This information is for educational purposes only. Common sense dictates that you ALWAYS check with your doctor first before trying any type of new therapy. I look forward to your feedback on this, and all, sections of Jacksonville Medical Park. Let us know what you want and we will do our best to bring it to you.

Charles H. Booras, MD
Co-Founder and Editor
Jacksonville Medical Park-online

December 1997

Tips for Fitness Walking
December 19, 1997

Thought you mastered walking at age one? Well, think again. Fitness walking isn't an afternoon stroll. We're going to get all of you exercise newbies moving with an easy walking program that's guaranteed to help you get fit, toned, and on track with a fun cardiovascular workout.

Before you get started let's run through some easy-to-follow walking tips. By following these key steps, you'll reduce your risk of injury, ensure that your body works at its peak, and show that you're serious and ready to get healthy.

Remember to:

Stand up straight. Look directly ahead. Imagine that a string is attached to the top of your head and is lifting you from the ground. Keep your shoulders back and relaxed, chest out, and tailbone slightly tucked under.

Relieve the stress points. Relax your shoulders and shake out any tension from your arms and wrists. Bend your arms at the elbow about 83 degrees. Wiggle your fingers and then hold your hands in loose balls (pretend you're clasping a jumbo-size magic marker against your palms). Swing your arms naturally as you walk, but try not to let your hands extend above your chest.

Keep your steps short and fast. The faster you move, the better your cardiovascular workout. Try to keep an even stride and maintain a steady pace.

Heel-to-toe motion. As you walk, your heel should be the first part of your foot to hit the ground. Roll along the length of your foot and push off with your toes. This motion reduces the risk of shin splints and tendon pulls.

Fitness assignment: This week hit the pavement for 10 minutes on three days. Watch your form as you walk!


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Five Food Tips to Fight Fatigue
December 9, 1997

You know the tell-tale signs: First your eyelids get droopy, then whatever's on your computer screen starts to swim around, and you feel glued to your chair. Yes, it's the afternoon slump. And for those who've had it everyday for years, it can seem hopeless. But there is hope. Try these five food tricks and see the difference it makes in your day.

1. Eat a light breakfast combining low-sugar cereal and low-fat milk or yogurt.

Here's why:
Not eating breakfast puts you at an energy deficit when you need the fuel the most. Sugar and carbohydrates alone will trigger an energy rush that quickly peters out. Carbohydrates combined with protein make for long-lasting energy. Fat and lots of calories will trigger serotonin production in your brain, making you more calm, almost sleepy.

2. Have one or two cups of coffee.

Here's why:
The caffeine in coffee stimulates your whole system. One or two cups makes you a coffee achiever. Caffeine is also a serious drug, and consuming more than five cups a day can trigger withdrawal symptoms when you are not drinking it. People who drink lots of coffee often spend their days on an energy roller coaster, with extreme highs after coffee and deep lows as it wears off. Not only is this depressing, it's exhausting.

3. Make lunch light and protein-rich -- with choices like a low-fat turkey sandwich.

Here's why:
Any meal over 1,000 calories will slow you down and make you drowsy. So heavy lunches can be your ruin. Too many carbohydrates without protein (pasta for example) will elevate serotonin levels in your brain, leaving you calm and sleepy for the afternoon. Too much fat will do the same thing. Lunch should be satisfying, you should feel lightly full afterwards. If you only eat salads with non-fat dressing, you're eating the equivalent of a fruit juice, without the sugar. Try adding some chick peas, or sunflower seeds for protein.

4. Snack on fruits, pretzels, fresh veggies, or granola between meals. Avoid sugar-rich candies or sweets.

Here's why:
Snacks are good for you. Eating small meals throughout the day gives you a steady supply of energy -- never too much, never too little. Sugar, which is supposed to be an "energy" food, actually slows you down. Not only does it raise serotonin levels in the brain, it also dumps into your system so fast that your body has to divert energy from other places just to process it.

5. Drink lots of water, even when you are not thirsty.

Here's why:
Dehydration, which is a lot more common than you might think, causes crankiness and fatigue.


