Adult HPV Vaccine Age, Guidelines

The HPV vaccine is having a significant effect of decreasing cervical cancer.  More recently HPV is associated with oral cancer and anal cancer.

HPV goes through latex And many of  other sexually transmitted diseases do not.  Many adults don’t know that the “safe sex” procedures they use may not work with HPV.

This recent review of this CDC information says that the vaccine has a low side effect rate in adults.  The CDC data is established up to age 26.  The CDC cannot recommend the vaccines for older adults.  Adults older than 26 years who are sexually active should examine this data and balance that with their HPV risks.

 Gardasil 9 has the broadest range of efficacy.  The Prevents infection by 9 different types of HPV virus.  These 9 types account for 90% of cervical cancers.”                                                                  Bill Chesnut M.D.

Return to New Health News,

  • ·         Why Adults Should Get the HPV Vaccine
  • ·         When Should Adults Get the HPV Vaccine?
  • ·         Are There Any Adults Who Should Not Receive the HPV Vaccine?
  • ·         What Are the HPV Vaccine Ingredients?
  • ·         What Are the Risks and Side Effects of the HPV Vaccine?
    Human papillomavirus (HPV) is the virus that causes cervical cancer in women and genital warts in men and women. The HPV vaccine effectively prevents infection with the HPV types responsible for most cervical cancers and can also prevent genital warts. HPV vaccination is most effective during childhood or adolescence, but adults can also benefit from the HPV vaccine.

Why Adults Should Get the HPV Vaccine

HPV infection is extremely common; most sexually active people will be infected with HPV at some point in life. HPV infection usually causes no symptoms, but can cause genital warts and anal cancer in both women and men. HPV can also cause throat cancer.

In women, HPV infection can cause cells in the cervix to grow abnormally. In a small fraction of women, these HPV-induced changes will develop into cervical cancer. About 12,000 women are diagnosed with cervical cancer each year and about 4,000 women die from the condition.

The HPV vaccine prevents infection by the HPV types responsible for most cervical cancers. There are three available forms of the HPV vaccine:

Cervarix: Prevents infection by HPV-16 and HPV-18. These two HPV types cause 70% of all cervical cancers. It is used for the prevention of cervical cancer and precancers.
Gardasil: Prevents infection by HPV-16, HPV-18, and also HPV-6 and HPV-11, the two HPV types that cause 90% of genital warts. It is used to prevent cancers and precancers of the cervix, vulva, vagina, anus, penis, and throat.
Gardasil 9: Prevents infection by the same HPV types as Gardasil, plus HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58. Collectively, these types are implicated in 90% of cervical cancers.
All HPV vaccines are extremely effective at preventing infection by the HPV types they cover. Getting the HPV vaccine reduces a woman’s risk of cervical cancer and precancerous growths substantially. Men cannot develop cervical cancer, but the HPV vaccine may prevent genital warts, anal cancer, and the spread of HPV to sexual partners. Gardasiland, Gardasil 9 are approved for males ages 9 through 26.

The HPV vaccine does not treat or cure an HPV infection in women or men who are already infected by one of these HPV types.

When Should Adults Get the HPV Vaccine?

The CDC recommends that all women ages 26 years and younger receive three doses of the HPV vaccine. The CDC recommends that all men ages 21 years and younger receive three doses of the HPV vaccine. It is an option for all men, but is recommended for men who have sex with men or who have a compromised immune system (including HIV) who are ages 26 and younger.

CDC guidelines recommend the three doses of the HPV vaccine should be given as follows:

First dose: ideally at ages 11 or 12
Second dose: one to two months after the first dose
Third dose: six months after the first dose
Some adults may have received doses of the HPV vaccine in childhood or adolescence. All three doses should be given to get the most protection from HPV infection. Re-vaccination in adulthood is recommended if the vaccination schedule was not completed.

Are There Any Adults Who Should Not Receive the HPV Vaccine?

Certain people should not get the HPV vaccine or should wait before getting it:

Anyone who has had a life-threatening allergic reaction to a previous dose of the HPV vaccine
Anyone who has had a previous life-threatening allergic reaction to an ingredient in the HPV vaccine
Pregnant women
Anyone with a moderate or severe illness; people who feel mildly ill may still receive the HPV vaccine.
The HPV vaccine is not known to be harmful to pregnant women or their babies. However, until more information is known, pregnant women are advised not to receive the HPV vaccine. Women who are breastfeeding can safely receive the HPV vaccine.

The HPV vaccine’s safety and effectiveness have not yet been studied in adults older than age 26. Until that information is available, the HPV vaccine is not recommended for adults older than age 26.

What Are the HPV Vaccine Ingredients?

The HPV vaccine contains no viruses and is not made from human papillomavirus. The active ingredients in the HPV vaccine are proteins that are similar to those found in the human papillomavirus. Genetically modified bacteria produce the proteins, which are then purified and mixed into a sterile, water-based solution.

What Are the Risks and Side Effects of the HPV Vaccine?

In clinical trials and in real-world use, the HPV vaccine appears to be very safe. More than 40 million doses of the vaccine — mostly Gardasil, which was approved in 2006 — have been given in the U.S. Cervarix was approved in 2009 and Gardasil 9 was approved in 2014.

From 2006 to 2014, there were about 25,000 reports to the government of HPV vaccine side effects. Over 90% of these were classified as nonserious. The most common side effects of the HPV vaccine are minor:

About one in 10 people will have a mild fever after the injection.
About one person in 30 will get itching at the injection site.
About one in 60 people will experience a moderate fever.
These symptoms go away quickly without treatment. Other mild-to-moderate side effects resulting from the HPV vaccine include:

Arm pain

Severe side effects, or adverse events, are uncommonly reported and have included:

Blood clots
Guillain-Barre syndrome
Chronic inflammatory demyelinating polyneuropathy
Systemic exertion intolerance disease (formerly called chronic fatigue syndrome)
Government, academic, and other public health investigators could not identify the HPV vaccine as the cause of any severe adverse event. There were 117 deaths as of September 2015, none of which could be directly tied to the HPV vaccine. The conclusion of public health investigators was that the HPV vaccine was unlikely to be the cause of these events. Such events occur at a certain rate in any group of tens of millions of people. The vaccination before each adverse event seemed to be a simple coincidence.


