Screening for cholesterol and lipids in childhood

Screening for cholesterol and lipids in childhood

On November 13, 2011, three major medical societies announced new recommendations for screening children for elevated cholesterol levels.

Major medical societies are endorsing the concept of treating elevated cholesterol levels with powerful medications at younger and younger ages.

In this instance, the American Academy of Pediatrics, the American Heart Association, and the National Heart, Blood, and Lung Institute (part of the NIH), all are agreeing that drugs such as Lipitor should be used in children before puberty.

There are several reasons to agree with these recommendations, but one reason suggests the recommendations are flawed and should not be followed, yet.  What is missing is any evidence that treating high cholesterol at young ages leads to longer or better life later on.  

Does lowering cholesterol at age 10 help someone be healthier at age 50 than lowering cholesterol at age 20?

This is important, because if someone starts a drug like Lipitor at age 10, they will have daily exposure to that drug during the critical years of puberty, and, compared to starting such treatment at age 20, will have 10 extra years of drug exposure.

Elevated cholesterol has been an interest of mine for many years.  In the late 1980's, I practiced in Boston, and led a cholesterol screening clinic there.  I helped form the New England Pediatric Preventive Cardiology Network, which came to include such clinics at Harvard, Yale, Dartmouth, and Brown.  We eventually published our experiences in Boston.

http://www.ncbi.nlm.nih.gov/pubmed?term=lavin%20AND%20newburger

Why look at cholesterol in childhood?

I got interested in this issue because it is well known that the arteries begin to clog with fat deposits as early as 2 years of age.  So it made sense to stop the clogging before the arteries get clogged.  It still makes sense to do that.  The key question is what actually succeeds in keeping the vessels from clogging?

With that goal in mind, we drew lipid panels on every child whose family had a history of heart attack or bypass surgery prior to age 55-60 years old.  We were able to find close to 100 children, some as young as 2-3 years old, with quite elevated cholesterol levels, sometimes as high as 400!

So we had a purpose in mind, stop arteries from clogging early.  We had a way to find those at highest risk, those with a positive family history of early age heart attacks or clogging.  And, we did succeed in finding children with very seriously elevated cholesterol levels.

Why not look at cholesterol in children?

But then we found the problem.    Here we had several dozen young children with very high cholesterols in whose families many people had suffered serious heart attacks in young adulthood.  It was obvious this group could benefit from treatment, right?  Not so.

First we attempted to lower cholesterol by strict dietary control:  no cholesterol, very low fat, high fiber, in the diet.  Every family consulted with a skilled dietician, but even with extremely strict diets, we could not lower cholesterols more than 10%.  That meant a child with a cholesterol of 290 could not get below 260 with diet alone.

Then we tried a variety of relatively safe medications, like cholestyramine, that bind cholesterol but do little to interfere with the body's chemistry.  These drugs had little impact.

The only class of drugs left that would make a real difference were statins, like Lipitor.  But these drugs are very powerful, could have significant side effects.  It was not clear then that it would be safe to put a 3 year old on them for their entire childhood.  

When all was said and done, we had created a group of children whose families now knew their cholesterol was dangerously high, but but nothing to do to really help.

Thoughts on Effective Screening Programs

What I learned from this experience is that a good screening program really has to fulfill all steps of being useful to really be useful. Those steps are:

1. The condition being screened has to be important.  No sense in screening for how long your hair can grow, finding that out does not improve anyone's health.
2. The condition being screened for must have a treatment that makes a difference, and a treatment that is safe and available when the test comes back abnormal.  This is where our clinic in Boston ran into an obstacle.
3. The timing of treatment should make a difference in actual outcome.  It makes little sense to screen if treating the condition leads to the same outcome whether one treats early in the course or later in the course of the condition.

When it comes to cholesterol, only one of the three key criteria for a good screening program is present- a high cholesterol is an important problem.

But the safety of treating young children with a very powerful category of medications, statins, is simply not yet known.

And perhaps most worrisome, no one actually knows if treating someone for high cholesterol at age 10 will indeed lead to a better or healthier life than starting treatment at age 20.