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Estrogen Helps Retain Memory
December 23, 1997

Taking estrogen after menopause may protect against age- related memory decline, a new study suggests. Women over 40 who took the hormone tended to score better on visual memory tests, and retain an edge over time, compared with women who never took estrogen, according to a report in the current issue of Neurology.

The findings may indicate that taking hormones can ward off memory decline, or even Alzheimer's disease, as some other reports have suggested. On the other hand, the study looked at estrogen-users in the general population, women who tend to have more money, education and healthier lifestyles than their peers - factors that may influence memory decline.

Overall, hormone users had an average of two fewer errors than women not taking estrogen. Test results from a small group of 18 women tested before and after starting estrogen suggested that the hormones protected against age-related memory decline.

Those who started taking hormones during the study "maintained stable performance over time, whereas women who remained off estrogen replacement therapy showed the predicted age-associated increase in memory errors," concluded lead study author Dr. Susan Resnick, of the Laboratory of Personality and Cognition at the National Institute on Aging in Bethesda, Maryland.

The study included 116 hormone users and 172 non-users who took the Benton Visual Retention Test (BVRT) in which a series of 10 different forms are shown for a few seconds, and then the participant is asked to reproduce them on a blank sheet of paper. Test scores tend to decline with age, particularly in the late 60s and early 70s, and may dip several years before Alzheimer's disease symptoms become apparent. The women took the test every six years from 1978 to 1991, and then every two years until 1994.

The findings "offer further support for a beneficial role of estrogen on cognitive function in aging women," the authors concluded.

SOURCE: Neurology (1997;49:1491-1497)


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Tips for a Healthier Lunch
December 24, 1997

It's one o'clock; you have a project that needs to be finished. But your stomach's growling so loud you're afraid the boss will hear.

Or maybe it's four o'clock, and you realize you've missed lunch altogether. For busy people, lunch may be the most difficult meal to squeeze into the day. And when you do find time to eat, you worry that you might face an after-lunch slump where your energy is low and urge to sleep is high.

But you've got to eat lunch! It's necessary for your body to stay energized until dinnertime. You simply need to choose healthy and satisfying foods. See what nutritionist Joan Salge Blake has to say about avoiding overeating at the food court. Also check out Joan's survival tips for eating a lean lunch and her game plan for healthy eating.

Instead of buying lunch, try the more tried-and-true method of packing a lunch at home. Here are some tips to get the most out of brownbagging it:

Go Heavy on the Veggies. Bring easy-to-eat foods, like chopped carrots or celery sticks filled with nonfat cream cheese. If you pack a salad as your main meal, include some chickpeas, kidney beans, or tuna, so you get your protein as well as your greens. To vary the flavors, add some raisins or shredded beets on top.

Soup It Up. Many of today's cup of soups are much lighter and healthier than the original versions. If you have a microwave at work, simply fill the cup with water and heat for a quick, filling meal.

Save Your Sandwich. Sandwiches are easy to make and transport. If you're sick of low-fat sliced turkey, try sliced chicken or low-fat sliced ham. Or make low-fat tuna sandwiches: Use tuna packed in water and mix with nonfat mayo or plain yogurt. A veggie sandwich filled with lettuce, tomatoes, sprouts, low- fat cheese, and a dab of mustard also makes a superb lunch.

Treat Yourself to a Tater. Bring a potato to work and bake it in the microwave. Top with fresh veggies, low-fat cottage cheese, or salsa for a real lunchtime treat.

Perk Up Your Pasta. Make more than enough pasta for dinner the night before and eat the extra for lunch the next day. Before you reheat the pasta, chop in a tomato and sprinkle on some fresh spices for extra zing.


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Five Tips for a Better Night's Sleep
December 23, 1997

"I'm exhausted" is the complaint of the '90s. How often have you heard a friend or coworker complain about not getting enough sleep the night before or wanting to take a long nap after eating lunch?

