). Why is it so prevalent among Americans?

“The rise in obesity is thought to play an important role in the rise of GERD,” says Shimpi.

“Simply, the increased abdominal pressure from excess weight promotes reflux.” (“Reflux” describes the often painful backflow of stomach acid into the esophagus.) Weight loss, it follows, may bring relief. “Avoiding fatty foods, alcohol, and caffeine, and quitting smoking can help,” adds Shimpi.

Several medications are also effective. “Antacids help ease symptoms, and a class of drugs called proton pump inhibitors (PPIs) are now available over the counter (under the brand names prevacid and prilosec), but avoid prolonged use of PPIs and be sure to talk to your doctor or pharmacist about potential drug interactions.”

7. You attend a dinner party and spend much of the next day with diarrhea and vomiting. Is the culprit a virus, or bacteria?

Food-borne illnesses can come from either one, and “as long as it’s self-limiting, it really doesn’t matter which you have,” says Shimpi.

“If you’re not better in 24 to 48 hours, see a doctor. And if you can’t keep liquids down, you’re at risk for dehydration and may need medical care sooner.”

8. At what point do digestive problems warrant a specialist’s care?

“People should consider seeing a GI specialist if their symptoms are severe, last more than a few weeks, or begin to worsen,” says Shimpi.

Also, see your doctor if you’re having GI problems and also fit any of the following criteria:

Your symptoms began after you turned 50
There is a history in your family of gastrointestinal cancer
Your symptoms are accompanied by weight loss, GI bleeding, difficulty swallowing, or anemia

Relieve Neck Pain With Yoga

Thu, 07 Oct 2010 08:46:52 -0400

Carol Krucoff, a yoga therapist with Duke Integrative Medicine, was an editor and reporter for the Washington Post back when the transition was made from typewriters to desktop computers.

“When they converted to computers, there was little or no ergonomic sensibility,” she recalls. Long periods of sitting with poor posture, aggravated by the tension of constant deadlines, led to chronic neck pain and occasional headaches.

Regular yoga practice made a dramatic impact on Krucoff’s pain -- and inspired her to write about health and wellness issues and eventually train in yoga teaching and therapy. Her recent book, Healing Yoga for Neck and Shoulder Pain, describes the physical and emotional mechanisms behind a common -- and sometimes disabling -- problem.

Here, Krucoff offers helpful guidelines for alleviating pain and improving alignment:

How Forward Holds Us Back

Ideally, the head should be balanced on top of the spine, but our everyday activities tend to drive it forward. “Almost every task we do, working on the computer, driving, picking up our children, cooking, rounds us forward,”says Krucoff.

That awkward head posture, where the head protrudes in front of the shoulders, creates a great deal of tension in the neck and shoulders. “The average head weighs about 10 pounds -- imagine a bowling ball perched forward on your neck for hours. The neck muscles must stay engaged to keep you from falling on your face.”

Add to that precarious posture the physical effects of stress and tension. “We tighten in response to stress; when we’re frightened, a typical startle reaction is that our shoulders jump up to our ears. Many of us live in a chronic tension state, and this physical reaction becomes habitual -- no wonder so many people are walking around in pain.”

Tweak Your Settings

Modest adaptations to the spaces we inhabit most can help reduce harmful postures. Krucoff uses an editor’s desk, which angles her paperwork upward for optimal viewing, resulting in less craning forward on her part.

“Look for ways to make your environment support what you’re doing,” says Krucoff. “I worked with a chemist who was using a microscope that she really had to contort her body to use. After a couple of years, she had terrible back and shoulder pain.” Part of the solution? A step stool. “It was simple, but it made a big difference.”

Bad Breath?

Deep, full breathing can enhance posture and promote relaxation -- and it doesn’t always come naturally. “Perhaps the single most important thing I do is help people relearn how to breathe properly,” says Krucoff.

“Infants are masters -- watch a baby breathing, and you’ll see the belly rise and fall with the breath. But many people forget this with age and become shallow chest breathers, sucking in their stomachs."

"Singers and musicians who play wind instruments are among the few who recognize that a full deep breath goes into the deepest portion of the lungs, so that the belly rounds and the rib cage expands. It also really brings you into the present moment.”

Pay Attention

That state of present awareness is the foundation of yoga, which Krucoff describes as “a discipline of getting to know yourself. It teaches being present in the moment and noticing what’s going on in your body, mind, and spirit.”

She suggests these simple initial steps to help heighten awareness of how tension is affecting the body, especially the neck and shoulders:

Lie down or recline comfortably in a chair and find your breath, observing the body’s sensations as you breathe in and out.
Pay exquisite attention to your body, especially your upper body. Identify any areas of discomfort or tension and see if you can relax and release them.
Recall a distressing memory and notice what happens in your face, neck, mouth, shoulders, back, belly, and breath as you mentally relive it. Make note of your discoveries.

Recognize that the stressful event isn’t really happening; just thinking about it is enough to create these effects in the body.

Creating self-reminders can help counter them, says Krucoff. “Tell yourself, ‘Lips together, teeth apart,’ or, ‘Shoulders relax’ -- Cues that help break those habitual patterns of tension.”

Movement as Medicine

Krucoff’s book outlines a series of yoga-based activities to ease neck and shoulder pain, but you need not be an experienced practitioner to benefit. Yoga is accessible to everyone, Krucoff emphasizes.

“A common excuse I hear is, ‘I’m not flexible enough,’ but it’s not just for the fit and flexible. I teach yoga to seniors regularly; if they can’t get down on the floor, they can practice sitting in a chair. Yoga is about balance and union -- about strengthening what’s weak, stretching what’s tight.”

It doesn’t have to require a huge time commitment, either. “Even a five- to 10–minute daily practice can help you relieve pain and enhance health. Yoga helps us reconnect with body, mind, and spirit -- and then we take those lessons off the yoga mat and into daily life.”

The New Arithmetic: 5-3-2-1-Almost None Equals a Healthy Lifestyle

Tue, 05 Oct 2010 15:46:49 -0400

One in three children in North Carolina is overweight -- and overweight kids are more likely than their normal-weight peers to suffer from health problems and social isolation.

Pediatricians Sarah Armstrong, MD, and Michelle Bailey, MD, say Duke’s Healthy Lifestyles Program helps kids and families find opportunities to be healthy and active, using their strategy of 5-3-2-1-almost none.

Eat at Least Five Fruits and Vegetables Every Day

Fresh fruits and veggies can be expensive, but frozen or canned foods are healthful alternatives that still have nutritional value.

Fruit packed in juice or (better yet) water is much lower in sugar than the fruit packed in syrup.

The Healthy Lifestyles program encourages five different kinds of fruits and vegetables every day, but the portion size depends on how old you are and how active you are. In general:

A five-year-old boy needs:
One and a half cups of fruit and one and a half cups of veggies

A 10-year-old girl needs:
One and a half cups of fruit and two and a half cups of veggies

A 15-year-old boy needs:
Two cups of fruit and three and a half cups of veggies

An adult needs:
Two cups of fruit and four cups of veggies

Eat Three Structured Meals Every Day

Eat together as a family as much as possible. Kids who eat meals with their families tend to eat more healthy overall, do better in school, and communicate better with their parents.

Serve food on plates instead of family-style, and cancel the “clean plate club” -- so that children can learn to eat when hungry and stop when satisfied.

When eating out, avoid all-you-can-eat buffets and combo meals, both of which almost always mean oversized portions.

Keep "Screen Time" to Two Hours a Day or Less

Children who eat while watching TV typically take in 400 to 600 more calories a day than children in families that do not eat with the TV on.

Get and keep the TV and computers out of the bedrooms, including your own -- they lead to more screen time and less sleep.

Don’t keep the TV on as background noise. Make a schedule and help your kids prioritize what they watch.

Treat TV and computer game time as a treat. Have your kids “earn” time for playing video games by doing their chores, their homework, or other positive things around the house.

Be Active for One Hour Every Day

Set a good example by exercising yourself.

Be active together as a family. Assign active chores like raking leaves, washing the car, or vacuuming.

Remember that activities don’t have to be team sports, and they don’t have to include expensive equipment. Walking, hiking, jump rope, Frisbee -- the options are endless.

Use TV time as an opportunity to get moving. Try jumping rope or doing jumping jacks during commercial breaks!

Almost None: Avoid Sweetened Drinks and Foods

Make water the go-to beverage for the whole family.

Juice has a lot of calories and sugar -- one cup a day is enough for anyone, no matter what the age, and kids under six should have no more than six ounces.

Sweetened beverages should be for special occasions only -- and watch the refills at restaurants.

Coughing 'til Morning, Parents Take Warning: Asthma Can Sneak Up on Some Kids

Wed, 06 Oct 2010 09:23:47 -0400

Kids and Cough

They go together like, well, kids and cough. A cold, the flu, even seasonal allergies can set kids off on a coughing binge that lasts forever -- or so it can seem to parents. Eventually, the nagging cough will cease. Until the next cold.

But what about the cough that really, truly doesn’t go away?

“Coughing -- especially coughing at night -- can be a symptom of asthma in children,” says Gregory Metz, MD, of Duke’s Division of Pulmonary, Asthma, and Critical Care Medicine. “In fact, sometimes it is the only one. For this reason, asthma in children often goes undiagnosed.”

Sneaky, Sneaky

Most parents know that wheezing and shortness of breath are telltale signs of asthma. But a cough is easy to chalk up to last month’s cold. “A prolonged cough that persists after the other cold symptoms have disappeared can point to asthma,” says Metz.

Exercise-induced asthma can be just as sneaky, especially in adolescents. “With exercise-induced asthma, there may be no symptoms outside of exercise,” says Metz.

“But during exercise or a few minutes after the child cools down after exertion, there can be coughing and wheezing.” Because the symptoms don’t last, kids often don’t report them, but Metz says that over time, this undiagnosed asthma can limit that child’s activity.

Wheezing in the USA

Studies suggest that rates of asthma have increased dramatically in this country in recent years. According to the Centers for Disease Control, about seven million children in the United States under the age of 18 had asthma in 2008. Metz estimates that number to be about 10 million today.

“Nobody completely understands the reason for the increase,” says Metz. “It probably has to do with genetic susceptibility and environmental factors -- that is, changes in how we live.” These changes might include moving from rural to urban settings, changes in air quality, changes in our housing, and exposure to new allergens.

One of the most interesting explanations for the nation’s increase in asthma in this country is the hygiene hypothesis. It goes something like this: When a baby’s immune system is exposed to germs it learns to act as an immune system should -- fighting infection.

In developed countries, environments have become cleaner, and there has been a reduction in childhood illnesses. And in the absence of the pathogens it evolved to fight, the immune system begins responding to things that it’s not supposed to be fighting, such as allergens in the environment or foods.

Although the hygiene hypothesis is unproven, the risk factors for developing childhood asthma are well accepted. They include family history, exposure to cigarette smoke, and presence of allergies, says Metz.

What You Don’t Know Can Hurt You

The bad news is that if asthma goes undiagnosed, it can ultimately affect lung function. “Prolonged, untreated asthma can lead to changes in the anatomy of the lungs and predispose you to lung problems,” says Metz. “That can mean exercise limitations, more respiratory illness, and asthma flares.”

There are other conditions that can lead to wheezing, including acid reflux, chronic nasal allergy, vocal cord dysfunction, and, rarely, foreign body aspiration.

To reach a diagnosis of asthma, a physician will take a patient history and conduct a physical exam, as well as perform noninvasive lung function tests in children who are old enough (typically five or six).

If asthma is diagnosed, says Metz, the physician will recommend treatment such as rescue inhalers for exercise-induced asthma, or preventive inhaled steroids to decrease inflammation.

“I think a lot of parents are surprised that their child’s chronic cough is caused by asthma, but they’re also surprised at how dramatically better the child can get with treatment.”

Brain Savers

Wed, 06 Oct 2010 09:59:35 -0400

For most of her life, Caroline Niblock had taken medication daily that affected her cognitive abilities, but controlled her seizures. It was a trade-off she had no choice but to accept.

Niblock, 40, had been born with a brain arteriovenous malformation (AVM), a tangle of abnormal, weakened blood vessels. AVMs can cause not only seizures but bleeding in the brain (hemorrhagic stroke), neurological injury, even death.

Since age 16, she had been on medication to control seizures caused by the AVM, the effect of which, she says, was like a “wet blanket over my brain.” And because of the increased risk of hemorrhage, her doctors advised her not to become pregnant.

Big Hammer, Tiny Nail

When Niblock was a child, her doctors had attributed her seizures to a fall: At two years old, she looked out a window and saw her grandfather drive up. She banged her tiny hands on the window screen to get his attention, and ended up on the gravel driveway two stories below. It was not until she was 16 that the real culprit, the AVM she had been born with, was discovered.

As an adult, Niblock searched for a neurosurgeon who could help her -- and moved ahead with her life. “I consider myself lucky,” she says. “I graduated from college, I played sports, I didn’t have other health issues.”

But still, the wet blanket. “The medication is like a big hammer on a tiny nail,” says Niblock. “It calms the seizures, but there were also cognitive effects for me. When I started taking the medication, even my teachers noticed a difference in my cognitive abilities.”

And there was the constant risk of rupture. Each year that went by meant about a four percent increase in her risk of stroke.

What You Wish for

Niblock continued to see neurosurgeons over the years, asking about her candidacy for surgery. “They all said the risks outweighed the benefits,” she says, but she persisted.

In July 2009, Niblock heard something unexpected: there was something else, something new. Go see Dr. Kirkpatrick at Duke Radiation Oncology.