Blood test helps measure women’s ovarian reserve

“News I did not know. Using AMH blood levels to monitor ovary productivity makes sense considering the risk/benefit ratio. For career minded or later married couples having this information will be helpful. Here is more information from a non-profit website. “ Bill Chesnut, MD.

To go back to New Health News:

Blood test helps measure women’s ovarian reserve _AMA Wire newsletter March 31, 2016.

NBC Nightly News (3/30, story 10, 2:00, Holt) reported, “It’s a question that can keep many women up at night, whether there’s still enough time to have a baby, but now more women are using an easy test that can take all the guesswork out of how much time is left on their biological clocks.” NBC News correspondent Janet Shamlian explained that “a simple blood test” with the nickname of “the baby deadline test is like a checkup for the ovaries.” The test “used to be for women already struggling to get pregnant,” but is “now being used to predict infertility problems.”

The NBC News (3/31, Dunn, Deo) website reports that the official name of the test is “the Anti-Müllerian hormone (AMH) test.” Some physicians “are now offering it as an option to healthy women to assess what they call their ovarian reserve.” The test, which “usually costs less than $100,” is a measure of AMH “circulating in a woman’s bloodstream” and “predicts the amount of possible eggs a woman has.”


Heavy marijuana use in late adolescence may put men at higher risk for death

“More long term effects of regular marijuana use continue to arrive. The plant bud is an anxiolytic drug. There are better and safer drugs for anxiety, including a daily workout.” Bill Chesnut, MD

To go back to New Health News:

Heavy marijuana use in late adolescence may put men at higher risk for death by age 60, study finds

The CBS News (4/22, Marcus) website reported, “Heavy marijuana use in the late teen years puts men at a higher risk for death by age 60,” the findings of a study published online in the American Journal of Psychiatry suggest.

HealthDay (4/22, Preidt) reported that men “who were heavy marijuana users in their late teens were 40 percent more likely to die by age 60 than those who never used the drug, the investigators found.”

AMA News _ April 25, 2016.

Using earplugs when listening to live music

“Have you noticed the volume of soundtracks in movie theaters? The noise of most projected movies now causes me to wear earplugs throughout. With plugs in, I still hear the audio plainly.  The movie is just as good and more comfortable if I wait for it to be online and listen to it at home. “  Bill Chesnut, MD

To go back to New Health News:

Study recommends using earplugs when listening to live music _AMA Morning Rounds April 8, 2016.

On its website, CBS News (4/7, Welch) reports a new study (4/8) published Thursday in JAMA Otolaryngology-Head & Neck Surgery recommends wearing earplugs when listening to live music. According to the National Health and Nutrition Examination Survey, the prevalence of hearing loss in US adolescents jumped 31 percent between 1998 and 2006. A major contributor to this trend “is the increase in exposure to recreational noise, including loud music at venues like concerts, music festivals, and night clubs.”

On its website, CNN (4/7, Manella) adds that researchers assigned 25 attendees of an Amsterdam outdoor music festival to wear silicone earplugs and 26 to not wear them. The time-averaged sound pressure level during the festival was 100 decibels. They took a baseline hearing test before the concert and immediately afterwards to determine if there was a loss in hearing. Researchers then found “that the group wearing earplugs had a temporary shift in hearing of 8%, while the group without earplugs had” a temporary shift of 42 percent. They also found that “people who wore earplugs had a lower percentage of tinnitus following sound exposure, 12% compared with 40% in the unprotected group.”


Proton Pump Inhibitors (Prilosec, Nexium, et. al.) may be linked to an increased risk of kidney disease

“If you take omeprazole Prilosec or The Purple Pill that is heavily advertised, consider switching to a non-PPI drug. Called H-2-receptor blockers, these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac).” Bill Chesnut, MD

To go back to New Health News:

PPIs may be linked to an increased risk of CKD, study reveals  AMA Morning Rounds, April 15, 2016.

ABC World News Tonight (4/14, story 10, 0:25, Muir) reported that a study has linked “proton pump inhibitors including Nexium [esomeprazole magnesium] and Prilosec [omeprazole] to an increased risk of chronic kidney disease [CKD].”

According to CNN (4/14, Christensen), some “173,321 people who used PPIs and 20,270” who “took a PPI alternative known as histamine H2 receptor blockers” were included in the five-year study.

The CBS News (4/14, Welch) website reports that “over five years of follow-up…15 percent of people using PPIs were diagnosed with chronic kidney disease, versus 11 percent of those on H2-blockers,” which “translated to a 28 percent increased risk of developing kidney disease for PPI users.” While just “a few patients in the study – less than 0.2 percent – developed end-stage kidney failure. The risk was 96 percent higher for those on PPIs.” The study was published online in the Journal of the American Society of Nephrology.


One-third of advanced-melanoma patients given nivolumab in study are alive five years after starting treatment

“You have got to read this. Using a stomach feeding tube to treat obesity? How about that.The treatments for medical conditions in severe obesity are not ideal. The surgery is complicated. This website explains the details of the types of gastrointestinal operations developed to try to reverse obesity safely. This simple idea of inserting a tube to drain the stomach appears to produce excellent results with minimal complications. The report of a new procedure was  April 11, 2016 at a conference of Interventional Radiologists. It is not FDA approved yet. Expect it will be approved and cost effective. This is great news for obese patients with severe degeneration in their backs, hips, knees and feet.” Bill Chesnut, MD

To go back to New Health News:

Reversible Gastrostomy Tube May Be an Alternative to Bariatric Surgery: Presented at SIR

Created 04/11/2016 – 16:21

By Lorraine L. Janeczko

VANCOUVER — April 11, 2016 — A tube running from the stomach directly out the body through the abdomen may be an alternative to bariatric surgery for obese patients, according to research presented here at the 41st Annual Scientific Meeting of the Society of Interventional Radiology (SIR).