It's especially important to get enough sleep during stressful times, like the holidays. You may feel pulled in many directions by visitors, errands, and meal preparation. But if you sacrifice sleep when you're stressed, you'll create a vicious cycle where you're tired all the time -- and you may end up getting sick as a result.

A good night's sleep helps you feel alert enough to deal with everything life throws at you -- whether it's at work, in a relationship, or simply day-to-day life. Most studies have found that, on average, adults need between seven and nine hours of uninterrupted sleep a night, though it varies widely from person to person. Try these five tips to increase your chances of sleeping more soundly:

1. Work Out.

Exercise relaxes muscles and relieves tension. Just make sure you don't exercise too late in the day: Since working out is an adrenaline-booster, you may find yourself too wired to sleep. A good rule to follow: Don't exercise for at least two hours before you go to bed.

2. Relax and Unwind.

Relaxation techniques calm you and let you forget your stresses for awhile. Yoga or meditation often does the trick, as does massage or even a nice, warm bubble bath. Aaaah. Lovemaking is also a natural relaxant that can be quite effective before bedtime!

3. Set Your Internal Clock.

It's important to establish a consistent time for going to bed and waking up. Your body becomes used to hitting the sack at a regular time, and this helps you fall asleep more easily.

4. Divert Yourself.

Once you get in bed, if you toss and turn and can't sleep a wink, go into another room and pick up a book for awhile or listen to some music. When you start feeling drowsy, head back to bed.

5. Factor Food In.

While you don't want to go to bed hungry, be careful of what you eat close to bedtime. Spicy, greasy, or heavy foods may not digest well and can cause you to wake up during the night with an unhappy stomach. Also avoid caffeine within six hours of hitting the sack. Better choices for before-bed snacks include foods high in carbohydrates, such as bagels or crackers, which digest more easily. And don't forget the old standby, a glass of warm milk -- it really may help soothe you to sleep.

If you try all of these techniques and still can't get enough sleep, or feel extremely tired the next day, you may have a sleep disorder such as sleep apnea. Sleep apnea is also known as "snoring sickness." It causes sufferers to wake up repeatedly during the night. See your doctor if you suspect you have this disorder. Anyone who's tired and low on energy during the day might also want to try these five food tips to fight fatigue.


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Exercises for Your Aching Back
December 22, 1997

Whether you spend most of the day sitting or standing, chances are you suffer from occasional back tension and fatigue. And nothing throws a monkey wrench into your exercise routine like an aching back. These stretches promise to keep your back healthy. They will improve your posture, reduce lower-back fatigue, and strengthen and condition your back muscles.

One yoga exercise that conditions your back and helps release the tension collected in your shoulders, neck, and lower back is the cat tilt. The cat tilt feels great after a day spent hunched over a keyboard.

To do the cat tilt:

1. Get on your hands and knees. You might want to grab an exercise mat if your floor is hard or cold; or a cushioned towel if your knees need extra support.

2. Place your hands, flush with the floor, shoulder-width apart and your knees directly under your hips. Keep your back parallel with the floor. Get comfortable. You should look like a table from the side.

3. As you exhale, slowly tilt your back up. Imagine that a string is lifting your middle back toward the ceiling.

4. Pull in your abdominal muscles, curve your shoulders and pelvis down. Move your head down, but try not to strain your neck. Get rounded. And feel the stretch along your back.

5. As you inhale, slowly rotate your head, shoulders, chest, and bottom up. Curve your stomach down.

6. Feel the stretch releasing the tension along the length of your back.

7. Repeat the cat tilt, six times, moving slowly and with control to your breath.

Fitness assignment: Add the cat tilt to your training exercises. In fact, do the cat tilt before you get started. The cat tilt helps you to loosen up and warms your back muscles. It also feels great. For variety, alternate the cat tilt with the cobra posture.


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FDA Approves Pill For Male Baldness
December 23, 1997

The U.S. Food and Drug Administration (FDA) granted approval of the drug Propecia on Monday, making it the first drug for male pattern baldness to be available in pill form.

The drug's active ingredient, finasteride, is already approved for the treatment of prostate enlargement and is sold by Merck & Co. under the brand name Proscar.