John Kirkpatrick, MD, PhD, was using the Novalis Tx to deliver radiation treatment to brain tumors and other lesions in the brain. In fact, just one year earlier, Duke had become the first medical center in the world to begin using the new stereotactic radiosurgery technology.

The Novalis Tx works by delivering high-energy, precisely shaped beams of radiation to the lesion from multiple directions. This allows the physician to target the lesion with extraordinary precision.

“They were enthusiastic,” says Niblock. “They told me that the technology had caught up with my AVM. And my reaction was, ‘Oops, I’m not prepared for this!’” Her persistence had paid off, but the path she had been on her entire life suddenly turned.

“I was shocked because this was the first time anyone had said the AVM could be treated safely,” she says. “But Dr. Kirkpatrick took his time to make sure I understood the whole process and all risks involved. His professionalism and wealth of knowledge made me feel very assured about the decision I made to go ahead with the treatment.”

The Team Grows

Before the treatment, there was important preparation to be done. Niblock’s team of caregivers would now include neurosurgeon Ali Zomorodi, MD.

Through an embolization -- basically plugging the vessels supplying the AVM using a groin puncture -- Zomorodi dramatically reduced the size of the lesion.

Kirkpatrick would have a much smaller, better-defined area to treat, and Niblock would have a reduced risk of side effects.

“You never know what you’re going to get after an embolization,” says Kirkpatrick. “An AVM is like a bird’s nest of vessels. The procedure can leave it even more irregularly shaped than before, and that was true in Caroline’s case.”

But as it turns out, an irregular shape was not a problem -- at least not the type of problem it used to be. “In the past, we would have had to use a bigger radiation field,” says Kirkpatrick. “Now, we paint only the area we want to treat. It’s incredibly precise.”

The radiation treatment in January 2010 was surprisingly easy. “It took about an hour. I was awake, listening to music,” she says. “I had a mild headache for a couple of days and that was it.” She also had some hair loss at the radiation site.

So Much to Look Forward to

Although Kirkpatrick will continue to watch Niblock, he does not foresee more treatments or problems. Her future now includes a greatly reduced risk of stroke, and more.

Pregnancy now could be an option for her, and Niblock can also look forward to a new way of thinking. “I will taper off my medications over the next two years,” she says.

“The wet blanket will be gone. Plus, the treatment means the AVM won’t monopolize the blood flow in my brain anymore. To be rid of this AVM, and off medication that I have been on since age 16, is a very good thing and I am excited about the future.”

Who Needs a Mammogram?

Thu, 25 Mar 2010 09:50:23 -0400

On November 16, 2009, the U.S. Preventive Services Task Force (USPSTF) recommended new guidelines on screening for breast cancer, including mammography and breast self-exams. The guidelines were met with considerable debate. “Very smart, reasonable people review evidence and see different things,” says Duke breast oncologist Gary Lyman, MD.

New guidelines, new controversies— just give us the facts, please!

“Any recommendations regarding screening -- whether for breast cancer, prostate cancer, lung cancer, or others -- are going to be met with differing opinions because the recommendations ultimately are based on differing value judgments,” explains Duke radiologist Daniel Sullivan, MD, who was a member of the 1997 NIH Consensus Panel that considered this same question (whether or not to recommend breast screening for women ages 40 to 49). “What is important to one person may not be as important to another, in terms of risks and benefits.”

“It is a complicated and complex issue and many well-respected experts have strong opinions,” says oncologist Amy Abernethy, MD, who heads the Duke Cancer Center Research Program.

While physicians and researchers will most likely continue to debate the issue, there are a few questions that women can get answers to now:

The discussion and debate regarding mammography guidelines can be confusing. What do the experts agree upon?

According to Lyman, Sullivan, and Abernethy, there are several points that most physicians seem to agree upon:

No screening test is perfect, and we always need to develop better ones.
Although we have made progress in our knowledge of breast cancer, we need to know more so that we can prevent occurrence. Until that time, we must continue our quest to determine how to treat every woman’s breast cancer in the most effective way possible.
Without a doubt, every woman should be familiar with her own breasts and should report any changes or concerns to her physician.
Each woman should talk to her physician about mammography and should be allowed and encouraged to make her own decisions about whether or not to have a mammogram.

What do the new USPSTF guidelines recommend?

In terms of traditional mammography, the task force recommends against routine screening mammography in women ages 40 to 49; their guidelines say the decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take into account the patient context, including her judgement about specific benefits and harms.

For women ages 50 to 74, the task force recommends mammography screening every other year. The task force also concluded that there is not sufficient evidence to warrant screening mammography for women 75 years and older.

The task force concluded that there was also insufficient evidence to warrant clinical breast exams and also recommended against clinicians teaching women how to perform breast self-exams.

Lastly, the task force concluded that there was insufficient evidence to assess the potential benefits and risks of digital mammography or magnetic resonance imaging (MRI).

What mammography guidelines do other organizations recommend?

Many groups -- the American College of Radiology and the Society of Breast Imaging, the American Cancer Society, the American Medical Association, the National Comprehensive Cancer Network, the Canadian Task Force on Preventive Health Care, and the American College of Obstetrics and Gynecology -- recommend that women ages 40 to 49 continue to have yearly or every other year mammograms.

The American Academy of Family Physicians recommends that decisions about mammography in women ages 40 to 49 should be based on an individual’s risk for breast cancer, while the World Health Organization recommends mammography every one to two years for women ages 50 to 69.

Do the new USPSTF guidelines deny any woman the ability to get a mammogram?

No. The task force doesn’t say that women should avoid mammograms. Instead, the task force “encourages individualized, informed decision-making about when to start mammography screening.”

The recommendation against routine annual screening does not apply to those women who are at an increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation.

Will insurance continue to pay for mammograms for women ages 40 to 49?

Most likely. On December 3, 2009, the Senate approved an amendment to its health care reform legislation that would require health insurers to cover mammograms for women ages 40 to 49. At the time of this article’s publication, the health care reform bill was not yet final.

What is the USPSTF?

The U.S. Preventive Services Task Force is sponsored by the Agency for Healthcare Research and Quality, part of the U.S. Department of Health & Human Services.

The task force makes recommendations about which preventive services for numerous diseases should be incorporated routinely into primary medical care and for which populations. The task force does not set federal policy and it does not determine what services are covered by the federal government.

Who are members of the USPSTF?

The USPSTF is a task force that comprises physicians specializing in a variety of areas, including epidemiology, internal medicine, and family medicine. View a complete list of task force members and their credentials.

What Puts a Woman at High Risk for Breast Cancer?

Tue, 23 Mar 2010 15:17:20 -0400

Victoria L. Seewaldt, MDHer sense of humor. Her impeccable timing. All 12 place settings of her wedding china. Of all the things you may hope to inherit from your mother, breast cancer isn’t one of them. But if she had it, aren’t you more likely to get it?

Not necessarily, says oncologist Victoria Seewaldt, MD, who directs Duke’s High-Risk Breast Clinic. “Breast cancer is a disease of aging and of just being female. Aging puts all women at risk. Having a mother who had breast cancer doesn’t automatically increase your likelihood -- a lot depends on her age at its onset, how many other relatives had breast cancer, and what type of cancer it is.”

The best way for a woman to determine her personal risk of breast cancer is to talk with her physician. Some of the things that might signal high risk include:

A family history of breast cancer that was diagnosed before menopause
A family history of ovarian cancer or breast cancer in a male relative
Prior abnormal biopsy

For women who are determined to be at high risk for breast cancer, Duke’s clinic offers screening and individualized prevention plans that may include medications such as tamoxifen. “We also work on diet and exercise,” notes Seewaldt. “We think that’s very important.

“It’s very easy, very human if you have a mother who has had breast cancer to think it’s inevitable,” says Seewaldt, “but at the High-Risk Breast Clinic we work really hard to help women understand they’re not automatically fated to get it.”

What About the "Breast Cancer Gene"?

A mutation in the BRCA1 and BRCA2 genes is the most common cause of hereditary breast cancer, though it accounts for only around 5 percent of all breast cancers, says Seewaldt.

The presence of the mutated gene can be detected through testing, so women with a strong family history of breast cancer may opt to find out if they have it, but Seewaldt says that decision is a very personal and individual one.

“We do offer testing, but before that we urge genetic counseling to help women decide if the test is appropriate for them.” Genetic counseling is also crucial in helping people interpret the results and make decisions about what measures to take, if any.

Going the Distance: How to Keep Your Body Safe When You Tackle Extreme Sports

Tue, 23 Mar 2010 14:59:57 -0400

In May of 2009, artist Lisa Oakley went out to dinner with a group of friends. “My friend Julie said, ‘Are you up for a big adventure?’ I must have been; I said yes first, then asked, ‘What is it?’”

Julie proposed that the friends take part in the Avon Walk for Breast Cancer in Charlotte that October, a two-day, 39-mile walk to raise funds for research and treatment. Oakley’s work as a glass artist is more physically demanding than the average office job, but regular exercise “went away with little kids,” she says. Still, she was game. “I figured I probably couldn’t run a marathon, but walking that distance felt like something I could do.”

In the past, extreme endurance sports such as marathons, triathlons, and long-distance cycling and hiking events were the purview of pure athletes -- fund-raising, cause-centered events used to be primarily 5K or 10K walks and “fun runs.”

But in recent years cause-related athletics have ventured into the realm of extreme sports, such as the Avon and Susan G. Komen foundations’ breast cancer walks (39 and 60 miles, respectively) and Team in Training events, which raise money through marathons, half-marathons, triathlons, 100-mile bike rides, and hiking adventures to support blood cancer research and patient services.

This trend significantly ups the physical ante for amateur participants who are dedicated to supporting their cause. David Berkoff, MD, who specializes in emergency medicine and sports medicine at Duke, says such events can really coax people off their couches. “I think it’s great. I’m seeing a lot of people that I would never have picked out of a lineup who are going to run a marathon.”

However Berkoff, himself a triathlete and distance cyclist, cautions newcomers to be aware of the rigors and risks of training and competing. “People are suddenly doing huge amounts of miles, and they may not be ready. You’d think these folks would slow down or stop when they get hurt, but they’re as committed to the cause as some athletes are to the race.”

Proper Planning for Peak Performance

Duke sports medicine experts David Berkoff, Priscilla Tu, and Andre Grant offer training tips that endure.Long distance runners, walkers, and cyclists face risk of injury to their bones, joints, and muscles from both accidents and chronic overuse. “Competition adds intensity,” says Duke family and sports medicine physician Priscilla Tu, DO. “There’s a much greater chance of injury -- your adrenaline’s kicking in, and you may not listen to your body.”

“I see a lot of knee injuries in my practice,” says Duke orthopaedic surgeon Andre Grant, MD, noting that different bodies are prone to injury in different areas. “Calf and hamstring problems are more common in men, whereas women experience more hip and pelvis problems.”

Ignoring pain or not giving the body enough recovery time can have long-term consequences. “We see patients who had an injury but kept pushing through the pain, and now they have a chronic problem,” says Berkoff. “They got a massage rather than seeing a doctor, when maybe we could have turned things around six months ago.”

“Let pain be your guide,” adds Grant. “If something doesn’t feel right, take time out, have it evaluated, and allow it to heal.”

Thoughtful training is key to preventing injuries. “The preparation has to be done over an extended period of time,” says Grant. “Don’t get off the couch a month before the race and expect to avoid injury. Probably the main reason people get injured is they increase their distances too quickly.”

And the greater the distance, says Grant, the more mindful you should become. “We’ve seen in the sports medicine literature that the risk of injury increases significantly once you’re logging over 40 miles a week.”

Oakley and her friends trained from May to October for the two-day, 39-mile walk, according to guidelines provided by the event’s organizers. Still, she admits, “we didn’t train for the long distances as much as we needed to. It was a huge time commitment -- our husbands weren’t always willing or able to give us all day Saturday and Sunday.”

The farthest distance they had reached before race day was 20 miles, but day one of the event was a 26-mile trek. “Around 21 miles was a near-breaking point for everyone,” she recalls. “I was having some foot pain. I probably should have stopped, but I had raised almost $2,700, I had told people I was going to walk 39 miles--I was going to walk. I was thinking about the women who went through chemo; they couldn’t stop just because they got tired!”

She completed the 26 miles and then spent about three hours in the medical tent, “nauseated and freezing cold. Then the next day I went on out and walked the last 13 a mile at a time.”

Endurance Events: Tips for Beginners

Check with your doctor: Before you start intense training, your doctor should make sure your heart is healthy and that your program won’t worsen existing conditions, like asthma or previous injuries.
Follow a training program: Many cause-affiliated events provide support and instruction to help participants prepare safely. A good rule of thumb for training safely is to increase your mileage no more than 10 percent each week.
Cross-train: Integrating different aerobic activities and a strength- training routine into your weekly workouts will engage different muscle groups and is a great way to ward off overuse injuries--and improve overall conditioning, as well.
Gear up: “The right gear and clothing are important considerations,” says sports medicine physician Priscilla Tu. “You need to get shoes with proper shock absorption and proper foot support, or you can really damage your feet and lower extremities.” Understanding the type of surface you’re walking or running on is also important. “Someone older who may already have bone loss could risk a stress fracture walking or running on concrete or asphalt, for example.”
Check the weather conditions: “Especially if you’re predisposed to heat illness, you need to understand how to properly hydrate yourself,” says Tu. And exercising in frigid weather requires warm, breathable layers of clothing to prevent hypothermia or frostbite.
Don’t go it alone: Extreme walker Lisa Oakley says she could never have gone the distance without her friends urging her along. “It’s a big bonding thing.”