“This is a safe, easy, relatively low-risk procedure that can be removed when desired and can result in high weight loss,” said Shelby Sullivan, MD, Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri. “Right now, very few patients are optimally treated for obesity, and we need to be able to treat more patients with additional tools like this device that have lower risk than bariatric surgery but that achieves higher weight loss than lifestyle therapy alone.”

The AspireAssist Aspiration Therapy System consists of a percutaneous gastrostomy tube with one end placed inside the stomach and the other end connected to a port outside the abdomen, as well as a removable siphon that facilitates aspiration. The device allowed each patient to expel roughly 30% of their most recent meal before it was digested. Although the study was planned to run for 1 year, 12 patients chose to remain implanted for 3 years.

To evaluate the weight-loss efficacy and safety of the endoscopically placed device, lead author Stephen Solomon, MD, Department of Radiology, Cornell University, New York, New York, and colleagues enrolled 25 obese patients with a mean body mass index (BMI) of 39.8 kg/m2 in a pilot study at Blekinge County Hospital, Karlskrona, Sweden, between July and September 2012.

Of these, 22 patients completed 1 year, 15 completed 2 years, and 12 completed 3 years. For the 12 who completed 3 years, the mean weight loss was 26 kg with a mean excess weight loss of 58%. The mean weight loss at the end of years 1, 2, and 3 was 48% (19 kg), 46% (18 kg), and 45% excess weight loss (19 kg), respectively, on an intent-to-treat basis using the last observation carried forward method.

“The misconception is that you can eat anything and then aspirate it,” explained Dr. Sullivan. “In reality, patients must eat less than before. The food particles have to be smaller than 5 mm in size to fit through the tube. To get good aspiration, patients have to chew their food until it disintegrates in their mouth.”

“People not only get tired of chewing and stop eating earlier in the meal than before, they eat more slowly, can sense feeling full and push away from the meal,” he said. “The patients also need to drink a lot of water with their meal to create a slurry that can be aspirated. This reduces the amount of food they can fit into their stomach.”

The device is available on a limited basis in Europe and select additional regions. It is not approved by the US Food and Drug Administration (FDA) yet.


FDA approves drug for epilepsy-related seizures_ Briviact

“This announcement is more great medical news for epileptic patients. I have a dear friend who had uncontrolled seizures before there were effective medications. He had extensive brain resection surgery to stop the seizures to save his life. Our hearts go out to those afflicted. They need this news about Briviact.” Bill Chesnut, MD

FDA approves drug for epilepsy-related seizures_ Briviact

Reuters (2/19, Shaji) reported that the Food and Drug Administration has approved UCB SA’s epilepsy-related seizure drug, Briviact (brivaracetam). The drug was approved for patients 16 years and older as an add-on therapy for the treatment of partial seizures due to epilepsy.

Gastric Bypass Surgery in Patients Aged Older Than 35 Associated With Improved Survival

“Great news here that gastric bypass surgery helps in adults aged 35 and older. This post from the AMA News joins similar results in orthopedic research including the benefits of gastric bypass surgery before knee replacement arthroplasty. I added the emphasis in the last paragraph highlighting the good news.” Bill Chesnut, MD

 Gastric Bypass Surgery in Patients Aged Older Than 35 Associated With Improved Survival                                                       February 10, 2016

Lance E. Davidson, Ph.D., of Brigham Young University, Provo, Utah, and colleagues examined whether gastric bypass surgery is equally effective in reducing mortality in groups undergoing surgery at different ages. The study was published online by JAMA Surgery.

Bariatric surgery is effective in reducing all-cause and cause-specific long-term mortality. Whether the long-term mortality benefit of surgery applies to all ages at which surgery is performed is not known. For this study, all-cause and cause-specific mortality rates were estimated from a cohort within 4 categories defined by age at surgery; younger than 35 years, 35 through 44 years, 45 through 54 years, and 55 through 74 years. A cohort of 7,925 patients undergoing gastric bypass surgery and 7,925 group-matched, severely obese individuals who did not undergo surgery were identified through driver license records.

The authors found that gastric bypass surgery was associated with improved long-term survival for all patients undergoing surgery at ages older than 35 years. The lack of mortality benefit for those younger than 35 years was primarily derived from a significantly higher number of externally caused deaths, particularly among women. “Importantly, this study implies that gastric bypass surgery is protective against mortality even for patients who undergo surgery at an older age. Gastric bypass surgery also reduces the age-related increase in mortality risk compared with severely obese individuals who do not undergo surgery.”

To read the full article and a related commentary by Malcolm K. Robinson, M.D., of Harvard Medical School and Brigham and Women’s Hospital, Boston, please visit the For The Media website.



Clinical Practice Guideline for Post-Surgical Pain Management

“Significant gains in surgery pain control are available now. They are the use of long established modalities now used safely together. The importance of the original research is to have the dosage chart for each of the modalities. The term multimodal therapy is used for the general area of surgery pain control. Multimodal therapy improves the quality of recovery, shortens complication rates and readmission rates. It also increases costs. Being aware and having a source may become helpful for someone who is having surgery. They should discuss these facts with their anesthesiologist and their surgeon.” Bill Chesnut, MD

 American Pain Society Publishes Clinical Practice Guideline for Post-Surgical Pain Management                                          February 17, 2016

CHICAGO — February 17, 2016 — The American Pain Society (APS) has released a new evidence-based clinical practice guideline with 32 recommendations to help clinicians achieve optimal pain management following surgery.

According to numerous studies, the majority of surgical patients receive inadequate pain relief, which can heighten the risk for prolonged post-surgical pain, mood disorders, and physical impairment.

“The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery,” said lead author Roger Chou, MD, Oregon Evidence-based Practice Center.

Dr. Chou said the key recommendation in the guideline, based on high-quality evidence, is wider use of a variety of analgesic medications and techniques.