Propecia, which contains one fifth the dose of finasteride found in Proscar, will be available by prescription only. Merck plans to have the drug on pharmacy shelves by mid-January.

Dr. Keith Kaufman, senior director of clinical research at Merck Research Laboratories in Rahway, New Jersey, says men with mild to moderate hair loss on the top of their heads and at the back of the scalp who took Propecia for 12 months either maintained or showed visible increases in the number of scalp hairs, compared with men taking a placebo (dummy) pill who continued to lose hair.

A one-year extension of the study in 1,200 men from the original sample with hair loss only on the top of their heads, showed that the effects of the pill continued in all but 17%. But 72% of men in the placebo group continued to lose hair.

"Propecia works by blocking an enzyme called 5-alpha reductase, which is responsible for the formation of DHT - dihydro-testesterone - in a man's body," Kaufman explains. He says the enzyme converts testosterone to DHT and "there is sufficient information at this point to identify that DHT is a key factor in the development of male pattern hair loss. Finasteride decreases the concentration of DHT in a man's scalp by about two-thirds when he takes it as a pill."

According to a Merck statement, it may take three months or more before men see a benefit from the drug, which is taken once daily. If the drug is stopped, the hair gained will be lost within 12 months of stopping treatment.

As to side effects, Kaufman and his colleagues told a telephone press briefing that less than 2% of men taking the drug reported a diminished desire for sex, difficulty in achieving an erection (impotence), and/or a decreased amount of semen. These side effects disappeared once the men stopped taking the drug, and they also disappeared in 58% of men who continued in the study.

"In regards to impotence, it's approximately only 1% of men who reported it at all," said Dr. Ken Washenik, a New York University dermatologist involved in the clinical studies. "This is only approximately a half of a percentage point difference from the men who were taking a placebo, or the fake medication."

Propecia can also affect the results of the prostate-specific antigen test (PSA), a blood test used to detect prostate cancer. Patients should tell their doctor that they are taking the drug when they have blood taken for a PSA test.

Propecia will not be marketed for women because the drug's safety and effectiveness have not been established in women, says the FDA, and it is associated with birth defects, such as hypospadias, an abnormality of the penis.

"In addition, women should not handle crushed or broken tablets when they are pregnant or may potentially be pregnant," according to a Merck & Co. statement. "Propecia tablets have a coating that will prevent contact with the active ingredient during normal handling, provided that the tablets have not been broken or crushed."


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More Support For Chicken Pox Vaccines
November 28, 1997

Health experts have been pleading with parents for years to get their kids inoculated against chicken pox instead of accepting its outbreak as a childhood rite of passage. Good advice, because much more serious complications sometimes develop.

Chicken pox can be followed by a bacterial infection called Group A Strep. Most infections are mild, but if it reaches sterile body parts like the blood or muscle it can be life-threatening. Johns Hopkins pediatrician Dr. Neal Halsey says about 100 Americans die each year following chicken pox.

"And a number of those [cases] are caused by a secondary infection with Group A Strep," explains Halsey. "The most important thing is it's totally preventable by preventing chicken pox through the use of the vaccine, which is now recommended for all healthy children everywhere in the country."

There was an alarming outbreak of Group A Strep at a Boston day care center earlier this year. Those children who already had their chicken pox vaccinations were not affected.


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The Prevalence of Osteoporosis in Men
November 24, 1997

All of us to a varying degree face the problem of thinning or brittle bones as we age. Yet public health campaigns that warn of osteoporosis are almost always aimed at women - a mistake experts say.

Up to a quarter of all hip fractures in the U.S. happen to men. Slowly falling levels of testosterone in men over age 50 put them at risk also for joint and spinal problems in their 70s and 80s. Diet, exercise, and alcohol intake also play a role in how quickly eroding bone mass is replaced.

"We do know that men lose bone mass as they age, and in some men this is accelerated and they will actually develop a more significant degree of bone loss, and will develop osteoporosis," explains Johns Hopkins doctor Michael Levine. "The reason we don't recognize osteoporosis in men as frequently as in women is that we're not thinking about it."