Leg Pain: When to Worry

Tue, 23 Mar 2010 16:51:35 -0400

Leg cramps are uncomfortable, sure, but most of us discount them. After all, it’s hard to get worked up about a condition commonly known as a “Charley horse,” for which your mother might tell you to eat more bananas.

But when leg pain starts regularly stopping you in your tracks, it’s time to take it seriously.

“Leg pain is like back pain in that millions suffer from it,” says Duke cardiologist Manesh Patel, MD. “Most assume that all leg pain is musculoskeletal or nerve-related, but people need to know that some forms of leg pain can be the first sign of heart disease.”

Claudication is the medical term for leg pain that happens during activity. “Most describe the pain as a cramp, occurring while walking, that is relieved with rest,” says Patel.

When such leg pain occurs each time you engage in exercise or movement, and it stops soon after you stop, it could be a sign of peripheral arterial disease, or PAD.

When Good Vessels Go Bad

PAD occurs when major blood vessels that supply blood to the limbs and other important areas of the body become partially or completely blocked by the buildup of fatty deposits.

Physicians Manesh Patel and Cynthia Shortell explain how leg pain may signal heart disease.This hardening and narrowing of the blood vessels, called atherosclerosis, occurs throughout the body, but in patients with PAD it can show up as leg pain, says Patel. “The more you use your muscles,” he explains, “the more blood flow you need, but that flow becomes restricted due to the buildup,” resulting in a cramping sensation.

“Unfortunately,” says Patel, “people who have this condition tend to dial down their physical activity to avoid the pain,” instead of seeking the advice of their physician. That can be a dangerous move, because people with PAD -- particularly smokers and diabetics -- are at risk for a lethal heart attack or stroke, and some severe cases can lead to limb loss.

Clearing the Channels

The risk factors for PAD are much the same as those for heart disease: obesity, high blood pressure, high cholesterol levels, smoking, and diabetes. And, like heart disease, there are many things that can be done to slow the progression of PAD, especially when it is caught early.

“We can successfully treat PAD,” Patel emphasizes. “We can reduce the risk of complications, and we can also help relieve your symptoms, but you need a diagnosis.”

That means taking recurring leg pain seriously, especially if you have the risk factors for PAD and heart disease. “If you get calf, buttock, or leg pain when you walk, requiring you to stop and rest, ask yourself: ‘What would I do if this was chest pain?’ You would probably get it checked out, even if you thought it might just be heartburn or reflux. This could be your equivalent of chest pain.”

Now What?: After a Diagnosis of PAD

What’s most important about having peripheral artery disease (PAD) isn’t the PAD itself -- it’s what it says about your risk for other, life-threatening conditions.

Cynthia Shortell, MD, head of vascular surgery at Duke, says that being diagnosed with PAD means one thing for certain: you’ve got atherosclerosis -- otherwise known as hardened arteries. “And you should definitely seek treatment and evaluation for that,” she says, as it’s a major risk factor for heart disease and stroke.

But she says that PAD is not, in and of itself, a condition that requires aggressive treatment in all people. Choosing treatment (or not) often depends on how much your symptoms interfere with your life.

In those with mild to moderate symptoms, Shortell says three therapies are most often recommended:

Smoking cessation: better blood flow in the limbs is one of many benefits to smokers who quit.
An exercise routine, which can be as simple as a daily walk, is a very effective way to build new vessels and improve circulation -- when the routine is maintained, of course.
In some patients, medications can be useful, but they do have important side effects that should be weighed carefully with your physician.

For people with severe symptoms -- persistent, debilitating leg pain or wounds that won’t heal -- surgical procedures can open up the blocked veins. These are similar to the procedures used to open blood vessels in patients with advanced heart disease: opening a blocked vein by placing a balloon or stent into the vessel, or performing a bypass, using vein taken from the patient’s thigh.

Shortell says that for most patients with claudication, deciding to have one of these surgical procedures is not unlike the decision to have knee replacement surgery. “It’s a quality-of-life decision,” she says.

The effects are long-lasting, but not permanent -- so in younger patients, or patients who have health problems that may require a bypass surgery later on, physicians often advise delaying extensive surgical treatment for as long as possible.

“We usually reserve bypass for very severe cases -- such as those where, if you don’t do something, the patient may lose his leg.” But she notes that very few people -- fewer than 5 percent -- will actually lose a limb due to PAD. Diabetes, kidney disease, and smoking are the main reasons that PAD could become a limb -- and life -- threatening condition.

Diet Soda: Too Good to Be True?

Wed, 24 Mar 2010 10:15:13 -0400

Fizzy, sweet, and calorie-free -- it has to be too good to be true, right?

Diet sodas have gotten a bad rap pretty much since their introduction to the marketplace. Fears that caffeine and artificial sweeteners cause cancer or that the carbonation would somehow leach the calcium from our bones have been long ago shelved, but these days some research points to possible links between diet soda consumption and increased risk of weight gain, metabolic syndrome, and yes, osteoporosis.

Thirsty for more knowledge? Duke experts weigh in on whether those links are strong enough to merit giving up a beverage that many cherish as a guilt-free indulgence.

A Dieting Detour?

The claim: Diet sodas will make you gain weight, possibly because the artificial sweeteners perpetuate your craving for sugar.

Duke physicians Howard Eisenson, Thomas Weber, Ann Brown, and Lillian Lien weigh in on the diet soda debates.Howard Eisenson, MD, executive director of the Duke Diet & Fitness Center, says there’s just not enough evidence to support that.

“The data are conflicting and limited. If there’s an association with increased weight, it could simply be because overweight people are drinking diet sodas, or because people who are drinking them are compensating for those calories elsewhere.”

In other words, you may rationalize eating a candy bar since you’ve been drinking diet soda all day -- a psychological effect rather than a biological one.

Eisenson says the basic principle of weight loss is “simple, but not easy: calories in, calories out. Here at the Diet & Fitness Center, where the diet is controlled, we help keep people within their caloric range by offering diet drinks and artificial sweeteners. We say, if you must drink soda, make it a diet -- but water should be the beverage of choice for adults, and for kids, water, low-fat milk, and very limited consumption of juice.”

Bones of Contention

The claim: Diet sodas may increase your risk of osteoporosis.

There’s no validity to the old claim that the carbonation in soda somehow robs the body of calcium, but all colas and some other types of sodas contain the flavoring agent phosphoric acid, a substance that may account for soda’s link to an increased risk of osteoporosis. A 2009 study showed an association between regular intake of colas and negative effects on bone.

“This is not an area that is rife with evidence,” says Duke osteoporosis specialist Thomas Weber, MD. “We need more studies, but so far the data show that an excessive intake of carbonated beverages, especially cola, appears to have somewhat of a detrimental effect on bone health. There is potentially a biological basis: if the increased acid load from soda exceeds what the kidneys can take on, the body looks to other buffers, so bone is tapped as well.”

The body may attempt to neutralize the excess acid by using calcium culled from the bones.

That theory is far from proven, though, Weber notes. The relationship between cola and bone could be from displacement -- devoted soda drinkers may not be getting enough bone-strengthening nutrients such as calcium and vitamin D if they’re not drinking milk, for example.

“My advice to patients is that most things in moderation are not going to be harmful. Those who drink five, six, seven sodas a day, that’s probably where the negative impact is.”

A Sobering Association

The claim: Diet soda contributes to metabolic syndrome.

A study published in 2008 tracking the health and diet of more than 9,500 men and women over the course of nine years produced a surprising piece of data: Participants who drank one can of diet soda a day had a 34 percent higher risk than those who drank none of developing metabolic syndrome, the name given to a collection of risk factors for heart disease and diabetes.

Duke endocrinologist Ann Brown, MD, says that, although the recent study did show an association, “the finding was unexpected and calls for further investigation.” She emphasizes, “There is currently no evidence that diet sodas cause metabolic syndrome.”

Lillian Lien, MD, a Duke expert on metabolic syndrome, affirms there is still a lot to learn. “Metabolic syndrome is a constellation of factors,” including waist size and blood sugar levels, so anything that’s going to increase the number of calories consumed could contribute to it. “If someone proved that there was a link between artificial sweeteners and an increased intake of calories, that could help explain the diet soda connection.”

Otherwise, the relationship between the two remains circumstantial for now.

The link between drinking regular soda and weight gain, however, is “pretty dramatic,” says Lien. “People are not aware of the calories they’re drinking. Bottom line is that I’m still drinking diet sodas. I gave up the regular stuff a long time ago and drink a lot of unsweet tea, but that gets a little boring, so if I see a diet drink, it may be a reasonable alternative until proven otherwise. More research is definitely needed.”

Metabolic Syndrome: What’s That?

Metabolic syndrome is a group of conditions that, when taken together, are a strong indicator of a person’s risk of diabetes, heart disease, or stroke. And it’s on the rise: the American Heart Association (AHA) reports that 50 million Americans have the condition.

According to the AHA and the National Heart, Lung, and Blood Institute, a person has metabolic syndrome if he or she has three or more of these components:

High waist circumference, based on your gender and ethnicity
High blood levels of triglycerides or low levels of HDL (“good”) cholesterol
High blood pressure
High fasting blood sugar levels

These factors can all be measured at your routine visit to your doctor. If you have metabolic syndrome, your primary care physician can discuss how to treat the condition, through changes in behavior or other approaches.

Stalling the Early Birds: Preventing Preterm Births

Tue, 23 Mar 2010 16:54:16 -0400

Amy P. Murtha, MDOne of the most curious and disturbing trends in American health is preterm births, which are on the rise in the United States -- up 36 percent since 1984, according to the U.S. National Center for Health Statistics.

Preterm births, defined as births occurring before the 37th week of pregnancy, are risky for mothers and newborns alike. “For the moms, there are risks in the treatments used to try to halt labor and risks of infection,” says Duke obstetrician Amy Murtha, MD, a specialist in high-risk pregnancies.

For the baby, there are a whole host of concerns that range from the immediate to the lifelong: lung and breathing disorders, problems with vision, and even cerebral palsy are much more common in these babies than in those who go full term.

“And even when the babies turn out OK,” says Murtha, “the costs and stress to families from weeks spent in the NICU can be huge.”

The most common immediate cause for preterm birth is early onset of labor, and the majority of those cases are the result of medical interventions -- situations where the health care provider must treat dangerous conditions in the mother or the baby, and that treatment triggers early labor.

In these situations, says Murtha, there’s sometimes more serious risk to the mother or the baby without intervention than the risks of early delivery itself.

But about 40 percent of cases of early labor are spontaneous, and determining why such preterm labor occurs is a complex puzzle.

“Several different factors may be in play, even in one patient,” says Murtha. “We’re working really hard in the lab to understand the whys behind preterm birth. There’s a lot related to inflammatory response -- you’ve had an infection, you smoke, you’ve had bleeding -- and the consequences of that inflammation,” which scientists believe may harm the tissues in the womb that nourish and protect the fetus.

Researchers are also finding some cases of bacterial infection that has been missed in routine testing during pregnancy. “These bacteria may turn out to be very important, perhaps ultimately something we screen for and treat.”

Delaying Gratification

To help more moms carry their babies to full term, prevention is the key. For the most part, that means moms-to-be doing everything they can to stay healthy before and during their pregnancy.

“Smoking and weight play a role in preterm birth, so there are things mothers can do,” notes Murtha.

But the biggest risk factor of all is prior preterm birth. “The risk of preterm birth is double among these women, and it goes up with each preterm birth that follows.”

For women who have had prior preterm births, a synthetic version of the hormone progesterone called 17P, which is given as a weekly shot starting at 18 weeks, has shown a 35 percent reduction in preterm births.

In 2006, the North Carolina General Assembly funded the 17P Project to educate health care providers and consumers about 17P and provide it free to low-income women.

But Murtha, who serves on the 17P Project’s advisory council, says she balances her counseling to patients about 17P because the long-term consequences of using this drug are not known. In the lab, she and her colleagues are taking a careful look at how the progesterone may play a role in protecting the tissues that surround and nurture a growing fetus.

“It probably protects the cells in these tissues from cell death,” she says, adding, “We don’t have a lot else to offer these women beyond close monitoring, so this treatment option is significant.”

Protecting Preemies

Ronald N. Goldberg, MDSome babies seem determined to come early despite all efforts to keep them in the womb to term. When preterm birth is inevitable, the focus shifts from prevention to maximizing the baby’s readiness for the world.

“We’ll give steroid injections to promote lung maturity and prevent those respiratory complications,” Murtha says. The steroids are intended to help prevent or minimize other common complications in premature babies, such as bleeding in the brain or intestinal complications.

“We have an incredible obstetrical team here at Duke,” says Ronald Goldberg, MD, who directs the Neonatal ICU. “We do well in large part because the obstetricians give us babies in better shape. What happens up to delivery makes all the difference in terms of the outcome.”

Nurturing the Neonates

Post-delivery, Goldberg and the rest of the Duke Neonatal Intensive Care Unit (NICU) staff use a variety of tactics to protect fragile preemies and help them thrive. The Duke team is part of the neonatal Research network, which reviews and develops evidence-based, “best practice” standards for the many issues that face premature babies, including:

Better breathing: By adopting a more consistent, standardized approach to getting infants off the respirator quickly, Duke significantly decreased the incidence of chronic lung disease in babies born with respiratory problems. An ongoing study is also showing positive prospects for less-invasive options for keeping the airways open and promoting healthy breathing patterns.