For both these reasons, it seems like a bad idea to screen young children for cholesterol elevations much before puberty- we do not know if the key drugs used are safe at this age, and we do not know if someone is better off starting treatment at the earlier age.

Bottom Line

• A major recommendation came out Sunday, November 13, 2011- young children should be screened for high cholesterol and if found to be high enough, start the powerful drugs in the category of statins.
• Proof of safety of statins in young children is not established, so starting such a drug will commit a child to taking a potentially dangerous drug every day for many, many years, during development.
• Most importantly, because it is not known at all whether starting treatment for high cholesterol in childhood yields a healthier adulthood, we do not even know if any benefit comes from starting statins as such early ages.
• Therefore, Advanced Pediatrics is not recommending that young children be screened for high cholesterol or other lipid abnormalities.  Clearly if a specific child has a problem requiring a look at the lipid profile, such testing makes good sense, but not as a test required of all children.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Good news on Urinary Tract Infections

Good news on Urinary Tract Infections:

UTI's in Childhood Cause no Harm to Adult Kidney Function

Over the last 50 years there has been a very disturbing idea put forward that urinary tract infections (UTI's) in children, given the right complications, could cause damage to kidneys that could cause kidney problems later in adult life.

This idea has fueled a great deal of worry and a lot of studies, the most uncomfortable of which is the VCUG, a test involving catheterization of the bladder.

The idea was based on the observation that children who have both a UTI and urinary reflux [this is when urine flows up to the bladder towards the kidneys, not just out of the bladder when one urinates] can develop scars in their kidneys, and that scars appear to be associated with the need for dialysis later in life.

The good news it that over the last year or so, important research has tested this idea, and found that it is not true.

Most recently, a very important study was reported in our lead journal, Pediatrics (128(5) Nov 2011, 840) where 1,576 cases of chronic renal disease in adults were reviewed.   In no instance could a clear connection to a UTI in childhood be linked to the cause of the adult chronic renal disease.  An accompanying editorial puts the matter very clearly:  "It's a Myth--UTI Does Not Cause Chronic Kidney Disease."

So now, we can safely say that a UTI is like most any other infection, worth treating to become more comfortable, but not an infection that puts one at risk later in life.

And, it means that the use of VCUG's in childhood is going to drop quite a bit, which is comforting news.

Bottom Line:

Urinary tract infections in children do not cause problems with kidney function later in life if the kidneys were normal to begin with.

UTI's should be diagnosed and treated to help your child feel better, not to prevent a danger.

If your child has UTI's that are severe or frequent enough to cause concern, a renal ultrasound is still a good idea to be sure the kidneys are normal, but the VCUG study will no longer be used routinely.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Cough- When to Worry, What to Do

Cough- When to Worry, What to Do

Cough is one of the most agonizing experiences a healthy person can have.

More than runny nose or itchy eyes, a cough really causes a lot of suffering.

The sound is irritating, and coughing whenever you breathe is exhausting, robs you of sleep, and hurts.

Also, cough, more than most problems, can keep happening.  Some people can cough every day for months and months.  But even a few weeks of coughing is enough to create tremendous discomfort. 

And yet, cough is one of the most common experiences of humanity.  Everyone coughs at some time in their life.

Here we have a problem that everyone experiences, literally everyone, so how can a parent tell if there child's cough is different from what we all see come and go without any harm done.

So what is a cough, when is it a problem, what helps?

What is a Cough?

A cough is a sharp exhalation, really an explosion of air out of the chest.

Coughs occur always in response to an irritation in the airway, and typically an irritation somewhere in the throat, vocal cord area, and/or lungs.

There are only a small number of causes of the irritations that cause us to cough:

• Viral infection (tend to last no more than a few days or weeks)
• Bacterial infection (tend to make one rapidly ill with high fever and getting sicker every hour or day)
• Allergy (may go on with no change in intensity for months)
• Irritation (such as smoke)

So coughs can cause a great deal of suffering, and last for many weeks and months, but the number of types of causes of cough is actually fairly small.

When to Worry?