But we should be, says Levine, because osteoporosis affects as many as five million older men in America.


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Supplement Guidelines Released
November 25, 1997

The Food and Drug Administration (FDA) should regulate some botanical supplements as over-the-counter drugs, says a Presidential Commission on dietary supplements.

And the FDA, supplement manufacturers, and physicians should work together to report adverse reactions in supplement-users, though no change in existing laws is recommended in a report released Monday by the Presidential Commission on Dietary Supplement Labels.

Overall, the safety of supplements are the responsibility of manufacturers, and the industry should develop an expert advisory committee to review safety, benefit and appropriate labeling of supplements, according to the seven member panel of experts. The Presidential Commission was mandated by the Dietary Supplement Health and Education Act (DSHEA) of 1994 to evaluate the best methods of getting information to consumers, so that they can make a decision regarding the use of dietary supplements.

Other recommendations from the report:

- The process for approval of health claims should be the same for dietary supplements as it is for conventional foods.

- The FDA should establish an over-the-counter review committee for botanicals, in case there is evidence of a therapeutic claim that goes beyond statements permitted by the DSHEA.

- The supplement industry could benefit from scientific input regarding the health and safety of dietary supplements, and thus should establish an expert committee to provide advice.

- The commission "strongly suggests" that manufacturers include appropriate warnings in product information, including advising women who are pregnant or breastfeeding to consult a physician before taking supplements.

- Health professionals and consumers should be provided with evidence concerning the benefit and safety of dietary supplements, but the commission did not recommend amending FDA regulations issued in September.

The new regulations require that vitamins, minerals, herbs, and other supplements contain label information on serving size, vitamin and mineral content, all ingredients found in the product and, in the case of botanicals, from what part of the plant the ingredients are derived.


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Smoking Cessation Cost-Effective
December 3, 1997

A new study of federal smoking cessation guidelines shows that efforts by physicians to promote smoking cessation are cost-effective when compared with other preventive interventions.

Results of the study evaluating the Agency for Health Care Policy and Research's (AHCPR) Clinical Practice Guideline appear this week in The Journal of the American Medical Association.

The guideline, released in 1996, recommends 15 smoking cessation interventions that were identified as effective. They range from use of transdermal nicotine patches and brief counseling by doctors to more intensive group counseling.

"That analysis is based upon the most comprehensive review of the scientific evidence regarding smoking cessation," says study co-author Dr. Michael C. Fiore, director of the Center for Tobacco Research and Intervention at the University of Wisconsin in Madison. "In essence, a panel of experts reviewed virtually everything that's been published about smoking cessation to answer one key question: what helps people quit smoking successfully and what does not? And based upon that, released in April of 1996, a series of recommendations for clinicians to be most effective for helping their patients to quit."

Fiore and his colleagues have analyzed the AHCPR's guideline and determined that the recommended smoking cessation interventions are cost-effective. Moreover, the greater the spending on interventions, the greater the net benefit in both money saved for society and quality of life for those who quit smoking.

"We know that 7 out of 10 smokers see a physician every year," Fiore notes. "There's not a single group that has the same access, the same opportunity to help smokers as physicians. Until now ... clinicians have not been maximally seizing this opportunity to help their patients successfully quit - and that's what this guideline is about - teaching physicians what they can do in a brief intervention to help patients quit."

According to Fiore, even "the simple kinds of advice that a clinician can provide in three minutes," including advice on the importance of social support, the importance of setting a quit date for total abstinence, and the importance of brief medication for smokers of more than 10 cigarettes a day, can be effective.

"If these interventions are put in place, if physicians across America took up this challenge and addressed tobacco with every patient who walks through their door, it will not only save lives, but it'll save dollars."

If the AHCPR guideline interventions were applied to 75% of smokers ages 18 years and older, the cost of implementation would be $6.3 billion in the first year. As a result, society could expect to gain about 1.7 million new quitters at an average cost of $3,779 per quitter, $2,587 per life-year saved (the cost to society to gain the extra life-years for smokers who quit through interventions), and $1,915 for every quality-adjusted life-year (QALY) saved. QALY refers to a year of healthy life.