A technique called high-frequency ventilation, which tends to be gentler to the lungs, has also come into practice, thanks in part to safety protocols defined by Duke researchers.

Protecting tender skin: The skin of premature infants is so fragile that attaching monitors could tear it, leading to infections. Duke neonatal nurses developed a skin care team that has succeeded in largely eliminating these skin problems.

Dampening sound: Current studies pointing to the damaging effects of noise on the development of preterm infants are making noise reduction a priority in the NICU.

Involving parents: “We’re now allowing the parents to participate in the medical team’s rounds,” says Goldberg. “They can listen, ask questions, and get instant feedback.”

Correcting the Curve: New Approaches to Scoliosis

Wed, 24 Mar 2010 10:17:04 -0400

Most of us remember Adam’s Forward Bend Test, though few of us are familiar with that name: you fold forward at the waist, arms dangling, and an examiner eyes your spine for any swerves in the ridgeline of vertebrae connecting your neck and the small of your back.

Children lined up for such annual scoliosis screenings used to be a familiar sight in school gyms across North Carolina. The problem was, says Duke orthopaedic surgeon Robert Fitch, MD, the process was expensive and largely ineffective.

Scoliosis includes any curvature of the spine that measures 10 degrees or greater; it’s quite common, says Fitch, who specializes in children and adolescents, and the vast majority of people who have it require no treatment at all. “After mass screenings, I’d end up with a flood of referrals. It amounted to a lot of unnecessary anxiety for parents.”

Those schoolwide screenings are no longer the norm -- nowadays pediatricians and general practitioners are the ones who keep their eyes on growing spines -- and a great deal more has changed in the way scoliosis is addressed.

For kids and still-growing teens whose curves are at 25 to 40 degrees, those awkward, cumbersome back braces once worn 24/7 have for the most part given way to lightweight devices that fit easily under clothing and allow for greater movement. “For certain curve patterns, a nighttime brace may even be sufficient,” says Fitch.

Adult Surgery Turned Sideways

Spine surgeon Christopher Brown explains a new procedure for adults with scoliosis.Scoliosis treatment for adults has also undergone significant remodeling. People whose spinal curves and accompanying pain are severe enough to need correction now have the option of minimally invasive surgical techniques, which means reduced hospital stays and shorter recovery times.

Scoliosis patients’ fear of back surgery is understandable, says Duke orthopaedic surgeon Christopher Brown, MD. The traditional surgical approach to correcting scoliosis involved “large, open incisions,” he says. “We had to cut all the way down the back, strip all the muscle off the spine, and insert screws and rods. If the correction was in the thoracic [chest] area, we might have to remove a rib or deflate a lung to reach the spine.”

With the minimally invasive approach, Brown makes one small incision directly over the side of the waist and another slightly behind it. He works through these incisions to place cages -- plastic implants -- in the disk spaces between the vertebrae, he explains.

“With the new procedure we can work right in the disc space, attacking curves where they begin. The discs themselves are so much of the problem, and this method approaches them directly; we’re trying not only to straighten curves, but also to stabilize the new alignment.”

This sideways, or lateral, approach to the spine means that the surgeon can avoid
both cutting through the large muscle groups on the back and maneuvering around the organs of the abdomen.

“Nerve-monitoring technology helps us avoid nerves -- that’s the technology that makes these small incisions possible,” notes Brown. “There’s less pain and a much lower infection rate because we’re not causing so much destruction to the tissues. Patients go home quicker -- on average three days earlier. Some even go home the next day.”

The procedure has broader applications than scoliosis, he says. “I use it any time a patient is a candidate for a fusion. I don’t operate on the lumbar spine without it for any of kind of stabilizing procedure.”

Kids’ Curves

For children and adolescents, whose spines are still developing, surgery is only done in very extreme cases with children or adolescents; the hope is to correct via bracing. For those rare cases that require surgery, the classic open procedure is still the norm. Kids simply fare much better than adults with the classic open procedure, says Brown. “They fuse and heal quickly, and they don’t get the infections that adults get.”

But the procedure is now less onerous for children and adolescents as well, explains Fitch. “What’s changed the most are the surgical implants, which have evolved to sophisticated degrees, allowing for better deformity correction, fewer post-op complications, and quicker recovery. We used to have to go through the chest to loosen the spine, then perform a separate procedure to plant the rods. What used to take two surgeries now takes one.”

Tending to Tiny Teeth

Tue, 23 Mar 2010 14:52:43 -0400

Want to help keep your child’s smile sparkling? Duke pediatric dentist Martha Ann Keels, DDs, PhD, fields some FAQs about children’s dental health.

Why choose a pediatric dentist instead of a regular dentist?

You can think of it as a parallel to choosing a pediatrician for your child over a general practitioner -- they’ve chosen pediatrics as their passion. Pediatric dentists have two to three more years of training that focuses just on pediatrics, and they’ve treated hundreds of children, whereas general dentists typically get very limited exposure to children in dental school.

That said, there are far fewer pediatric dentists than general dentists out there. If you don’t have the option of a pediatric dentist in your area, make sure your general dentist is comfortable and knowledgeable about treating children. It’s worth doing some research to ensure that your child’s early visits go well -- trying to rebuild trust after a bad experience can be very difficult.

At what age should I bring my child in for her first dentist visit, and how can I help prepare her for it?

Most dental guidelines say you should have a dental home by age one. I fine-tune that to recommend bringing children in once they have eight teeth.

One way to help make sure your child does not have a negative experience is to prevent tooth decay. Start brushing as soon as their teeth appear, and then your child will get used to you -- and the dentist -- being in their mouth. You can use a washcloth for the first eight incisors, but molars needa toothbrush. Practice leaning them back and counting their teeth.

There are lots of books in the library and online to share; Dora the Explorer and the Berenstain Bears have stories about going to the dentist, and there’s a great new book out called Tooth Fairy Island. Keep it light and fun -- skip the dental drill parts!

When should flossing start?

As soon as there are any two teeth touching, they need to floss between them. With primary teeth, those back molars are normally the first to touch. Young children get most of their cavities in between their baby molars, which flossing helps prevent.

At what age can kids be allowed to brush by themselves?

Supervise brushing and flossing at least until age eight -- you want to make sure they conceptually understand what they’re preventing.

Develop routines that stick. It doesn’t matter much whether they brush before or after breakfast, for example, and it may be easier to get it done before. Make it fun. Disclosing rinses and tablets that stain the teeth can show them how thoroughly they brushed.

Also train your child to be a tongue inspector. Have them practice cleaning their teeth with their tongue; prompt them to make sure the teeth feel slick after meals. You can get your teeth about 80 percent clean with your tongue. Toothbrushing and flossing removes the food particles and plaque remaining after your tongue sweep.

Are all sweets equally bad for the teeth?

No: M&Ms are actually a dentist’s favorite candy because they melt! Ice cream also has a fast clearance off the teeth. Stay away from sticky and sour candies, like gummies -- including gummy vitamins. Go for chalky, dissolvable, chewable vitamins.

The second most common tooth disease after cavities is acid erosion directly from food; those sour candies, fruit rollups, gummies, Skittles and Starbursts are burning holes in the teeth. For the same reason, don’t drink soda -- it’s extremely acidic. Likewise, avoid juice or limit it to four ounces a day for children under eight.

When should orthodontic care start, and what role does the dentist play?

Pediatric dentists are looking at orthodontics from day one, but definitely by age seven, a child should have an orthodontic screening. Braces are now used for a lot more things -- protrusive teeth need treating not just for looks, but to prevent breakage or trauma. A seven- or eight-year-old, for example, may only need a few braces for a year. A small movement here or there may prevent bigger problems when they’re 10 or 12.

How often should you change toothbrushes?

At least every three months or when the color strip on the bristles fades. To help keep bacteria in check, run the toothbrush under hot water or pour mouthwash over it -- and any time you’ve been sick, especially after strep throat, throw the brush away and get a new one.

How important are baby teeth? Do I really need to worry much about cavities before my kids get their permanent teeth?

Baby teeth are much thinner and therefore more cavity-prone. When neglected, decay can quickly lead to an abscess, which is very painful. If baby teeth have to be pulled, that predisposes permanent teeth to becoming crowded because you’re losing that placeholder for the adult teeth.

And remember, many children have their baby teeth until age 12. A healthy smile is key to their self-esteem. With proper dental care and good habits, kids can make it to age 100 fit and healthy and cavity-free. I just saw one of my patients who is in college now and he has never had a cavity. That’s my wish for all my patients; I would love never to drill another cavity.

Computers Make It Personal

Wed, 11 Nov 2009 10:44:40 -0500

Ah, the waiting room. No matter what kind of appointment you're waiting for, it's almost always the same: vintage Family Circle magazines to browse, easy listening or talk radio droning in the background, and those clipboards with forms to be filled out in triplicate.

You may while away the time pondering such questions as: Is your personal information disappearing into a file somewhere? Do they really need your address and insurance ID numbers again?

The cancer clinics at Duke are changing this waiting game with a digitized experiment.

When patients arrive for an appointment, instead of the clipboard they're given a wireless, tablet-style computer. It guides them through a series of questions about their symptoms and quality of life.

Their clinician gets a report of the answers, and he or she can use the information to make the visit more productive -- whether that's by adjusting medical treatment of a particular symptom, providing an educational video for the patient to view while waiting for an exam or during chemotherapy, or some other service.

Amy Abernethy, MD, who directs the Duke Cancer Care Research Program, says that patients find the new system easy and even pleasant.

They're presented with a symptom such as headache and asked to rate the severity from zero ("not a problem") to 10 ("as bad as possible"). They touch the appropriate number with a stylus, it vanishes from the screen, and the next symptom or question appears.

The format makes it easier to provide frank answers to sensitive questions. "Our studies are showing that the computer allows people to say things they wouldn't have otherwise said. We really saw the difference in reporting difficulties with sexual function and social support. It can be hard to be honest when your spouse is right next to you looking over your shoulder at the clipboard, but electronically, you provide the answer and it disappears."

The clinician can immediately compare the patient's answers with those from previous visits and get a strong sense of whether or not symptoms are truly improving.

"Research shows these reports to be very reliable," notes Abernethy. And in the aggregate, the information patients provide here helps create a bigger picture of what's happening to a group of cancer patients over time.

Researchers and clinicians are assessing this long-term data and using it to improve patient care. "For example, among the breast cancer patients we noticed that sexual distress was an underserved concern," says Abernethy.

"I don’t think anyone had any idea just how much of an issue it was, but one in three people were scoring over five in that area. [A score of four to six denotes a moderate problem, while seven to nine denotes a severe problem.]

So this was remarkable. It very quickly put us onto two pathways: offering patients more education through the tablets and working with psychologists to develop coping methods for patients who report that problem."

Abernethy describes the system as providing "a kind of triage. Through this technology we can better understand patients' needs, whether they require more education about their condition or help with transportation or payment. There's so much support on hand at Duke; we just need to appropriately match our patients with what is available."

Rather than having a distancing or depersonalizing effect, handing patients a computer has become a means to provide comprehensive, whole-person care.

"I'm interested in improving the cancer patient's experience," says Abernethy. "You can't do that if you don't know what the problems are, how to measure them, or how good of a job you're doing. We're taking care of the whole person here, not just their cancer."

The Detox Delusion

Thu, 12 Nov 2009 09:06:35 -0500

Beth Reardon, MS, RD

Like your lemonade with a dash of hot pepper and maple syrup? Enough to consume it exclusively for days or even weeks on end?

That’s the sum-total menu of the "Master Cleanse," current king of the so-called "detox diets," which purport to rid the body of harmful toxins while helping it shed unwanted pounds.

Detox diets typically involve fasting or food restriction and may include some combination of nutritional supplements -- products that could also contain laxatives, diuretics, or stimulants. Some regimens recommend frequent colonics or enemas as part of the cleansing process.

The evidence supporting detox diets is slim to none, but they’re often touted as holistic and popularized by celebrities small and smaller. Scores of slender starlets can’t be wrong -- can they?

Beth Reardon, MS, RD, nutritionist for Duke Integrative Medicine, gives us the skinny on a recurring diet craze.

Flushing Out the Truth

It’s not merely the lure of plummeting pounds that draws people to detox diets. There’s powerful appeal in the promise that these diets will cleanse our body of toxins, observes Reardon.

"We are so bombarded by our food supply, what’s in it, what’s not. We hear about additives, preservatives, dioxins, carcinogens; we see some horrific pictures from the Internet of something that supposedly came out of a colon; and we’re just overwhelmed.

The fear factor is pretty convincing. People are grasping to do what makes sense, and the notion of detoxifying the body sounds right. But there just isn’t good science behind detox diets."

Claims Don’t Hold Water

Most detox diets are awash in fluids; the Master Cleanse’s liquid-only regimen includes, in addition to six to 12 eight-ounce daily servings of lemon drink, a quart of water with added sea salt -- the "saltwater flush" -- as well as herbal laxative teas to combat the constipation that can result from the lack of food intake.

Reardon warns that overuse of these electrolyte mixes or laxatives can "disturb our natural balance, causing dehydration, nausea, cramps, dizziness. And excessive fluid intake can lead to hyponatremia: low sodium in the blood.”

She says that people who are taking medication for their heart or to regulate blood sugar are at great risk for this serious complication.

Not So Fast

Reardon respects limited fasting as part of one’s religious or cultural practice, but as a dietary strategy, she stresses that fasting or extreme food restriction is ineffective -- and it can be dangerous. "Cutting calories ultimately slows down your metabolism, which prevents weight loss."