“The guideline strongly advises use of multimodal anesthesia that target different mechanisms of actions in the peripheral and central nervous systems,” he said. “Randomized trials have shown that multimodal anesthesia involving simultaneous use of combinations of several medications — acting on different pain receptors or administered through different techniques — are associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered by one technique.”

Dr. Chou added that evidence also indicates that non-pharmacological therapies, such as cognitive behavioral therapies and transcutaneous elective nerve stimulation, can be effective adjuncts to pharmacological therapies.

Written by a 23-member expert panel representing anesthesia, pain management, surgery, nursing, and other medical specialties, the APS guideline — published in the Journal of Pain — is based on the panel’s review of more than 6,500 scientific abstracts and primary studies.

The guideline’s 32 recommendations are rated as strong, moderate or weak based on scientific evidence cited as high, moderate or low quality. The recommendations are based on the premise that optimal pain management begins in the preoperative period and should be based on assessment of the patient and development of individual care plans for the surgical procedure involved.

Three other recommendations in the APS guideline are graded strong with high-quality evidence. They are:
• Adults and children can be given acetaminophen and/or non-steroidal anti-inflammatory drugs as part of multimodal analgesia for management of postoperative pain.
• Clinicians should consider surgical site-specific peripheral regional anesthetic techniques with proven efficacy in adults and children for certain procedures.
• Spinal analgesia is appropriate for major thoracic and abdominal procedures, particularly in patients at risk for cardiac and pulmonary complications or prolonged intestinal distress.

The APS Guideline offers 11 other strong recommendations, based on moderate or weak evidence. They include:
• Clinicians should provide patient and family-centered, individually tailored education to patients and caregivers about treatment options for postoperative pain.
• Oral administration of opioids is preferred to intravenous administration for post-operative analgesia.
• Intravenous patient-controlled analgesia (PCA) can be used when parenteral administration of analgesics is required.
• Clinicians should consider giving preoperative doses of celecoxib in appropriate adult patients.
• Gabapentin and pregabalin can be considered for multimodal postoperative analgesia. The medications are associated with lower opioid requirements after surgery.
• Surgical facilities should provide clinicians with access to a pain specialist for patients with inadequately controlled postoperative pain.

The APS postoperative pain management guideline was endorsed by the American Society for Regional Anesthesia.

SOURCE: American Pain Society


HPV infections falling among young women

“Great news here that needs to be widely disseminated in my view. We should encourage the use of the HPV vaccine in children 11-12 years of age. This post is from AMA News and links to the original article. I  posted the original article abstract below for your information. As parents, it is easy to forget this information. Secondly it may be difficult to explain to the child it a necessity to prevent cancers in young adults. Important.” Bill Chesnut, MD

 HPV infections falling among young women, study shows

USA Today (2/22, Painter) reports a study published in Pediatrics suggests that “thanks to a vaccination program that began a decade ago, fewer U.S. women are entering adulthood infected with” HPV. This study “is the first to show falling levels of dangerous strains of the” virus “among women in their early 20s.”

The Pittsburgh Post-Gazette (2/22, Sostek) reports that the study found “girls between 14 and 19 years old saw infection rates on the four types of HPV covered by the Gardasil vaccine fall 64 percent from the rate prior to the vaccine’s introduction — from 11.5 percent in 2003-2006 to 4.3 percent between 2009 and 2012.” Meanwhile, “in women ages 20 to 24, prevalence of the infection declined 34 percent in those years, from 18.5 percent to 12.1 percent.”

Pediatrics ___________________________________

March 2016

Prevalence of HPV After Introduction of the Vaccination Program in the United States

Lauri E. Markowitz, Gui Liu, Susan Hariri, Martin Steinau, Eileen F. Dunne, Elizabeth R. Unger

BACKGROUND: Since mid-2006, human papillomavirus (HPV) vaccination has been recommended for females aged 11 to 12 years and through 26 years if not previously vaccinated.

METHODS: HPV DNA prevalence was analyzed in cervicovaginal specimens from females aged 14 to 34 years in NHANES in the prevaccine era (2003–2006) and 4 years of the vaccine era (2009–2012) according to age group. Prevalence of quadrivalent HPV vaccine (4vHPV) types (HPV-6, -11, -16, and -18) and other HPV type categories were compared between eras. Prevalence among sexually active females aged 14 to 24 years was also analyzed according to vaccination history.

RESULTS: Between the prevacccine and vaccine eras, 4vHPV type prevalence declined from 11.5% to 4.3% (adjusted prevalence ratio [aPR]: 0.36 [95% confidence interval (CI): 0.21–0.61]) among females aged 14 to 19 years and from 18.5% to 12.1% (aPR: 0.66 [95% CI: 0.47–0.93]) among females aged 20 to 24 years. There was no decrease in 4vHPV type prevalence in older age groups. Within the vaccine era, among sexually active females aged 14 to 24 years, 4vHPV type prevalence was lower in vaccinated (≥1 dose) compared with unvaccinated females: 2.1% vs 16.9% (aPR: 0.11 [95% CI: 0.05–0.24]). There were no statistically significant changes in other HPV type categories that indicate cross-protection.

CONCLUSIONS: Within 6 years of vaccine introduction, there was a 64% decrease in 4vHPV type prevalence among females aged 14 to 19 years and a 34% decrease among those aged 20 to 24 years. This finding extends previous observations of population impact in the United States and demonstrates the first national evidence of impact among females in their 20s.

  • Accepted October 30, 2015.


If you’re diabetic, alcohol can cause dangerously low blood sugar. So check your level after drinking, especially before bed.