Most of us get worried about a cough if it sounds bad, lasts too long, or is bothersome.
One would think these are good signs to watch for, but it turns out that these clues tend not to help figure out if you are in trouble.

Keeping in mind that a cough almost always is a sign that the lining of the airway is inflamed, the key thing to worry about with a cough is if it indicates that the inflammation is serious enough to interfere with air coming in and out of the body.

Here is another way to think about this.   The air moves in and out of our body via a set of hollow tubes.  Every one of those tubes has a living lining.  That lining often gets inflamed, meaning it can get swollen, make lots of mucus, and get very tender.  If the lining of a tube gets swollen and makes mucus, the whole tube gets more narrow.  If the tube gets narrow enough, air does not pass in and out of the tube very well.

So, a cough is a clear sign that the tubes that carry air in the body are inflamed.  So now the key question becomes: how inflamed are the tubes?  Are they inflamed enough to interfere with air flow or not?  If so, then we have a serious problem, a potentially dangerous problem.  If not, then the cough is a sign of an inflammation that is harmless and will go away.

This leads us to the key signs that someone with a cough is of concern:

• Most Important:  Do you have any trouble breathing when not coughing?
• The best indicators of trouble breathing are:
• breathing rapidly
• tugging or working hard to get air in or out of the chest (not nose)
• skin on the chest tightening with each breath
• grunting with breaths
• if the child says they are having trouble getting air in and out of the chest

If none of these symptoms are present, and your child looks very comfortable breathing when not coughing, then the tubes carrying the air are likely not too swollen, and the inflammation is very likely mild and harmless.

If ANY of these symptoms are present, you should call for medical attention.

How to Get Rid of Cough?

The next question when it comes to cough is how to get rid of it.

That all depends on the cause:

• Bacterial infections are best treated with antibiotics, and antibiotics are only helpful for this cause.
• Allergic reactions are best treated with antihistamines and inhaled steroids
• Irritations are best treated by removing the irritation.
• Viral infections are incredibly resistant to all known drugs.  There are no drugs yet invented that can significantly reduce the inflammation caused by viruses.  This includes cough syrups.  No cough syrup has yet been shown to decrease the number of coughs one has per hour or days one coughs.   In fact, the FDA launched an investigation of over 500 cold remedies in March of 2011 with an eye towards exposing which  are frankly ineffective and/or fraudulent.

Bottom Line

• Cough means the airways are inflamed.
• The causes are usually one of four causes
• The best indicator that a cough is worrisome is how you are breathing when not coughing.
• The cough itself can be quite agonizing even if the underlying condition is harmless
• Coughs caused by viruses (colds, flus) cannot be stopped by any known medication, including cough syrups and antibiotics.
• If you think your child is having any trouble breathing, getting air in and out of their chest, call for medical help immediately

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Vitamin Pills Not so Good For You

Tetrahydroimidizalone or Tomato:  

New Evidence that Foods are Better than Vitamins

The word vitamin is a marketing triumph.  It speaks of vitality, it speaks of Superman, and put those ideas and feeling together and you have a winner.  As a result, any chemical that can bear that name has had extraordinary success in the marketplace.  About 50% of all American adults take a multivitamin every day.

This makes vitamins the #1 set of chemicals that Americans take.  The question is, does taking a multivitamin really deliver?  Or like any other drug, are there down sides?

A new study published in the Annals of Internal Medicine, took a look at the fate of 38,772 women, average age 62, some who took multivitamins, and some who did not.  The study looked at how each group fared over a nearly 20 year period.  What they found was that the group that took multivitamins died a bit faster.  The study looked at a number of supplements.  The most dangerous was iron which substantially increased the rate or risk of death.  Just taking Vitamin A or D had little impact on the rate of dying, but taking a multivitamin did, it increased it.

This study adds further fuel to the argument that taking any drug, even one that sounds safe like vitamins, is not nearly as good for you as eating good food.