And what about that "natural high" some people ascribe to fasting? "Reaching some altered state, feeling euphoric -- it’s ketones, a metabolic disturbance. Soon you’ll start feeling low energy and fatigue.

Without food, in a matter of days glycogen stores are depleted and the body starts breaking down muscle tissue, harming the heart and other organs. It’s not healthy for extended periods."

Don't Be a Yo-Yo

The rapid and dramatic weight loss reported by some -- singer Beyoncé’s 20-pound dip in two weeks was the big buzz this year -- is largely due to fluid loss. And once you resume normal eating, the weight rebounds quickly.

A more effective approach to weight loss, and what our bodies really need, says Reardon, is a "plant-based, whole foods diet. That means aspiring to eat nine to 12 servings of fruits and vegetables a day and opting for most of your protein in the form of legumes and seafood, with occasional poultry or grass-fed beef. You will naturally 'detox' and feel better when you stop eating all the processed and packaged foods that cause jags in blood sugar."

Finally, says Reardon, you just don’t need to go to extremes to cleanse your body of toxins.

"Give your body more credit. We have evolved over two-and-a-half million years with highly effective detoxification systems -- such as the liver and kidneys. We naturally detox most substances that could be harmful. Our bodies are designed to do this -- if we give them proper food and hydration and don’t stress our systems by eating a diet that includes a disproportionate amount of processed foods."

Assess Your Headache

Wed, 11 Nov 2009 16:33:03 -0500

For someone with a history of migraine headaches, the signs are familiar and unmistakable.

Scott Huler of Raleigh, age 50, who has had migraines since adolescence, describes "a neon flashing in my eyes, a small blot that eventually spreads to about 90 percent of my vision; I can still see but am unable to drive or read. Soon after, there's a piercing, almost electrical pain that to me is completely different from a regular headache."

But for others the distinction is not always so clear. There's a wide range of possible migraine symptoms, due to the complex activities occurring in the brain, says neurologist Heather Adkins, MD, who specializes in headache and face pain at the Duke Pain Clinic.

"A migraine is an event in the brain that actually starts well before the pain begins. A neuron in the brain's cerebral cortex becomes activated, and that activation spreads to other neurons -- it's almost like what happens in a seizure."

But while a seizure is a spreading wave of increased brain activity, a migraine is a wave of decreased brain activity -- that’s why early symptoms can include vision problems, difficulty concentrating, or numbness or tingling in the extremities.

The pain of a migraine occurs when the trigeminal nerve is stimulated and releases substances that inflame and dilate the blood vessels around the meninges, which are pain-sensitive membranes encasing the brain.

Distinguishing Headache Types

So how do you know if you have a migraine? Migraine sufferers often report throbbing or pounding sensations, whereas tension headaches are more commonly described as a tightening or steady ache, often a band-like sensation around the head.

Tension headaches at their strongest may be hard to distinguish from migraines, but they don’t tend to have the additional symptoms associated with migraines, such as migraine aura that involves visual disturbances and tingling. Nausea and increased light and sound sensitivity, frequently reported by migraine sufferers, are uncommon for tension headaches -- which, by definition, cannot have more than one of these symptoms.

Also, physical activity does not typically increase tension headache pain as it does migraine pain.

Another strong indicator of migraine is having a family history of it. "Since so often there are multiple family members with migraines, we think the cause is primarily genetic," says Adkins.

There may be a hormonal component to migraines in women, she adds. "Men and women have the same rate of migraines until puberty; after that, women are at greater risk. Many women report migraines flaring up or worsening around the menstrual cycle or after pregnancy."

Treatment for Headache Pain

Whether it’s a tension headache or a migraine, treatment is available. "Treatment of migraine has advanced significantly in the last several years," notes Adkins, "so if you couldn't find adequate relief before, it's worth seeking help again; we have a lot of new options available, and more are on the horizon."

It's vital to seek immediate help for sudden, severe headache, which can be an early sign of stroke. Other warning signs include: numbness or weakness in the face, arm, or leg; confusion such as difficulty speaking or understanding; vision problems in one or both eyes; or trouble walking, dizziness, or loss of balance.

"For a thunderclap type of headache, go to the ER immediately," stresses Adkins. "And any time you have a headache that's different from usual -- if it's changed in pattern, in frequency, in intensity -- call your doctor."

Get Serenity Now

Tue, 10 Nov 2009 15:48:55 -0500

The link between emotional and physical health is not a theory -- it’s a fact.

"We know there's a relationship between mental health and heart health," says cardiologist Christopher O’Connor, MD, director of the Duke Heart Center and co-director of the new Duke Heart-Mind Center.

Christopher O'Connor, MD"For example, people with depression are shown to have blood platelets that are stickier and therefore more likely to form a clot; it’s also associated with an increase in inflammation and heart rhythm disturbances."

And there’s a behavioral component, as well: a person under stress tends to isolate herself more, which means less social support, a key factor in healthy living. Stressed people are also less likely to take their medication responsibly or to actively participate in their health care, he says.

It all adds up to a higher likelihood of health crises, complications, and perhaps a shorter life. As study after study offers yet another compelling reason not to let stressful emotions wreak havoc on your body, perhaps it’s finally time to take the advice of teenagers everywhere to heart -- and just chill. Here’s how:

Just Sit There

Jeffrey Brantley, MDPeople who practice meditation and mindfulness have better health outcomes than those who don’t, according to Jeff Brantley, MD, director of the Mindfulness-Based Stress Reduction Program at Duke Integrative Medicine and the author of several how-to books on the subject, including Calming Your Anxious Mind.

"Research has shown that the ability to concentrate attention can promote deep relaxation in the body, and that the ability to be more mindful in each situation can help break the destructive habitual reactions to stress."

One simple exercise for deep relaxation, described in Brantley’s book Five Good Minutes, involves focusing on the sensations of the breath. Imagine that you are taking in feelings of calm and peacefulness with each inhalation, and expelling tension with each exhalation.

Simmer Down

Redford B. Williams, MDAnger management techniques have proven remarkably successful in reducing blood pressure and alleviating depression, says Redford Williams, MD, director of Duke’s Behavioral Medicine Research Center and co-founder with his wife, Virginia Williams, PhD, of LifeSkills, a psychosocial skills training program.

Williams suggests writing down specific episodes of anger to help identify your unique patterns, triggers, and responses. And when faced with enraging situations, stop to assess before taking action.

Look at the facts objectively, then ask yourself his four "I Am Worth It" questions:

I: Is this matter important to me?

A: Are my thoughts and feelings appropriate to the situation?

M: Is the situation modifiable in a positive way?

Worth It: When I balance the needs of others and myself, is taking action worth it?

Positive takes practice

Negative emotions may be bad for you, but Williams says research also shows the converse to be equally true. A recent Women’s Health Initiative study associates optimism with a reduced incidence of heart disease and total rates of death.

But can a dedicated cynic be reformed? Williams says optimism may come more naturally to some people than others, but anyone can cultivate the trait with practice.

"Simply learning to cope better increases optimism. As people improve their anger and stress management skills, they realize they are not at the mercy of the situation." In fact, they have the power to improve it.

Improving personal relationships is another path to a positive outlook. "Listening is key," Williams advises. "Keep your mouth shut until the other person is finished speaking, and try to be open to the possibility of being changed by what you hear."

One of the exercises he gives to people in LifeSkills is to "think of someone you encounter every day, list five positives you can inject into that relationship, then do them." The psychologic and physiologic benefits of such practices are measurable: participants’ satisfaction with life and social support go up, overall blood pressure goes down, and blood pressure surges during stressful times are less acute.

Don't Blow Off the Blues

"People who are depressed die at a greater rate than those who aren't, and those deaths are largely related to heart problems," says O’Connor.

Because the links are so strong and the stakes so high, he believes depression screening should be part of a routine cardiac workup.

O’Connor notes that your primary health care provider already has tools to screen for major depression -- if a patient answers "yes" to either of these questions:

During the past month, have you often been bothered by feeling down, depressed, or hopeless?
How about by little interest or pleasure in doing things?

"The questions can help doctors identify more than 90 percent of patients with major depression," O’Connor says -- and can make a lifesaving difference. "We think it's as important to check as blood pressure, glucose, or cholesterol."

Build Your Bones

Wed, 11 Nov 2009 08:40:07 -0500

Oddly enough, the bone-weakening disease osteoporosis isn't something you can feel in your bones. All too often, people remain unaware until it makes its presence known via a disabling fracture in the hip or spine.

Nearly half of women and one in four men over age 50 will break a bone as a result of osteoporosis, according to the National Osteoporosis Foundation. But prevention, detection, and treatment of osteoporosis have made great strides in recent years.

You may not be able to alter certain risk factors such as gender (80 percent of those affected are female) or genetic predisposition (present in 66 percent of people with osteoporosis), but being aware and proactive can help you maximize your bone density.

Duke physical therapists Peggy Anglin and Courtney Frankel, who train and educate people with osteoporosis every day, share their thoughts on optimizing bone health at every age and stage of life.

Big Builders: Kids and Teens

It's crucial to build strong bones in childhood and adolescence, when 85 to 90 percent of bone mass is acquired. Anglin notes that the decline of physical education and recess in schools means parents need to step up efforts at home. "Do everything you can to get your kids involved in physical activity."

Adds Frankel, "Kids should be running, jumping, and playing, really putting that maximum impact on the bones. Sports are a fine venue to get children and teens moving."

Both caution parents to look out for emerging eating disorders in adolescents. Extreme dieting and over-exercising can seriously affect bone density.

Primetime: The Roaring Twenties

Bone mass usually peaks at skeletal maturity in the early 20s and is normally maintained until around the mid-30s.

"These are your prime years," notes Anglin. "Athletes are usually at their top performance levels during this time." Still, it’s easy to get derailed by accidents or injuries.

Start taking care of your back; learn proper lifting postures to avoid bending over at the spine, which could set you up for compression fractures. Frankel advises developing a fitness routine if you haven’t already.

"Young adults should aim to do weight-bearing exercise three to five days a week and weight-training two to three days per week."

Reclaim, Maintain: Mid-Thirties to 50

Bone mass starts to level off around age 35, when age-related bone loss begins. That’s all the more reason to stay fit.

"Especially if you’re a parent," says Anglin, "this can be a really busy stage with plenty of lifting; old injuries may tell on you, and stiffness may develop. It is a good time to focus on healthy habits and posture."

Strengthening your abdominal area will help straighten posture and protect the lower back, and stretching helps avoid stiffness after exercise. Particularly for woman approaching menopause, Frankel recommends a fitness routine that includes four to five days of weight-bearing exercise per week and two to three days of weightlifting or weight-resisting exercise per week.

Anglin advises that women request a bone density scan around age 50 if they’ve never had one.

Developing Strong Bones at Any Age

Things you can do at any age to reduce the risk or impact of osteoporosis include getting good nutrition, maintaining a healthy weight, quitting smoking, and reducing or eliminating alcohol.

Exercise is especially vital for building or maintaining bone mass. "These healthy behaviors are not something you do for a few weeks to accomplish a goal," stresses Duke physical therapist Courtney Frankel, "but as part of daily life."

Kids' Health Q&A

Thu, 12 Nov 2009 10:40:53 -0500

Duke pediatricians William Lawrence, Martha Gagliano, and Michael Land talk turkey on school lunches, nasty noses, seasonal sneezes, and scabs.

School is starting again, and I'm afraid that when left to their own devices, my kids will subsist on cafeteria corn dogs and Tater Tots. How can I make sure they’ll eat healthy meals?

William Lawrence, MD: Whenever feasible, we encourage packing a breakfast or lunch to send to school. It really gives you control over content. Most children don't get enough fruits and vegetables in their day, so send things that are packable and won’t quickly spoil: apples, bananas, carrot sticks.

And for breakfast, try thinking beyond traditional foods like pancakes. A little bit of protein and a good carbohydrate source, like a stick of mozzarella and a piece of fruit, can make a healthy breakfast.

While packing meals is not always practical, simply knowing what's on the school menu [check your school's Web site] can help you steer your child toward healthier options.

Depending on your child's specific dietary needs, good everyday choices may include 1 percent milk instead of whole or chocolate milk, or opting for water instead of juice -- there are a lot of concentrated calories in juice, so cutting it out can really have a good impact.

At our house, we know it's autumn before the leaves change color because our child's sneezing and runny nose really ramp up. Can you recommend any natural remedies for seasonal allergies?

Michael Land, MD: There is not enough strong evidence to recommend the use of herbal supplementation, acupuncture, or "special diets" for the treatment of allergic rhinitis. Some patients benefit symptomatically from nasal saline rinse, which washes out debris and pollens.

Allergy shots are considered by some to be a natural way of dealing with allergies, although they are still a medical treatment given by a doctor. These injections actually expose your body to small amounts of what you’re allergic to. By starting with tiny amounts and gradually increasing regularly, these injections slowly change your immune system to be able to tolerate larger amounts of the allergens.

The best way to get rid of the symptoms of allergic rhinitis would be to avoid the allergen that is triggering them. Reducing exposure to outdoor allergens is important when the pollen count is high.

To avoid outdoor pollens, keep the windows closed in your home and car. Also, pollens are often emitted in the early morning hours (between 5 a.m. to 10 a.m.), so avoiding early morning outdoor activity can help extremely sensitive people.

Is it really better to "air out" a scab and keep it dry, or should you keep it covered and moist -- or does it make a difference?

Martha Gagliano, MD: Airing out scabs has fallen out of favor among dermatologists. Scabs itch and kids pick at them.