“Important warning in this post from Cleveland Clinic. My experience is this reactive low blood sugar is more likely to occur in people with a tendency to hypoglycemia normally. A lot of us have exceptionally low blood sugars while fasting, hypoglycemia, but never enough to be clinically diagnosed.” Bill Chesnut, MD

If you’re diabetic, alcohol can cause dangerously low blood sugar. So check your level after drinking, especially before bed.   

by Cleveland Clinic Wellness Editors 2.11.16

People with diabetes are particularly susceptible to the effects of alcohol. For people on blood-sugar-lowering medications, alcohol can cause blood sugar levels to drop dangerously low for up to 12 hours after drinking, because the liver has to work to remove the alcohol from the blood instead of doing its job to regulate blood sugar.  If you have diabetes, never drink alcohol on an empty stomach. Monitor your blood sugar before, during and after drinking — and don’t go to bed without checking it. Aim for a level of between 100 and 140 mg per deciliter. Women should have no more than one drink per day; men, no more than two per day — guidelines are the same for people with or without diabetes. If either your diabetes or your drinking is not under control, talk to your doctor.

You may also want to know:


The USPSTF recommends physicians routinely screen teens for depression.

“This advisory panel is giving good advice.  There are more articles In this site  about depression. It is most effectively corrected by therapy in the young. Depression affects a large % of the population, depending on the age cohort. When you see or live with young people who are acting out or unusual, look up a depression screen and see if there may be an underlying depression showing as misbehaviors.” Bill Chesnut, MD.

“The USPSTF recommends physicians routinely screen teens for depression.

AMA Wire 2.9.16.

The Los Angeles Times (2/8, Healy) “Science Now” blog reports that yesterday, the US Preventive Services Task Force (USPSTF) “recommended that physicians routinely screen children between 12 and 18 for depression and have systems in place either to diagnose, treat and monitor those who screen positive or to refer them to specialists who can.” The USPSTF’s recommendations now “bring depression screening for adolescents into line with recently issued depression-screening recommendations that apply to adults.”

According to CNN (2/8, Storrs), the USPSTF has decided that “for children younger than 12, there is not enough evidence around which tests work and which treatments are effective to recommend that doctors screen all individuals in this age group.” For children 12 and older, the USPSTF supports “the use of antidepressant medication for treating adolescents who have depression,” in addition to cognitive behavioral therapy or a combination of CBT and medication. Therecommendations were published online in the Annals of Internal Medicine.


Why you should use self-measured blood pressure monitoring.

“This newsletter for physicians patient instructions is good advice. The graph of the blood pressure readings is very helpful to any provider.” Bill Chesnut, MD.

 Why you should use self-measured blood pressure monitoring

AMA wire­2/8/2016, 3:37 PM

In the last decade, the number of hypertension-related deaths in the United States increased by 66 percent according to the Centers for Disease Control and Prevention (CDC). Self-measured blood pressure monitoring (SMBP) is a great way to engage patients in managing their hypertension. With American Heart Month underway, we’re sharing three key advantages to using SMBP in your practice.

Sometimes called home blood pressure monitoring, SMBP is any self-measured blood pressure that occurs outside the clinical setting. Research has shown that SMBP not only improves blood pressure control, but also increases patient engagement in making healthy lifestyle changes and improving medication adherence.

Here are three clinical benefits of using SMBP in your practice:

  • SMBP is a better predictor of health. Randomized controlled trials have shown that blood pressure measurements conducted at home predict cardiovascular morbidity and mortality better than blood pressure measurements taken at the doctor’s office.
  • You will obtain more blood pressure readings over a longer period of time.Having blood pressure readings that are more representative of a patient’s true blood pressure are crucial to accurately diagnosing and assessing blood pressure control options for patients with hypertension.

    SMBP also helps guide your decision making when trying to diagnose a patient with high blood pressure. Using blood pressures measured outside of the office is now recommended by the U.S. Preventive Services Task Force to confirm the diagnosis of hypertension when office blood pressures are high.

  • SMBP helps patients take control of their own health. Patients often adhere to treatment more often when they feel like they are a part of the process of improving their health.

    Read how one patientpartnered with his physician to improve his health using self-measured blood pressure.

Other ways to improve blood pressure monitoring

Make sure your health care team is getting the most accurate readings and taking the most effective action to help your patients with hypertension get their blood pressure under control. The AMA’s Improving Health Outcomes initiative offers several resources for your team and your patients.

The “M.A.P.” (Measure accurately, Act rapidly, Partner with patients) collection of tools includes:

  • Common errors in blood pressure measurement
  • Posters that shows the proper positioning for the patient and the cuff
  • Additional resources about self-measured blood pressure



Un-Hyping Recent Joint Replacement–MI Finding- a correction.

‘’This is an important correction of a report about heart attacks after total knee replacement surgery. Here is the source, from the Journal of Bone and Joint Surgery,[email protected]&l=7777447_HTML&u=507396709&mid=186947&jb=0Un-Hyping Recent Joint Replacement–MI Findings “ Bill Chesnut, MD

Un-Hyping Recent Joint Replacement–MI Finding

A late-August headline on MedPage Today ominously read, “MI Risk Soars After Joint Replacement.” The article cited a recent Arthritis & Rheumatology study that found a more than 8-fold increase in risk of myocardial infarction (MI) for one month after knee replacement and a more than 4-fold increased risk during the month after hip replacement, all compared with equal numbers of matched controls who did not have joint replacement surgery.

A look at the absolute risk instead of the relative risk, however, reveals a different and less scary story. For example, among the 13,849 patients who underwent knee replacement, 306 (2.2%) had a heart attack within the first month after surgery. The rate of heart attacks among the equal number of people who did not have a knee replaced was 2.0%. Also, the increased MI risk seen during the first month after surgery steadily declined with increasing length of follow-up to the point where it became statistically insignificant at 6 months after surgery.

There’s little doubt that major orthopaedic surgery can stress the heart, but the many long-term cardiovascular benefits of joint arthroplasty, including advantages from increased physical activity and decreased use of NSAIDs, seem to outweigh the short-term risk of a heart attack.


Study finds physicians may be hesitant to recommend HPV vaccine for young adults

“This is so important to protect our youth. Do everything you can.” Bill Chesnut, MD.