Consider just one vitamin.  This vitamin contains tetrahydroimidizalone, and is found in abundance in tomatoes.  Imagine someone trying to get you take a  tetrahydroimidizalone pill every day, it would be a very tough sell.  All your warning flags would be aroused.  What is  tetrahydroimidizalone?  Sounds very technical and dangerous.  What side effects does it cause?  And yet, about 50% of all adult Americans take this chemical every day, as long as it is called Vitamin B7, or biotin.

Now, there is no doubt that if you do not eat enough biotin, bad things happen to you.  But the question is, are you better off eating biotin-containing foods, or taking a pill of it?  The evidence for food is overwhelming at this point.  And the reason that makes sense is clear.  A tomato has lots of  tetrahydroimidizalone-rich biotin in it.  But it also has thousands and thousands of other compounds.  Further, humans and tomatoes evolved together.  As our ancestors found vines whose fruits helped us live, we cultivated those vine more.  As the benefit from a food grew over time, humans helped that food prosper.  The trend led to the evolution of highly complex foods that help us live.  Vitamins are a part of nearly all plants that we cultivate.

And yet, with only one exception, we have found that taking the vitamin out of the plant helps us in any way.  Vitamins work best when they work in concert with the tens of thousands of other chemicals in plants that we evolved to live on.  The one exception to date is folic acid, which as a pill, does prevent the development of spina bifida in pregnancy.

This study of so many women adds a dramatic extra level of evidence for this point.  In fact, now we can say that not only do multivitamins offer no benefit over eating a piece of fruit, but they may cause harm.

BOTTOM LINE

Despite the reassuring sound of the category, vitamins are like every other pill, they can cause harm.  A recent study demonstrates that the harm might include dying at a younger age.

We recommend that all your vitamin needs, with the exception of folic acid, be met by eating food.

We recommend that no one take a daily multi-vitamin, unless you have a specific medical condition requiring it.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

A Word on Screening

The Uproar over Screening for Prostate Cancer:

A Lesson in the World of Screening for us All

One of the most surprising aspects of modern medicine is how hard it is to create a screening test that  works well.

After all, what could be simpler than screening?  Screening just involves measuring something in everyone and finding those few whose measures are abnormal.  And then, knowing which of us has the problem, we can cure or eliminate it before it does any harm.

This is, in fact, the idea behind screening.  Find the problem early, reap the benefits of taking care of the problem before it causes any harm.

Some screening test methods do just that.  The best of them is the newborn screening test for a condition called PKU.  It was the first of all the newborn screening tests and it has all the features of a good screening program:

1. The test is simple, inexpensive, and extremely safe.
2. Essentially everyone with PKU tests positive, and everyone without PKU tests negative.  
3. If you are found to have PKU in the newborn period, there is an action that can be taken that will ensure no harm will come to you.  If you have PKU and no one knows it, the intervention, which is simply to change your diet, cannot be offered and severe mental retardation will result.  The test result makes a dramatic difference.
4. There is a system that allows all Americans to be tested at birth, for all positive results to be reported to the family and their doctor, and for those with PKU to receive the life-saving intervention.

The dirty little secret of screening, however, is that most techniques to do this do not work very well.  With few exceptions, most screening tests used in medical practice have a tremendous overlap, that is, people with positive results often do not have the problem.  Also, too often there is no clearly defined intervention or treatment that leaves the person reliably better off.

And yet, there is an explosion in the number of screening tests being developed.  As a result, every American is asked to be screened for a widening variety of problems, often without a good screening technology in place.  The test is available, but the test is often not a very good performer, not like the PKU test at all.

This has all come to our attention with the recent announcement that the screening test for prostate cancer, PSA, does not work very well.  This was the finding of the nation's leading authority on screening tests, the United States Preventive Services Task Force (USPSTF).  The USPSTF exists for only reason, to study screening tests and see if they work.

How could a screening test fail?  Well, it turns out that when you study them, they nearly all fail in some way or another.  The bottom line is that a screening test fails if, when all is said and done, it is likely not to help you.