We'd rather keep it covered and not let it form that thick, itchy scab. Coat the scab in an antibiotic ointment like Polysporin, then bandage it to keep it moist and not let it get crusty.

My day-care provider says my child should probably stay home if he's got "green snot." Does that mean he has an infection? When should I take him to the doctor, and when can he just ride it out at home?

Gagliano: That's a myth -- the color of mucus is completely irrelevant. Kids don’t blow their noses very well, so the mucous turns green.

The younger a child is, the harder it is to know how serious an illness is. Both viral and bacterial infections can make very young children quite ill, so with infants it's best to be proactive and to follow your instincts: If your baby is listless, eating poorly, or just doesn't look "right" to you, call your doctor.

Any fever in a baby less than one month old is worrisome, and you should call your doctor immediately.

For older children, things are a little easier. In general, viruses cause lower fevers (less than 102.5º), are accompanied by symptoms such as a runny nose, hoarseness, vomiting, or diarrhea, and improve over three or four days.

The illness is more likely to be bacterial if the fever is high, if it lasts longer than four days, of if there is specific pain (like a sore throat or an earache).

Note that antibiotics don't work on viruses, only on bacterial infections. We have a huge problem with drug resistance because of the overuse of antibiotics, so you don’t want to use them unless they will really do some good.

For a virus, keep your child comfortable and hydrated and wait it out. Most viruses are at their worst for three to four days, so if it lasts longer, or if the fever is 103° or higher, go to the doctor.

While we're on the subject of fevers, is it better to let a mild fever go? If I bring down my child’s temperature with Tylenol or Motrin, for example, am I hampering the body’s ability to fight infection?

Gagliano: That's controversial -- maybe the fever's doing some good, but maybe not. If your child is uncomfortable, treat the fever. Most kids look terrible with a fever, so they're very difficult to assess.

Controlling the fever allows both the doctor and parent to assess how that child is doing. Also, kids get dehydrated easily; when they have a fever, they're losing water and need more, but they often won't drink as much, so they’re at higher risk of dehydration. My opinion is to go ahead and treat those fevers.

Pain without Purpose

Fri, 27 Mar 2009 13:16:35 -0400

Winston C.V. Parris, MD

Pain has its point, says Winston Parris, MD, director of Duke’s Pain Clinic.

"Acute pain gives us very useful information about what’s happening to our bodies," he says. “If it wasn’t for pain, my foot could be in a fire and I might not know it until I smelled steak. But chronic pain,” he says, “is never useful.”

Chronic pain takes a measurable toll on your physical, mental, and social health. It increases your body’s physiologic stress response, which makes you vulnerable to illnesses ranging from high blood pressure to depression. It reduces the amount of exercise you get (heightening other physical problems).

Most chronic pain sufferers report a strain on their personal relationships, less productivity at work, and less socializing compared to when their lives were pain-free.

Chronic pain is sometimes triggered by an initial injury or illness, and is sometimes the result of an ongoing problem such as arthritis or cancer. And in some people the pain arises without any clear cause.

Pain affects some 77 million Americans -- more than are affected by diabetes, heart disease, and cancer combined. But the most important and most striking thing about chronic pain is that its sufferers often suffer needlessly.

No matter your age or how long you’ve already labored under its yoke, says Parris, chronic pain is a condition that can -- and should -- be treated.

Duke pain specialist Christopher Edwards, PhD, says that patients too often believe that pain is a one-shot process -- see one doctor, take one pill, feel better (or don’t). Repeat as needed (or give up).

“Quantity of care does not equal quality of care,” Edwards says. “Many patients have seen doctors who are not necessarily experts in pain. Just because that patient hasn’t seen resolution to his pain, it doesn’t mean resolution isn’t possible.”

Specialized pain programs can offer patients the team approach needed to address chronic pain. These programs combine the efforts of pain management specialists including neurologists, neurosurgeons, anesthesiologists, psychiatrists, physical therapists, and psychologists, in order to address the multiple facets of each patient’s pain.

“A referral to a psychiatrist or a psychologist does not mean that the doctor believes that the pain is all in your head, or that you have a substantial mental illness,” says Edwards.

“Nothing could be further from the truth. For patients whose pain can’t be completely alleviated, mental health services are among the most effective resources to help those patients develop coping skills, which are proven to reduce a patient’s experience of pain.”

Many patients fear or fixate on drug treatments, but they are usually only part of the solution, and sometimes they are not needed at all. “Using just one drug to treat a chronic pain problem can be like using a hammer instead of a toolbox,” he says. At Duke’s Pain Clinic, he says, an aggressive but conservative approach gets better results.

“We use evidence-based medicine. There are some treatments out there that people claim are helpful, but they are not. We use what works, including conventional and unconventional tactics, such as acupuncture and biofeedback.”

Why Me?

Pain and pain tolerance are different for every individual, and why some people are more dogged by pain than others is still a mystery. Parris says the answer lies in the nervous system. “Some people’s electrical pain mechanism stirs up a variety of cell signals in the brain that we call the inflammatory soup,” he says.

The jury is still out on how this soup works, but for some people it creates persistent, debilitating pain. The job of a pain specialist, says Parris, is to manipulate that process, to try to suppress the things that make pain worse and enhance the things that minimize it.

“Depending on the type of pain and its source, that equation will be different for different people. A good pain doctor will be able to determine what sort of pain you are experiencing, and how best to treat it.”

There is great variability in outcomes, says Edwards, but there are also established and effective principles that guide the treatment of all types of pain. “Most patients are treated by a variety of professionals, with a variety of techniques,” he says.

“At Duke we provide avenues to integrate all these components. We also include compassion for the experience of chronic pain -- not just the biomechanics of pain, but the suffering, the loss. We want patients to feel that we respect their experience.”

Upright Burdens

Fri, 27 Mar 2009 13:19:03 -0400

Of the millions of Americans who say they live with pain every day, the most common source of pain is in the low back. Winston Parris, MD, says the back, by design, is the perfect place for chronic pain to start. “The good Lord made us, tragically, on two legs,” he says.

Walking upright means the network of 33 vertebra that protect our spinal cords endure more pressure than the spines of four (or more)-legged animals. As a result, over the course of a lifetime, almost every human spine suffers degenerative changes in either the vertebra or the disks between them.

These disks -- the spine’s shock absorbers -- are often ground zero for back problems. When a disk begins to wear down, it begins to swell -- bulging like a boxer’s punched lip, says Parris.

That swelling puts pressure on the nerves nearby, radiating pain as far out as your leg. Herniated disks are one of the most common causes of back pain, but they certainly are not the only one.

Spinal stenosis, which is pain resulting from a narrowing of the spinal cord, is a common condition that occurs after injury or surgery or as a part of the aging process; it’s the most common reason for back surgery in people over age 60.

Most of us will experience back pain in our lives, but for most of us this pain resolves on its own in a few weeks. Of people who see a doctor for lingering back pain, medication and physical therapy will usually do the trick.

Only a fraction will ultimately need surgery to treat their troubled spine. And of those who undergo surgery, 95 percent of them will enjoy a much-improved quality of life after the procedure.

Parris notes that there are a variety of ways to treat back pain, many of which incorporate exercise, physical therapy, and lifestyle changes. The Duke Pain Clinic is one of the few places in the United States that offers a new procedure called percutaneous neuroplasty to patients with spinal stenosis and failed back surgery.

This treatment, which involves injecting a solution into the affected area of the spinal column, can offer significant relief where traditional approaches to spinal pain have failed.

“Twenty years ago, everyone with back pain essentially got the same procedure or the same pain medicine,” he says. “Now physicians know how to tailor their approach to what’s going on in each patient’s body.”

When to Seek Specialized Pain Care

Most cases of back pain can be treated by your primary care provider and will abate in about six weeks, according to Duke back pain experts.

You might need specialized attention if you experience:

Severe or persistent radiating pain: back pain that radiates to your legs or that’s accompanied by tingling, pain, or numbness in the arms or legs.
Sudden changes in pain, such as if you’ve had pain while standing or walking and suddenly develop sharp pain shooting down a leg or arm.
Pain accompanied by other symptoms, such as significant weakness in the legs, problems with walking, bowel and bladder issues, weight loss, or fever.

Parris says that if you are experiencing pain of any sort that has persisted for three months or more -- and you’ve already received treatment from a specialist -- it’s time to seek out the services of a pain doctor.

The Duke Pain and Palliative Care Program treats joint-related pain, migraine headaches, fibromyalgia, sickle cell crisis, and other chronic painful conditions. To reach the Duke Pain Clinic, call 919-684-7246 or 888-ASK-DUKE (888-275-3853).

Rethinking Vitamin Supplements

Fri, 27 Mar 2009 09:53:34 -0400

Health, in one simple pill. That’s the perceived promise behind multivitamins and dietary supplements. Millions of Americans dutifully take their dose every day, believing it will ward off a cold (it won’t) or prevent cancer (it definitely won’t), or simply make us more healthy (only some of us).

For many, supplements also serve as nutrition insurance, covering a multitude of food sins -- a candy bar for lunch, drive-thru for dinner. But research is showing that this shortcut to “perfect nutrition” may be giving short shrift to your health, occasionally even doing more harm than good.

Message: Not in a Bottle

“Contrary to common perception, there’s actually little evidence that healthy individuals will gain health-promoting benefits from taking a multivitamin,” says Duke nutrition scientist Connie Bales, PhD, RD.

There’s no research to support that they prevent cancer or other chronic diseases, and they cannot effectively replace a well-balanced meal, according to Duke researcher Denise Snyder, MS, RD, CSO, LDN. “Most vitamins and minerals that people need can be obtained by making better food choices -- a diet that includes a variety of healthful foods in lots of colors on your plate.”

Research even suggests that vitamins and minerals are more effective when in food form -- in other words, taking the carrot out of your beta-carotene may actually make it less helpful to your body.

Approved for Some Audiences

Of course, there are always exceptions. “If your eating habits are severely compromised -- for example, due to severe food allergies, pronounced loss of appetite, or if your body is unable to absorb nutrients normally -- supplements can help to fill a gap,” says Bales. Reaching certain life milestones -- pregnancy, menopause, and the big 5-0 -- also justifies the need for specific supplements.

“Your body requires more vitamins and minerals [think calcium and vitamin D], while at the same time, the likelihood increases that you’re not getting enough,” she says. Strict vegetarians, people prone to osteoporosis, and the elderly should also discuss supplements with their doctor.

Side Effects May Include...

Supplements are neither tested nor approved by the Food and Drug Administration before hitting the shelves. Most people underestimate supplements and their potent effects, neglecting to inform doctors of their medicine cabinets’ complete contents.

“Supplements with very high levels of various nutrients can have serious consequences if they counteract any drug or medical therapy,” says Bales. “Especially when combined with other supplements or highly fortified foods, these products can lead to toxic effects due to overdose.”

This is especially true for sensitive groups, such as cancer survivors. The National Institutes of Health issued a 2006 statement on the link between supplementation and increased risk of cancer recurrence or a secondary cancer. But a new study by Snyder showed that 75 percent of cancer survivors 65 years or older reported taking some form of supplement.

Put Food First

“Dietary supplements are just that -- a supplement,” says Snyder. “They can be expensive and completely unnecessary. If you do take a supplement, make sure not to take more than 100 percent of the daily values for nutrients. Tell your doctor, exercise caution, think moderation, and look to food first.”

Primary Care Q & A

Fri, 27 Mar 2009 09:54:32 -0400

Duke primary care specialists J. Brinkley Sugg, RN, FNP, Scott Joy, MD, and William Hebda, MD, answer a few questions about primary care.

J. Brinkley Sugg, RN, FNP

What do most people misunderstand about preventive medicine?

Sugg: Many patients believe that if they don’t feel bad, if they don’t have a family history, or if they don’t have any symptoms, then there is no need to do anything.

Hebda: Some people are afraid that if they go looking for “trouble,” they might find it. I tell them that yes, we might find a problem, but that is why we do it -- if we catch it early, we can usually take care of the problem without too much trouble.

Scott Joy, MDJoy: Most people think that prevention is more complex and time-consuming than it really is. Exercise, mammograms, colonoscopies, vaccines -- these are not complicated or flashy, but they are crucial to maintaining health.

What makes preventive care worth it?

Joy: Every dollar that is spent on preventive care saves about two to three dollars in medical costs over the long term. As a patient, how do you want to spend your money -- with prevention now, or with procedures or surgeries later on?

William Hebda, MDHebda: It’s the same reason we change the oil in our Toyota. Do we treat our car better than we treat ourselves?

Sugg: Preventive care is the cheapest, most effective, and most reliable way to maximize your ability to enjoy the things in life that truly matter to you -- whether that’s your family, career, faith, hobbies, or just being alive and well.

Will genomics play a role in preventive medicine?

Joy: It already is. Genetic testing that is currently available allows us to identify patients who are at higher risk for developing conditions such as diabetes, heart disease, and breast and prostate cancers.

Sugg: Genomics has the potential to “customize” preventive medicine for patients. We know a lot about preventive care by looking at large populations; genomics can provide a more sophisticated way to zoom in on specific individuals who are identified as being at higher risk.

Hebda: But it’s important to remember that environmental influences still play an important role. For example, your genes may show a risk for heart problems, but if you exercise and eat healthy foods and avoid cigarette smoke, you will mitigate or lower your risk.

The Inside View on Hardened Arteries

Fri, 27 Mar 2009 10:56:21 -0400

Impotence, gangrene, dementia. These aren’t the most common results of the disease atherosclerosis, also known as hardened arteries, but they are possible effects. The more common complications are the more deadly: stroke and heart attack.