Study finds physicians may be hesitant to recommend HPV vaccine for young adults

NPR (10/23) reports in its “Shots” blog that vaccination rates for human papillomavirus (HPV) “have remained far lower than rates for other routine childhood and teen immunizations.” A study found the reason for the low rates may be that primary care physicians “treat the HPV vaccine differently from other routinely recommended immunizations, hesitating to recommend it fully and on time and approaching their discussions with parents differently. In the actual NPR newsletter the title is Doctors, Not Parents, Are The Biggest Obstacle To The HPV Vaccine.

“The single biggest barrier to increasing HPV vaccination is not receiving a health care provider’s recommendation,” said lead study author Melissa Gilkey, an assistant professor of population medicine at Harvard Medical School. That’s more of an issue, she says, than parents’ decisions to refuse or delay HPV vaccination.

“Discomfort talking about sex appears to be a more salient factor” than safety concerns about the vaccine.

Nearly all cervical cancers result from HPV infections, which can also cause vaginal, vulvar, anal, penile or head and neck cancers. Although most strains of HPV infections go away on their own, a three-dose series of the vaccine protects against the strains responsible for an estimated 90 percent of HPV-related cancers.

The Centers for Disease Control and Prevention recommends it for all girls and boys ages 11 and 12 because it’s most effective prior to first engaging in sexual activity.”

Read the entire report here:



Teens see lasting health benefits from bariatric surgery

“This study is good news that decreasing obesity by surgery in teenagers clears type 2 diabetes in 95%, return to normal kidney function in 86%, remission of pre-diabetes in 76%, correction of hypertension in 74% and a return of cholesterol to normal in 66%. That adds more pressure to develop effective treatments for obesity to be used in the young and to continue to use bariatric surgery until we have a less invasive equally effective treatment. Yahoo.” Bill Chesnut, MD

 Teens see lasting health benefits from bariatric surgery, study suggests

 The AP (11/7, Tanner) reported, “The largest, longest study of teen obesity surgery shows huge weight loss and health gains can last at least three years.”

Stat (11/7, Samuel) reported that in the study, which was published in the New England Journal of Medicine, adolescents “received one of two common bariatric surgeries – Roux-en-Y gastric bypass or sleeve gastrectomy – and were followed for three years after the procedure.” Teenagers “who received either surgery showed significant improvements in both their weight and quality of life at the end of the study period.”

MedPage Today (11/7, Brown) reported that the teens not only lost weight, but 95 percent of patients who had type 2 diabetes at the start of the study experienced a remission of the disease. What’s more, “emission of abnormal kidney function occurred in 86% of patients (95% CI 72%-100%), remission of prediabetes in 76% (95% CI 56%-97%), remission of elevated blood pressure in 74% (95% CI 64%-84%), and remission of dyslipidemia in 66% (95% CI 57%-74%).”


Ultimate cause of Alzheimer’s may be fungal, cadaver study suggests

“This new finding is remarkable in many ways. Has anyone heard about this work in the media? Pub Med includes a 2014 article in J. Alzheimers Disease of fungus  in Alzheimer’s brains. The abstract says:

To our knowledge, these findings represent the first evidence that fungal infection is detectable in brain samples from Alzheimer’s disease patients. The possibility that this may represent a risk factor or may contribute to the etiological cause of Alzheimer’s disease is discussed.

A Google review today finds the study in GIZMODO October 26, 2015.

Clearly this is astoundingly good news by opening a possible treatment for Alzheimer’s. I am eager to follow this topic.” Bill Chesnut, MD

 Ultimate cause of Alzheimer’s may be fungal, cadaver study suggests

 The Economist (10/23) reports that a study published online Oct. 15 in the journal Scientific Reports suggests that “the ultimate cause of Alzheimer’s is fungal.” Researchers arrived at this conclusion after examining “brain tissue from 25 cadavers, 14 of which belonged to people who had had Alzheimer’s disease when alive.” The study authors now “think a clinical trial of anti-fungal drugs is the next logical step.

From the abstract of the study: The possibility that Alzheimer’s disease (AD) has a microbial aetiology has been proposed by several researchers. Here, we provide evidence that tissue from the central nervous system (CNS) of AD patients contain fungal cells and hyphae. Fungal material can be detected both intra- and extracellularly using specific antibodies against several fungi. Different brain regions including external frontal cortex, cerebellar hemisphere, entorhinal cortex/hippocampus and choroid plexus contain fungal material, which is absent in brain tissue from control individuals. Analysis of brain sections from ten additional AD patients reveals that all are infected with fungi. Fungal infection is also observed in blood vessels, which may explain the vascular pathology frequently detected in AD patients. Sequencing of fungal DNA extracted from frozen CNS samples identifies several fungal species. Collectively, our findings provide compelling evidence for the existence of fungal infection in the CNS from AD patients, but not in control individuals.

Pisa, D. et al. Different Brain Regions are Infected with Fungi in Alzheimer’s Disease. Sci. Rep. 5, 15015; doi: 10.1038/srep15015 (2015).


Using Warfarin with Diabetes Drugs May Elevate Risk Of Severe Hypoglycemia

“This study is of the medical records of 465,918 Medicare patients who filled prescriptions for warfarin and the sulfonylureas glipizide and glimepiride. This record analysis shows a substantial positive association was seen with the use of warfarin with glipizide/glimepiride and hospital admission/emergency department visits for hypoglycemia and related diagnoses, particularly in patients starting warfarin. The findings suggest the possibility of a significant drug interaction between these medications, Follow the link “study” for details.” Bill Chesnut, MD

 Using Warfarin with Diabetes Drugs May Elevate Risk Of Severe Hypoglycemia In Older Adults, Study Says

Medscape (12/22, Tucker) reports that a study published in the BMJ found that “concurrent use of warfarin and the diabetes drugs glipizide and glimepiride appears to dramatically elevate the risk for severe hypoglycemia in older adults.” Researchers say they found a “substantial positive association” between the use of the drugs and visits to the emergency department, hospital admissions due to hypoglycemia and fractures from falls.


Who should use statins?