Looking at the cost per life-year saved, Fiore says the smoking cessation interventions "are 20 times more cost-effective than mammography screening, about 40 times more cost effective than treatment for high cholesterol - it's probably the most cost-effective prevention intervention a physician can engage in."

The researcher says he hopes the new report will also have an impact on health insurance policy. "It's a paradox in America that virtually every (health) insurance policy pays for the outcomes of smoking, whether it's a heart attack, or stroke or cancer, but only about half of them pay the $100 to $200 it would take to prevent those very expensive illnesses," he says.

"One key recommendation from our report is that insurers - health maintenance organizations and private insurers - need to begin to do the right thing, and that is to encourage their subscribers to quit smoking. And one important way to do that is to make smoking cessation treatments that are effective a covered part of every insurance plan in America."

SOURCE: The Journal of the American Medical Association (1997;278:1759-1766)


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Communication Can Avert Medical Problems
December 3, 1997

Nine doctors in 10 say serious medical conditions could be averted if patients were more willing to talk about their problems.

Reporting Tuesday in New York, former Surgeon General C. Everett Koop reported on the results of a national survey by the Louis Harris organization. He identified a series of barriers that must be overcome in unsatisfactory communications between patients and their medical providers.

To tackle those isues, Koop announced formation of the Take Time to Talk Advisory Council, of which he is chair. The council, representing key national health care organizations, will focus on what he called the ''tremendous consequences of allowing sensitive health issues to remain unaddressed and unresolved.''

''All in all,'' Koop said, ''the art of medicine is being overshadowed by the science and the business of medicine.''

Both sides in the doctor-patient relationship face obstacles to good communication, Koop said. Among physicians, more than two-thirds reported ''serious difficulties'' treating patients who are too embarrassed or otherwise hesitant to talk about their health problems. A similar number of doctors said that not being able to spend enough time with patients is a problem. And three out of five responded that they were not well-prepared for communication with patients during their medical training.

Patients for their part reported finding themselves particularly uncomfortable when the subject touches on incontintence and sexual matters, including sexually transmitted disease, sexual dysfunction, gynecological difficulties, abuse, fertility, and prostate problems. Patients are also likely to feel embarrassed about bringing up emotional difficulties, such as depression.

A quarter of the patients surveyed also said that not having enough time to visit a doctor was one of the main reasons they postposed seeking medical attention.

Koop said, ''Without the trust and confidence instilled by honest and empathetic interchange, patients are more inclined to avoid proper medical care.''


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Annual Mammograms Benefit Women 40-50
December 2 1997

Mammograms performed once a year in women 40 to 50 years of age could result in a breast cancer mortality reduction of up to 75%, experts say.

"Mammographic screening can reduce mortality from breast carcinoma in women age(d) less than 50 years," conclude researchers at Sahigrans University Hospital in Gothenburg, Sweden. Their study appears in the current issue of the journal Cancer.

The researchers examined the long-term breast cancer mortality of nearly 12,000 women, each of whom was between 39 to 49 years of age when the study began in 1983-1984. The women agreed to undergo mammographic screening once every 18 months over the next 10 years.

The subsequent breast cancer mortality of this 'study' group was compared with that of a 'control' group of 14,217 middle-aged women. Those women delayed having mammography performed until a full six to seven years after the women in the study group.

The Swedish researchers discovered that the women who began regular screening relatively early in life were 45% less likely to die from breast cancer than those who delayed mammography.

Regular screening may spot more cancers at an earlier age. The researchers point out that about two thirds of all breast cancers detected in the study "were diagnosed before age 50 years."

Dr. Stephen Feig, a radiologist at Philadelphia's Jefferson Medical College, believes the Swedish study may help settle the ongoing debate as to the efficacy of regular breast screening in women under 50.