Hardened arteries is a bit of a misnomer: the smooth muscle cells that make up the vessels of our circulatory (vascular) system don’t themselves harden, but they do become encrusted, like poorly tended pipes in a house.

Fatty residue and calcium plaques build up inside artery walls, and as it gets worse, it can make your arteries so rigid and thick that blood can’t flow through them easily -- or at all.

When bits of this residue break off and travel through the bloodstream, they can enter the heart, brain, and other critical organs, sometimes with catastrophic results.

Untreated atherosclerosis can lead to vascular disease, the dangerous condition that is the driving force in many strokes, the number-one cause of heart attacks, and (as peripheral artery disease) the culprit behind a range of maladies including impotence and gangrene.

In short, atherosclerosis is the leading underlying cause of death in the United States.

Larry Goldstein, MDDuke neurologist Larry Goldstein, MD, adds that the conditions that create atherosclerosis can advance other illnesses, as well. “New research shows that blood vessel disease is the second major cause of dementia after Alzheimer’s disease,” he says, “and many people have both conditions. Risk factors for stroke and heart disease may also be risk factors for Alzheimer’s disease.”

Risk Reductions

Atherosclerosis is very rarely isolated to just one part of the body, says Duke vascular surgeon Jeffrey H. Lawson, MD, PhD.

“Plaque tends to be deposited throughout the vascular system in a process that takes many years, so symptoms in one area of the body -- the legs, heart, or kidneys, for example -- are usually a marker that other systems are at risk.”

Jeffrey H. Lawson, MD, PhDMost people with atherosclerosis don’t know they have it, so people with risk factors should be screened by a physician. Those factors include all the usual suspects: high cholesterol or triglyceride levels, smoking and secondhand smoke exposure, excess weight, advancing age, sedentary lifestyle, diabetes or insulin resistance, and high blood pressure.

And because there is evidence that atherosclerosis has a strong genetic component, a family history of the condition or of early-onset heart disease can also up your odds.

Different families have different patterns of disease, Lawson says, but in general, if a close relative suffers from atherosclerosis, there’s a good chance that you will develop it, as well.

As they say, you can’t pick your family -- and therefore your genetic risk for atherosclerosis -- but you can reduce or eliminate some of the other risk factors by making healthful lifestyle choices in terms of diet and exercise.

And because cigarette smoke exposure narrows and damages arteries, kicking the habit is particularly important. Research shows that cigarette smoke can significantly speed up the progression of atherosclerosis.

For patients diagnosed with atherosclerosis, the first order of business is lifestyle modification to reduce the risk of life-threatening complications. Other treatment options include cholesterol-lowering drugs such as statins or drugs that reduce the risk of blood clots.

Patients with advanced vascular disease may need surgical procedures that can help clean up or bypass major arteries or veins that have become dangerously narrowed or blocked.

The best way to determine your risk for atherosclerosis is through regular visits with your primary care physician, says Lawson. He or she can diagnose the condition on an outpatient basis using one or more non-invasive techniques -- and make recommendations to head off related medical conditions before they occur.

“Identifying those at risk and making appropriate interventions early on can have a profound impact on the disease process later on,” Lawson says.

Keeping the Flow Going

Because atherosclerosis is a systemic disease, vascular specialists look at patients as a whole package, Lawson says. Research at Duke is broadening the spectrum of treatment strategies to choose from; recent updates include:

Genomic analysis

Like many diseases, atherosclerosis varies from patient to patient. A first-in-man study, led by Lawson, examined and characterized genes that are activated in diseased arteries. The goal of such research is to tailor treatment to the genetic type of atherosclerosis in each patient.

Biotherapy

A handful of studies are looking at therapies that involve injecting stem cells into muscle tissue to promote the growth of new blood vessels (angiogenesis) around diseased arteries in patients who aren’t candidates for traditional surgeries.

New drugs

Duke investigators are working with an international team to study new drugs that may prevent blood clots -- a common problem in people with atheroslerosis -- as well as drugs to lower cholesterol and control blood sugar in these patients.

New tools

Lawson says that miniaturized intravascular devices are part of a rapidly growing field of technologies for treating vascular disease. Used to reach blood vessels that couldn’t be reached even five years ago, many of these devices are less invasive than traditional surgical treatments.

New understanding

Duke researchers are investigating possible genetic causes of brain vascular disease that can lead to dementia. The results may provide clues leading to new treatments to reduce not only stroke, but also vascular dementia.

How to Keep Your Kids Safe in the Sporting Life

Fri, 27 Mar 2009 14:02:11 -0400

If your children play sports, you’ve probably seen a few bumps, bruises, strains, and sprains -- or worse.

While preventing injuries in active kids is almost impossible, William E. Garrett Jr., MD, PhD, orthopaedic surgeon and team physician for the Duke and U.S. national soccer teams, offers some advice for keeping mishaps to a minimum.

The basics involve choosing the right team for your child. Do the coaches and referees insist on the proper equipment for the sport, and are they knowledgeable about proper warm-up, heat illnesses, and rest and nutrition off the field? Do they strictly enforce rules that prevent dangerous play?

It’s also important to do a quick check on the adults’ intentions behind childhood sports. “Sports can be a great socializing tool for children,” says pediatric sports medicine specialist Deborah Squire, MD, “but adults’ expectations of performance often bring too much structure and pressure into what should be a fun time for kids.”

Parents should be mindful of their children’s physical limits, she says, whether they’re new to rough-and-tumble sports or strong athletes. “When children begin to show promise in a sport, there’s a strong tendency on the part of coaches and parents to push them to focus on it more exclusively than they might choose to do on their own,” Squire says, adding that kids are as vulnerable as adults to repetitive motion and overuse injuries.

Because girls run, jump, and land differently than boys do, they sustain acute injuries more often on a per-exposure basis. In sports like basketball and soccer, girls’ overall injury rates can be from two to eight times higher than those for boys, particularly between ages 11 and 17.

For example, ACL injuries are much more common in females across the board. “Injury-prevention programs for athletes of both genders are being created and improved throughout the country,” says Garrett, “with a number of teams working with physical therapists and athletic trainers to address this issue.”

For any kid and any sport, Garrett says the following tips can keep sports mishaps to a minimum:

Start with passing grades. Children who have ever experienced any significant medical problems or symptoms should be specially screened before playing sports -- and all young athletes should get regular physicals.
Know the basics. Most serious sports injuries result not from overuse, but from a single awkward step or bad landing, especially among junior and senior high school-age children. Coaches should be sure kids master a sport’s fundamentals, such as running, pitching, cutting, falling, and pivoting.
Even the playing field. There’s a huge variability in physical maturity among kids the same age -- and among boys and girls on co-ed teams. Injuries are more likely to happen when a 12-year-old who weighs 85 pounds goes head to head with a 12-year-old who’s 120 pounds, so look for teams classified by size, not age.
Teach kids about pain. Kids should never “play through the pain.” If something starts to hurt, they should stop doing it. Don’t assume that pain is part of any sport; if an injury doesn’t get better in a day or so, see a doctor.
Listen to your child. If he or she isn’t feeling well or is poorly rested, mentally distracted, or emotionally upset, don’t force participation in a sports event. If participation in a particular sport seems to be taking a toll on your child physically or emotionally -- or if he or she clearly doesn’t enjoy it -- talk about it. Perhaps he or she would like to try a different sport or way of staying active.

In the final tally, the goals that really matter are the ones your child scores off the field -- nurturing a healthy, growing body and developing a good attitude about health, fitness, and safety.

Heart Flow

Fri, 19 Sep 2008 15:25:34 -0400

Do you know the best way to protect yourself from heart disease? For women, it really can be as simple as one, two, three:

1: Check Your Style

Before you focus on specific illnesses, cultivate the behaviors that are proven to reduce your risk from all manner of maladies, from heart disease to cancer:

Smoking cessation
Heart-healthy eating: at least four daily servings of fruits and of vegetables; at least three servings of whole grains; lean proteins and dairy such as fish, nuts, and low-fat yogurt; healthy fats such as olive oil
Regular physical activity: at least 30 minutes of aerobic activity every day
Weight management
Stress management: eliminating or seeking treatment for chronic stress, anxiety, or depression

Making these elements a part of your lifestyle now is the most important thing you can do to prevent heart disease from striking you.

2: Know Your Risk

You are at risk for heart disease if you meet any of these criteria, no matter your age:

A member of your family developed heart problems early in life: men less than 55 years old, women less than 65 years old
Your doctor has told you that you have: High blood pressure, high cholesterol, vascular disease, an abdominal aortic aneurysm, diabetes or metabolic syndrome*, or chronic kidney disease
Your habits include: smoking, an unbalanced daily diet (fewer than five servings of fruits and vegetables; regular eating of sugary sweets or sugar-sweetened beverages, processed foods, and refined sugars and flours), no regular exercise, or obesity (especially when your excess weight is around your abdomen—waist size greater than 35 inches for women or 40 for men)

3: If You Are at Risk

For women with no previous heart-related health problems and no symptoms of heart disease or heart failure, your doctor is likely to prescribe:

blood pressure or cholesterol medications
aspirin or another drug to control blood clotting
a statin drug
blood sugar medication

You may want to ask your doctor about:

supplementing your diet with omega-3 fatty acids
depression treatment if you think you may be depressed
referral to a cardiologist if your risk factors can’t be controlled

If you are not currently at risk: Visit your doctor every year for a wellness checkup. He or she will monitor your weight, lifestyle, and bloodwork to make sure you stay in optimal health. In the meantime, repeat step 1.

*Cardiologist Kristin Newby, MD, adds that metabolic syndrome may be the most important marker for early detection of heart disease in women. Metabolic syndrome is a collection of health risks that includes obesity, high blood sugar, and other abnormal blood work results that your doctor can measure. It often precedes type 2 diabetes, but it also increases the chance of developing heart disease and stroke. Newby says many people with metabolic syndrome may develop heart problems even before they are diagnosed with diabetes.

Where Do These Recommendations Come From?

In 2007, the American Heart Association released updated recommendations for how women can best prevent heart disease. They’re based on a review of clinical evidence analyzed by 33 of the nation’s leading experts on women’s heart health. Duke’s clinical data formed the bedrock for much of these recommendations, and Duke cardiologist Kristin Newby, MD, internist Rowena Dolor, MD, and neurologist Cheryl Bushnell, MD (now of Wake forest), were among the expert panelists.

The Real Deal On Omega-3 Fatty Acids

Fri, 19 Sep 2008 15:09:56 -0400

Just when you thought your dietary supplement recipe had been perfected with a multivitamin, a dash of calcium, and maybe a twist of glucosamine, there’s a new buzzword in nutrition: omega-3 fatty acids. But what exactly is omega-3? What does heart disease have to do with it? And did someone say “fish burps”?

Elisabetta Politi, RD, nutrition manager of the Duke Diet & Fitness Center, walked us through the oily world of omega-3:

Three of a Kind

In terms of nutrition, omega-3 describes a family of fatty acids: ALA, EPA, and DHA. ALA comes from food such as flaxseed, walnuts, almonds, and soybeans, but it must be converted into EPA, which (like DHA) comes from oily fish -- think salmon, sardines, herring, and mackerel -- so Politi says fish are the best source.

Elisabetta Politi, RDOmega-3s are proven to be energy sources for muscles and a boost to heart health. “They help lower the risk of heart rhythm problems, lower triglycerides, raise HDL (“good”) cholesterol, decrease blood pressure, and maintain healthy blood vessels,” says Politi. There are also claims that omega-3s can improve your metabolism, mood, and thinking -- Politi says that researchers are investigating its positive effects on cognitive function, but she’s yet to see research that supports using it for weight management or emotional well-being.

Food or Pill?

According to the American Heart Association, omega-3 fatty acids are best sourced through food, but to do so would mean eating a 3-ounce serving of salmon or 1 tablespoon of ground flaxseed every day. Add to that concerns over toxins found in some fish species, and fish-oil pills -- stripped of contaminants during the manufacturing process -- become an appealing way to fill the gap.

“As with any dietary supplement, if you decide to take fish-oil pills, tell your doctor so you can avoid any potential drug interactions,” says Politi.

The Omega Seesaw

Not all omegas are created equal, it seems. Omega-6 fatty acids, which ideally work with omega-3s in the body to keep us healthy -- can cause havoc when in excess. “In the last 30 to 40 years, we have dramatically increased the levels of omega-6 fatty acids in our diets,” says Politi. “Omega-6 fatty acids come from cheap-quality oils, and the food industry puts it in anything processed -- rice casseroles, chicken nuggets, frozen dinners, you name it.”

When omega-6 dominates omega-3, the body responds with increased inflammation, which is associated with a higher risk of heart disease, osteoporosis, and cancer. The solution? Stick with fresh, unprocessed foods as much as you can.

Pardon Me

Fish-oil pills can have their own problems: primarily, the “fish burp.” To reduce a fishy aftertaste -- and remain in good standing with your friends and family -- take the pill prior to a meal, freeze it, or look for coated versions.

Is There Poison in My Plastic Bottle?

Fri, 19 Sep 2008 15:13:30 -0400

For decades, the chemical known as bisphenol A (BPA) has been an odorless, tasteless part of clear, shatterproof polycarbonate plastics such as baby bottles, as well as the epoxy resins that line many food and drink cans. Though durable and versatile, these ubiquitous containers have had a recent streak of bad publicity as scientists continue to look into the potential effects of BPA consumption. Many don’t like what they’re seeing.