“Statins are even more important than previously thought. More people qualify for them. They have side effects, including muscle cramps. Know the side effects you might have while you take these marvelous health aides.” Bill Chesnut, MD

USPSTF releases draft recommendation on who should use statins

The AP (12/22, Neergaard) reports that the US Preventive Services Task Force (USPSTF) has issued a draft recommendation on “who qualifies for cholesterol-lowering stains.” In the new “draft guidelines” released Dec. 21 for public comment, the USPSTF “says the…medications will be of most benefit to some people ages 40 to 75 whose risk of cardiovascular disease over the next decade is at least 10 percent.” According to the AP, the task force recommendations “are similar to…2013 guidelines from the American Heart Association and American College of Cardiology.”

TIME (12/22, Park) reports that physicians can assess patients’ “10-year risk by plugging certain information into a web-based calculator formulated by the” AHA and ACC. Two years ago, “the two groups debuted” a “revised algorithm, along with their recommendation that people with a 7.5% or greater risk of heart events in the next 10 years consider taking a statin to reduce that risk.” The USPSTF, however, “concluded that people with a 10% or greater risk of heart problems in the next 10 years, based on the 2013 AHA-ACC calculator, and who have diabetes, high cholesterol, high blood pressure or who smoke, can lower their risk of having a heart attack or stroke by a ‘moderate amount’ by taking a statin.”

HealthDay (12/22, Thompson) reports that the “panel added that people with a 10-year risk of heart attack and stroke between 7.5 percent and 10 percent might also benefit from statins, and should discuss the matter with their” physician.


Wear and Osteolysis of Highly Crosslinked Polyethylene at 10 to 14 Years

“How long will the plastic liner in total hips last? You won’t believe how good this stuff has become.” Bill Chesnut, MD

Wear and Osteolysis of Highly Crosslinked Polyethylene at 10 to 14 Years: Predicts 345.8333333333333 years of wear available for 28 mm cup.        Paul F. Lachiewicz MD, Elizabeth S. Soileau BSN, John M. Martell MD

Background. Highly crosslinked polyethylene (XLPE) was introduced to decrease periprosthetic osteolysis related to polyethylene wear, a major reason for revision of total hip arthroplasty. However, there are few reports of wear and osteolysis at 10 years postoperatively.

Questions/purposes.    (1) What are the linear and volumetric wear rates of XLPE at 10 to 14 years? (2) What is the relationship among linear wear, volumetric wear, and femoral head size? (3) What proportion of hips developed osteolysis and was there a relationship between osteolysis and femoral head size or polyethylene wear?

Methods.  We evaluated a previously reported cohort of 84 hips (72 patients) with one design of an uncemented acetabular component and one electron beam 10-kGy irradiated and remelted XLPE at a mean followup of 11 years (range, 10–14 years). The choice of femoral head size was based on several factors, including the outer diameter size of the acetabular component implanted, the perceived risk of dislocation (including the history of alcohol abuse and patient age), and liner availability from the manufacturer. The femoral head sizes used were 26 mm in 10 hips (12%), 28 mm in 31 hips (37%), 32 mm in 31 hips (37%), 36 mm in eight hips (10%), and 40 mm in four hips (5%). Measurements of linear and volumetric wear were performed in one experienced laboratory by the Martell method and analyzed using the first-to-last method. Standard radiographs, with additional Judet views, were used to detect periprosthetic osteolysis. Statistical analysis of wear and osteolysis compared with head size was performed.

Results. For the entire cohort, the median linear wear rate as 0.024 mm/year (95% confidence interval [CI], 0.016–0.030) and the median volumetric wear rate was 12.19 mm/year (95% CI, 6.6–15.7). With the numbers available, we found no association between femoral head size and linear wear rate. However, larger femoral heads were associated with more volumetric wear; 36/40-mm femoral heads had higher volumetric wear (median 26.1; 95% CI, 11.3–47.1) than did 26-mm heads (median 3.1; 95% CI, 0.7–12.3), 28-mm heads (median 12.3; 95% CI, 3.0–19.3), and 32-mm heads (median 12.9; 95% CI, 6.6–16.8; p = 0.02). Small osteolytic lesions were noted in 12 hips (14%), but with the numbers available, there was no association with head size or volumetric wear rates.

Conclusions.  This uncemented acetabular component and this particular XLPE had low rates of linear and volumetric wear. Small osteolytic lesions were noted at 10 to 14 years but were not related to femoral head size or linear or volumetric wear rates. We recommend additional longer-term clinical followup studies and perhaps alternative imaging studies of patients with XLPE and osteolysis.

CRR: Feb1, 2016

Chronic Lymphocytic Lymphoma drug trial of Zydelig combined with Rituxan and Treanda unblinded early due to success.

“Sing praises for another medical breakthrough of research by a publicly traded American company. Gilead is in Foster City, California. Many of us have been with loved ones as they died with a leukemia and it brings tears for years. Yes, it still does, as I write this. “Bill Chesnut, MD

Chronic Lymphocytic Lymphoma drug trial of Zydelig combined with Rituxan and Treanda unblinded early due to success.

Reuters (11/17, Berkrot) reports that a Phase III clinical trial of Gilead Sciences’ chronic lymphocytic leukemia (CLL) treatment was unblinded after independent observers concluded the drug was significantly effective at slowing the progression of the disease. The study tested Gilead’s Zydelig (idelalisib) in combination with Rituxan (rituximab) and Treanda (bendamustine), compared to Rituxan and Treanda alone.


AMA News, November, 2015.

Nearly one-third of all cancer cases may be linked to inherited genes

“This report needs wide dissemination and understanding. There are several common sense conclusions. One is that not all cancers can be prevented, so searching for cancer proactively is warranted. Some of the searches involve blood tests that are usually negative, leading some to conclude they aren’t necessary as a part of prevention. Another conclusion is to know your family cancer history, first and second generation, including aunts, uncles and cousins. Tell you providers that you have this family history and want to be carefully managed. Know the list of common inheritable cancers listed here.” Bill Chesnut, MD

 Nearly one-third of all cancer cases may be linked to inherited genes, research finds

On its website, NBC News (1/6, Fox) reports that research published in the Journal of the American Medical Association suggests that approximately one-third “of all cancer cases can be blamed on inherited genes.”