In an editorial appearing in the same issue of Cancer, Feig notes that annual mammograms may even more beneficial than the once-every-18-month exams evaluated by the Swedish team.

In fact, Feig estimates that annual mammography could cut breast cancer deaths in women under 50 years of age by as much as 75%.

He explains that breast tumors in young women generally grow faster than those found in older women. "For mammographic screening to be effective in women age(d) less than 50 years, screening must be more frequent than in older women."

Feig also believes that improved screening technologies are making it easier to spot tumors in the breast tissue of younger women, which is usually denser and more difficult to interpret radiographically than that of older women.

SOURCE: Cancer (1997;80)


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Elderly Going Without Vaccines, Tests
December 5, 1997

Nearly half of the elderly are going without important preventive vaccines and medical tests, experts say, even though Medicare provides these services free-of- charge.

"Health care coverage alone does not ensure use of preventive services," conclude researchers at the Centers for Disease Control and Prevention (CDC). Their report appears in this week's edition of the CDC's Morbidity and Mortality Weekly Report.

Investigators evaluated data from the CDC's 1995 Behavioral Risk Factor Surveillance System survey, an annual random telephone survey of the health habits of over 100,000 Americans in all 50 states.

Focusing on 22,500 Medicare recipients over 65 years of age, the report discovered that many are not receiving pneumonia inoculations, annual influenza shots, mammograms, and Pap smears. Each of those services has been fully covered by Medicare since at least 1993.

Statistics varied greatly between states. Some of the study findings:

- More than half of Medicare recipients in Alabama, Alaska, Georgia and New Jersey did not receive flu shots in 1995. Elderly residents of Utah were most likely to take advantage of the free shot, with a 70.3% inoculation rate.

- Only one quarter of Kentucky and Louisiana elderly had ever received the one-time (lifetime) pneumococcal vaccine. None of the states reported more than a 50% pneumococcal inoculation rate for its elderly population.

- While 4 out of 5 elderly women in Alaska had received their biennial mammogram, nearly half (47.3%) of female New Jersey Medicare recipients went without the procedure.

- Government experts recommend that women over 65 have a Pap smear once every 36 months. However, just 54.6% of elderly women in Louisiana reported doing so. In contrast, Arizona led the nation, with 88.5% of its elderly female population undergoing recent Pap smears.

Most of these statistics fall far short of current federal health objectives. The CDC experts aren't sure why many Medicare recipients do not take advantage of potentially life-saving preventive procedures, or why statistics should vary so widely state-to-state. But they believe the risk for avoidance of these services is increased in "lower income and education groups."

They say "the development of outreach programs of clinical preventive services targeted to older adults" could help encourage wider utilization of vaccinations and testing.

Preventive measures are of key importance to the health of elderly populations, who remain especially vulnerable to both cancers and infectious disease.

SOURCE: Morbidity and Mortality Weekly Report (1997;46(48):1138-1143)


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Drug-Resistant Bacteria On The Rise
December 5, 1997

Certain strains of a potentially life-threatening bacteria appear to be developing resistance to the last antibiotic that can still kill the organism, according to a Japanese report. The bacteria is Staphylococcus aureus and it can cause anything from boils on the skin to pneumonia to septicemia, a potentially deadly blood infection.

About 20% of multidrug-resistant strains of S. aureus isolated from patients in Juntendo University Hospital in Tokyo showed signs of partial resistance to vancomycin, the antibiotic doctors now rely on to kill such difficult-to-treat bacteria.

About 9% of strains isolated in other Japanese hospitals were also partially resistant as were 1% of strains isolated from non-university hospitals and clinics, according to the report in the current issue of The Lancet. The researchers tested a total of 1,149 strains of bacteria from patients in 203 hospitals.

They began the study after discovering a vancomycin-resistant S. aureus (VRSA) in a Japanese child last year who had an infected surgical wound that did not respond to 29 days of vancomycin treatment.

None of the strains in the new study were completely resistant to the drug, but they showed heterogeneous or variable resistance - that is about one in every million bacteria in the strain could survive the antibiotic. If even a few resistant bacteria survive, they can grow and then spread in the population, causing virtually untreatable infections.