Randy Jirtle, PhD“Think of BPA as a food additive,” says Duke researcher Randy Jirtle, PhD. “When these containers come into contact with acid or heat, BPA begins to leach into the food or liquid that’s in them.”

After that -- well, it’s still a matter of debate among scientists. BPA mimics estrogen; its half-life is a mere six hours, but we are constantly exposed to it. In 2007 the Centers for Disease Control and Prevention (CDC) reported detecting BPA in the urine of nearly 93 percent of 2,517 Americans tested (age six and up). But what level of human exposure leads to which effects, if any, isn’t yet known.

Researchers in Jirtle’s lab have proven that for mice, BPA exposure in the womb -- an especially sensitive period -- points to obesity, diabetes, high blood pressure, and delays in brain development. “BPA didn’t change their genes, or their ‘hardware,’" says Jirtle.

“But BPA did affect their epigenome, the ‘software’ that tells the genes how to express themselves. BPA effectively put bugs in the software, and it didn’t end with one generation. If our findings are echoed in people, that would mean the effects of BPA can potentially be inherited.”

To counter the effects of BPA, the mice in Jirtle’s lab were given genistein, a plant estrogen found in soy products like tofu. “When the mothers were exposed, it didn’t just reduce the negative effects of BPA -- it completely blocked them,” he says. But Jirtle warns against battling BPA with an all-tofu diet. “As a society, we have a bad habit of thinking that if something is good, a lot must be better.”

What’s the Bottom Line?

So, what should consumers do in the battle over BPA? Jirtle himself eschews the stuff, but other researchers are unsure about the true harms of the substance, which has been documented as an artificial estrogen since the 1930s.

We asked two Duke toxicologists -- both of whom made clear that they are not experts on BPA -- what they thought of the risks associated with BPA contamination in food products.

Woodhall Stopford, MD, says he did a brief assessment when his grandchild was born, and was “not impressed” by the potential risks from using plastic baby bottles.

Dennis Darcey, MD, says that though the ultimate risks aren’t clear, “prudent avoidance would seem to be a reasonable approach,” especially when there are substitutes. These days it’s easy to find BPA-free baby bottles and water bottles -- look for bottles with the recycle numbers 1, 2, 4, and 5, and avoid 3, 6, and 7 -- though Jirtle points out that canned foods haven’t received the same public and media scrutiny.

“And until consumers use the power of their wallets,” he says, “there’s no incentive for companies to change anything.”

Note: Plastic bottles labeled with the recycling number 1 are designed for one-time use only -- they should be recycled instead of reused.

Mending a Broken Back

Fri, 19 Sep 2008 15:27:17 -0400

Because they are the hardest material in our bodies, it can be difficult to remember that our bones are always changing -- their cells are in a constant state of renewal, with new bone cells always being created and old bone cells always being destroyed.

But this balance of regeneration and destruction can get out of whack as we age -- and when bone cells break down faster than they are made, osteoporosis is the result.

Like hypertension, osteoporosis is a silent disease. It may advance quietly for years, until a person’s bones become so fragile that even actions as small as turning or bending can cause a fracture. The delicate bones of the spine are those most at risk.

Many older women develop fractures in their vertebra, and two-thirds of them don’t seek medical help because they don’t feel much pain as a result. But in some people, these fractures cause persistent, sometimes excruciating pain.

Physical therapy researcher Kathy Shipp, PT, MHS, PhD, is looking at interventions that can ameliorate this pain and assist in healing these cracked protectors of the spinal cord.

Staying Stable

For fractured vertebra to heal, they must be stabilized -- a challenge in this most mobile set of bones. One of the most common ways to do so is surgery -- procedures called vertebroplasty and kyphoplasty can fill the degraded bone with cement.

These procedures often relieve pain, but they are still undergoing formal study to determine their long-term effects. Some patients -- and even some physicians -- forego these procedures due to questions about side effects and effectiveness.

Shipp believes that physical therapy alone can go a long way toward stabilizing these fragile joints, and a pilot study she conducted makes the case for her hypothesis. In her study, a small group of elderly women were randomly assigned to either standard care or home visits from physical therapists.

“We taught them to find the straightest, most erect position of their trunk, and to move so that they stayed in that position. We worked on conducting daily activities while maintaining that position -- getting up and down from a chair, brushing their teeth, washing dishes, moving around in bed.”

These women also were given high-quality rolling walkers, so that their spine would be better stabilized and under less pressure when they were walking.

Though Shipp describes the techniques as “just very basic movement retraining,” she says they made a world of difference in the study participants’ reported pain.

The women who received the home visits had far less pain than the control group -- a 90 percent decrease after three months, where the control group had a 33 percent increase in pain. This study was a small one, so Shipp hopes to be funded to test the technique in a larger group. If her methods are proven successful, they could provide a new standard of care for vertebral fracture patients.

“My belief is that it won’t take all the pain away, but it will help people get through their recovery phase and make it less hard on them."

How to Have a Happy Memory

Fri, 19 Sep 2008 15:16:50 -0400

Treat your brain well and you may never again find yourself in that awkward position of trying to conjure up an acquaintance’s name at the supermarket.

That claim might be a bit optimistic, but there are things you can do to ward off such “senior moments” according to Murali Doraiswamy, MD, chief of biological psychiatry at Duke and co-author of The Alzheimer’s Action Plan.

Murali Doraiswamy, MDTo begin with, says Doraiswamy, calling a short-term memory lapse a “senior moment” only perpetuates the negative -- and untrue -- stereotype that age inevitably leads to memory decline. He prefers the term, “‘wisdom moment’ -- because our brains also get wiser as we get older, so it’s not all bad.”

In fact, recent research shows that senior moments might simply be a reflection of the brain working to sort through its years of accumulated knowledge -- which is a good thing, because it means your brain has more information available to it.

Most people are only half joking when they refer to these lapses, because deep inside they fear something is wrong. Not necessarily, says Doraiswamy.

What doctors look for in memory health is a change from the usual. Forgetting where you put your checkbook once in a while is not worrisome; forgetting how to balance it is. Temporarily forgetting the name of an acquaintance is not unusual for most people, but forgetting the faces of familiar colleagues at work is.

Other red flags include forgetting how many grandchildren you have, what you ate last night, your ZIP code or area code, the name of your doctor, the names of the schools you attended, or what you read in the newspaper this week.

Doraiswamy says an important distinction is the inability to recall this information later, when you are not trying so hard, or when you are given cues. People with Alzheimer’s disease usually cannot recall information even given time or hints.

If you are concerned that memory loss is affecting your daily life, the best thing to do is see your doctor.

Tips on how to really love your brain

Is It Really Alzheimer’s?

Alzheimer’s disease and other forms of dementia can start as memory lapses, but memory lapses don’t always lead to Alzheimer’s. Many things can cause unsettling memory lapses:

Depression
Thyroid deficiency
Diabetes
Heart, lung, or circulation problems
Vitamin deficiencies

But these conditions are all treatable.

One of the most common causes of dementia is vascular illness and stroke, so stroke prevention is another good way to preserve your memory and mental function.

How to Really Love Your Brain

Fri, 19 Sep 2008 15:19:30 -0400

Although there is no sure-fire way to prevent dementia, memory expert Murali Doraiswamy, MD, says there are many things you can do to keep your mind sharp as you age:

It’s like a garden: fertilize it. Studies have shown that mental activities such as working crossword puzzles or playing chess can not only maintain your brain, they can improve its function. Mental activities seem to boost production of nerve growth factors -- sort of a fertilizer for the brain, says Doraiswamy. This keeps your nerve cells more connected, and the more connections one has the more reserve capacity one has to stave off diseases like Alzheimer’s.

It’s like an athlete: cross-train it. Beyond your usual sudoku or bridge, look for new activities to cross-train your brain. Your brain will benefit from the workout -- like using muscles that rarely get worked. Learn a new skill or attend a lecture on an unfamiliar topic. Try something you’ve never done before -- such as learning to upload videos to YouTube -- or perform a routine activity in a different way.

It’s like a teenager: let it hang out with friends -- and sleep in. Be a social butterfly and avoid being isolated. Your brain likes being around people. It also uses sleep as valuable time for turning experiences into memories, so don’t skimp on shut-eye. In fact, chronic sleep deprivation can cause Alzheimer’s-like symptoms.

It has cravings: indulge it. The brain’s favorite foods are the same as the heart’s favorite foods: richly colored fruits and vegetables and omega-3 fatty acids. The best bets in terms of nutritional supplements are B vitamins, folic acid, and fish oil. Your brain also craves a good aerobic workout, which stimulates blood flow, enhances levels of brain-healthy chemicals, and improves stress, depression, and sleep -- a triple treat for the brain.

It has its limits: don’t stress it. While excess cholesterol is probably as bad for your head as it is for your heart, stress is the ultimate enemy of brain function. In addition to aerobic exercise, yoga, meditation, and mindfulness can help you worry less and be happy more. "The brain likes optimism," says Doraiswamy.

Take Action

The tips on this page are all adapted from The Alzheimer’s Action Plan. Doraiswamy teamed with Lisa P. Gwyther, MSW, founder and director of the Alzheimer’s Family Support Program at the Duke University Center for Aging, to co-author this book, which is a step-by-step guide for memory problems or Alzheimer’s, as well as those simply interested in prevention.

The book, praised by national memory experts and health advocates, is a guide for patients and their loved ones, with advice on everything from medical options to emotional well-being. It includes tips for a brain-healthy lifestyle, treatment myths, and a peek at the future of Alzheimer’s treatment.

Osteoporosis: Bolster Your Defenses

Fri, 19 Sep 2008 15:29:49 -0400

Most people know how important calcium is to maintaining bone health, and it’s not hard to get enough of this mineral: by eating adequate amounts of calcium-rich foods, one can get plenty of calcium without even taking a supplement.

Physical therapy researcher Kathy Shipp, PT, MSH, PhD, who serves on the scientific and educational committees of the National Osteoporosis Foundation, says that there are two other bone protectors that need more attention: vitamin D and exercise.

Today’s indoor culture has created an “epidemic of calcium and vitamin D deficiency,” she says, and our sedentary ways are taking a toll on our bones.

Vitamin D

This vitamin is important because it helps your body use the calcium it gets. We can manufacture vitamin D in our skin following direct exposure to sunlight -- sun exposure of about 15 to 20 minutes without sunscreen can help most fair-skinned people make the amount they need.

But people with dark complexions, as well as older people whose skin doesn’t manufacture vitamin D as efficiently as younger skin, may need more exposure.

And, in the wintertime, even those of us in the temperate climate of North Carolina aren’t getting enough of the sun’s potent rays to make the adequate levels -- only latitudes of Atlanta and south receive that amount of light.

Because it’s difficult to get the vitamin D you need through sunshine and food sources, says Shipp, just about all of us should take a supplement. This year the national osteoporosis foundation revised its recommendations for vitamin D supplementation to 800 IU for people under 50, and 1,000 IU for those over 50 years old.

Exercise

People of every age need to stay active for a variety of physical, mental, and emotional health reasons. But Shipp notes that there’s a misconception that aerobic activities like walking are enough activity for bone health.

“Really what’s best for people to prevent fractures and falls is muscle strengthening exercises, which should be practiced two to three times a week.”

To learn more about the National Osteoporosis Foundation’s recommendations for preventing and treating osteoporosis, visit their Web site.

Q&A with Sam Katz, MD

Fri, 19 Sep 2008 15:32:33 -0400

Some parents fear vaccinations because of Internet and media stories linking them to autism. Samuel L. Katz, MD, co-creator of the measles vaccine and chairman emeritus of pediatrics at Duke, answered a few questions about the truth behind the rumors.

How did vaccinations become linked with autism?

Autism began being linked with vaccines because of a single, flawed study in the United Kingdom in the late 1990s involving 11 or 12 children. The conclusion of this research has been proven totally false.

Sam Katz, MD

Are there scientific studies that link vaccines to autism?

No. Scientific investigations have failed to demonstrate vaccines as a cause of autism.

Are any vaccines singled out?

In the United Kingdom, the measles, mumps, and rubella (MMR) vaccine is implicated by parents as a cause of autism, in part because of the temporal relationship of the two.

That is, the first MMR vaccine is administered around 12 to 15 months of age, a typical age for the diagnosis of autism -- although there is no evidence to suggest any other connection. In this country, that theory was quickly dropped, and what persists is the idea that vaccines containing the preservative thimerosal cause autism. However, thimerosal was removed from vaccines for children (except some influenza and virus vaccines) in 2001, and the cases of autism continue to increase instead of decrease.

What causes autism?

We don’t yet know the cause of autism. I think we will find there is not a single cause, but a number of contributing factors, including genetic predisposition.

Why has the number of diagnoses of autism increased?

The definition of autism in recent years has broadened to include a whole host of learning disabilities and psychiatric disorders that, in the past, were not labeled autism.

Why do the misconceptions about autism persist?

There is an abundance of misleading and scientifically unreliable information on the Web and in the media from alleged authorities and even celebrities. However, the world’s leading health organizations -- the Academies of Pediatrics and General Practice, the Centers for Disease Control, the Institute of Medicine, and the World Health Organization -- have all agreed that vaccines do not cause autism.

What are the risks when parents refuse vaccinations?

There have been outbreaks of preventable diseases among unvaccinated children in this country -- very recently in San Diego and Hawaii. All of the cases of measles we’ve had in this country in the past 16 years have been due to importations from countries abroad where measles still exists. The disease then spread into clusters of unvaccinated children. Diseases are just a jet plane ride away, and children who are not vaccinated are at risk.