STAT (1/6, Swetlitz) reports that investigators looked at data on “identical and fraternal twins in Denmark, Finland, Norway, and Sweden, who were part of the Nordic Twin Study of Cancer.”

Newsweek (1/6, Firger) reports that the researchers found that “overall heritability for cancer was 33 percent among the entire study population, and notably higher for certain types of cancers.” Newsweek adds, “Significant heritability was found in 58 percent of diagnosed skin melanomas, 57 percent of prostate cancers, 43 percent of non-melanoma skin cancers, 39 percent of ovarian cancers, 38 percent of kidney cancers, 31 percent of breast cancers and 27 percent of uterine cancers.”

HealthDay (1/6, Thompson) reports that the researchers also “identified a set of cancers in which genetics play a very small role.” This group includes “lung cancer (18 percent), colon cancer (15 percent), rectal cancer (14 percent), and head and neck cancer (9 percent).”

JAMA Newsletter 1.7.16.

High-dose vitamin D3 may modulate immune system in patients with MS

AMA News 12.31.15 reports that vitamin D3 taken as a supplement to patients with multiple sclerosis showed a decrease of harmful cell activity at 10,400 international units a day. This finding is important because MS touches many of us and its effects are profound. It is easy to check possible overdoing the Vit D3 with a simple blood test. You want your blood level of Vit. D3 to be < 100 ng/dl.” Bill Chesnut, MD.

High-dose vitamin D3 may modulate immune system in patients with MS

Newsweek (12/31, Main) reports that in a study published online Dec. 30 in Neurology, researchers “tested the impact of two levels of vitamin D supplementation among 80 patients” with multiple sclerosis. Half the patients “were given 10,400 international units of Vitamin D, and the other 40 took 800 IUs of the supplement per day.” Researchers found that patients “in the high-dose group had significantly reduced levels of activity among a certain type of immune cell thought to be involved in multiple sclerosis, compared with those in the low-dose group.”

According to MedPage Today (12/31, Jackson), in patients taking high-dose vitamin D3 (cholecalciferol), researchers found “in vivo pleiotropic immunomodulatory effects” as evidenced by the “significant reduction in the proportion of interleukin-17+CD4+ T cells (P=0.016), CD161+CD4+ T cells (P=0.03), and effector memory CD4+ T cells (P=0.021),” as well as “a concomitant increase in the proportion of central memory CD4+ T cells

AMA Wire newsletter January, 2016.

Gene test, Oncotype DX, may reveal which women with early-stage breast cancer can skip chemo

“Oncotype DX may help a lot of women avoid chemotherapy with the comfort of confidence that they do not need it. Pass the information along and follow the development in Europe and as it becomes used in the US.” Bill Chesnut, MD.

Gene test may reveal which women with early-stage breast cancer can skip chemo.

The Wall Street Journal (9/28, Winslow, Subscription Publication) reports that research presented at the European Cancer Congress in Vienna and published online in the New England Journal of Medicine suggests that a gene test known as Oncotype DX may help certain women with early-stage breast cancer skip chemotherapy.

The AP (9/28, Marchione) reports that “the test accurately identified a group of women whose cancers are so likely to respond to hormone-blocking drugs that adding chemo would do little if any good while exposing them to side effects and other health risks.” Researchers found that “women who skipped chemo based on the test had less than a 1 percent chance of cancer recurring far away, such as the liver or lungs, within the next five years.”

AMA Newsletter 9.28.15

Sparing ovaries and removing fallopian tubes may cut cancer risk, but few have procedure

“This is important for women and their families to understand. They might think that removing the Fallopian tubes is an unnecessary additional surgery. There is an important reason patients facing hysterectomy should research this more. For the average person to be able to go to the Internet and find good explanations of complicated medical advances is another blessing of these last 20 years.” Bill Chesnut, MD

  • Sparing ovaries and removing fallopian tubes may cut cancer risk, but few have the procedure.

During hysterectomies for non-cancerous conditions, removing both fallopian tubes while keeping the ovaries may help protect against ovarian cancer while preserving hormonal levels, but few women receive this surgical option, according to a new study by Yale School of Medicine researchers.

Published in the February issue of the journal Obstetrics & Gynecology, the study was led by Xiao Xu, assistant professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at Yale School of Medicine.

In hysterectomies to treat benign conditions, removing both of the ovaries in addition to the fallopian tubes has been used as a way to reduce ovarian cancer risk. But this practice can induce surgical menopause, which adversely affects cardiovascular, bone, cognitive, and sexual health. New evidence suggests that ovarian cancer often originates from the fallopian tube, rather than from the ovaries. This led the American College of Obstetricians and Gynecologists (ACOG) to issue a statement in 2015 suggesting that the practice of bilateral salpingectomy with ovarian conservation — surgical removal of both fallopian tubes while retaining the ovaries — may be a better option for ovarian cancer prevention in women at low risk for ovarian cancer.

Xu and her co-author, Dr. Vrunda Bhavsar Desai, conducted the study using data from the 2012 National Inpatient Sample. The team studied 20,635 adult women undergoing hysterectomy for benign conditions who were at low risk for ovarian cancer or future ovarian surgery.

“We found that among women undergoing inpatient hysterectomies in 2012 who were at low risk for ovarian cancer, very few of them received bilateral salpingectomy  with preservation of the ovaries,” said Xu. “The rate of bilateral salpingectomy with ovarian conservation was 5.9% in this population. This study provides important baseline information on national practice patterns prior to the ACOG recommendation.”

Xu added that the rate of bilateral salpingectomy with ovarian conservation varied widely among 744 hospitals across the country, ranging from 0% to 72.2%.

“The wide variation in hospital practice may result in differential access to prophylactic procedures depending on where patients access care,” said Xu. “This can have longer-term health implications given the benefits of ovarian conservation.”