The appearance of hetero-VRSA strains in two distant areas in Japan - the Hiroshima area and Tokyo - "suggests that wide dissemination might occur and indicates the need for special precaution to limit the spread of VRSA strains in Japan (and the world)," reported lead author Dr. Keiichi Hiramatsu, of the bacteriology department at Juntendo University.

Since strains of S. aureus resistant to methicillin and other antibiotics began appearing in the 1980s, "vancomycin has been the drug of choice and commonly the sole antimicrobial agent available for the treatment of serious methicillin resistant S. aureus," according to an editorial by Dr. Soad Tabaqchali, of the medical microbiology department at the Royal London School of Medicine and Dentistry in London, U.K.

Now multidrug-resistant strains of S. aureus that appear to be developing resistance to vancomycin have popped up in both Japan and the U.S.

"These findings emphasize the need to improve our laboratory methods to detect such strains and monitor their emergence, especially in patients unresponsive to vancomycin therapy," Tabaqchali wrote. "There should be strict infection-control measures and affected patients should be isolated to prevent spread and the risk of these strains becoming endemic."

Another preventive method? Avoiding overuse of antibiotics, which hastens the development of drug-resistant bacteria.

SOURCE: The Lancet (1997;350:1670-1673)


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How Depression Affects Heart Attack Patients
December 5, 1997

A key part of recovering from a heart attack is following the doctor's orders, whether they are to exercise more or eat a healthier diet. But nearly a quarter of heart attack patients just can't do it - they're too depressed.

A recent Johns Hopkins study tracked more than 200 people who survived a heart attack. Those who reported feeling depressed soon after the event also reported trouble sticking to a healthier lifestyle, even when they really wanted to.

"They were less likely to follow a low cholesterol and low-fat diet," explains the lead author of the study and Hopkins cardiologist Dr. Roy Ziegelstein. "They were less likely to reduce stress in their lives, less likely to exercise, and if they were diabetic, less likely to follow a diabetic diet."

Ziegelstein says some depressed patients may lack the help and encouragement from others that's crucial for making major changes in lifestyle. He says the study underscores the need for better psychological care for people who have suffered heart attacks.


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Low-Dose Estrogen Works, Fewer Side Effects
December 9, 1997

NEW YORK (Reuters) - A plant-derived Estrogen is just as effective at preventing bone-thinning in postmenopausal women, but it can be used at lower doses - and therefore may have fewer cancer-promoting side effects.

The esterified Estrogen can be used at about half the dose as the type of Estrogen found in most hormone replacement regimens, according to a report in the Archives of Internal Medicine.

In the new study of 406 women, those taking esterified Estrogen had an increase in bone mineral density in their spines compared with those taking a placebo or inactive medication. And the drug increased HDL (or "good") cholesterol while decreasing LDL (or "bad") cholesterol.

Only those taking the highest doses - 0.625 milligrams (mg) or 1.25 mg of esterified Estrogen - had an overgrowth of cells in the endometrium or uterine lining. The condition, known as endometrial hyperplasia, causes bleeding and can increase the risk of cancer. The side effect can be prevented by taking progestin, a hormone that can have its own unpleasant side effects, such as breast tenderness or menstrual-like bleeding.

"Estrogen is a first-line therapy for osteoporosis prevention," said lead author Dr. Harry Genant. "Yet, to be beneficial, long-term use is needed. Many women drop out of therapy after a short time because they don't like the side effects," said Genant, of the University of California School of Medicine at San Francisco.

The researchers found that low doses, 0.3 mg per day, protected bone and lowered cholesterol without causing endometrial hyperplasia. Other estrogens are used at a dose of 0.625 mg or 0.5 mg a day to prevent bone-thinning.

The new study was funded by Solvay Pharmaceuticals Inc., the Marietta, Georgia-based company that manufactures esterified Estrogen under the trade name Estratab.

SOURCE: Archives of Internal Medicine (1997;157:2609-2615)



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