How could a screening test turn out to cause more harm than good?  Here are some ways:

1. The test could be so expensive, painful, and/or dangerous, that you are left more hurt than the problem you are looking for could have made you.
2. The test could tell far too many people that they have the problem or disease when in fact they do not.  Imagine taking a test that told you had cancer when in fact you do not.  This turns out to be the most common problem with screening tests.
3. The test could tell far too many people that they do not have the problem or disease when in fact they do.  This is a potentially devastating outcome, but fortunately, one problem current screening tests tend to avoid most of the time.
4. When you look at everyone with a positive result and see how their problem eventually pans out, you might find they fare no better than those who skipped being screened who have the same problem.  That is, early detection may not make any difference.
5. For some tests, there is no treatment available to help.  This makes the finding out early about the problem a rather futile exercise.

Figuring out how well a screening test actually performs turns out to be a tricky and complex task.   That is why the United States Preventive Services Task Force (USPSTF) deserves nothing but gratitude.  The USPSTF is a very thoughtful and careful group.  They review thousands of studies and look at screening tests for years before coming to a decision.   In the case of the PSA screening test for prostate cancer, they spent a very long time looking at the data, came to a conclusion in 2009, and then decided to spend two more years looking at the data again, to be sure they were advising us as accurately as possible.

What the USPSTF found was that the PSA test for prostate cancer is really a miserable failure as a screening test.  About half the men who are told they have prostate cancer as a result of this test turn out to not have any sort of cancer that would ever cause them harm.  Worse, of any group of men who have a positive PSA, no one can tell which of these men have actual, dangerous cancer, and which do not.  That dooms all men with a positive PSA to endure the burden of thinking they have cancer, and undergoing serious and potentially dangerous treatments.

The USPSTF found that when all is said and done, no lives have been saved by the PSA screening test, but tens of thousands of men have been rendered impotent, incontinent, or both, for no very good reason.

It is the response to this finding that exposes the power of the screening test in today's modern medical world.

In a  more rational world, one would expect the findings of an organization like the USPSTF to be accepted with tremendous interest and even gratitude.  Years of careful review and study should be.

But the medical world has reacted to this report with a howl.  Leading the charge are the urology associations.  Their response is clearly emotional and contains little data.  They state that they refuse to stand by and let their patients die by not having them screened with the PSA.  Of course, they have no information that demonstrates dropping the PSA test would actually lead to anyone dying.  Rather, they present stories of individuals whose lives appear to have been saved by the PSA test turning positive.  

Now, we all know which story is most convincing:

A harrowing story of a 58 year old man who thought he was well, only to find his PSA level was elevated, getting a prostate biopsy that shows he has prostate cancer, and then having his prostate removed and cured of a disease that could have killed him if he hadn't been screened.

A highly technical scientific report looking at the sensitivities, specificities, negative predictive values, and positive predictive values of the PSA test.  And in that same report, numbing tables and graphs looking at the statistical patterns of outcome for men screened with the PSA.

And yet, that really boring scientific report demonstrates that the 58 year old man in the first story has a very good chance of being misled.  The odds are so good that he did not really face any threat from prostate cancer, that he would have been just as likely to live out a healthy life without the PSA test!

Turns out facts do matter.

Sadly, as an outstanding group of epidemiologists at Dartmouth have found (and reported in their book Overdiagnosis, an outstanding book that I have blogged on earlier), money often trumps facts.  And the money element of screening is that it can turn a whole nation of healthy people into paying patients.

BOTTOM LINE

I present this story of the USPSTF, of PSA, of prostate cancer, to illustrate why we at Advanced Pediatrics take the science of screening so very seriously.

We look at every screening test recommended and look for data that groups like the USPSTF have on its performance.  If the test is a lousy performer, we do not recommend it.  We will never recommend a screening test simply because it screens for a serious illness, the test must actually deliver some benefit for us to tell you it's a good idea.

In the meantime, do trust the USPSTF.  They are careful, deliberate, and quite wise.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Intuniv- A Newer Medication for ADHD May Improve Working Memory

Intuniv- A Newer Medication for ADHD 

May Work By Improving Working Memory

Not too many years ago, a new medication was approved for use in treating attention deficit/hyperactivity disorder (ADHD).  That drug was brand-named Intuniv, an extended release form of the drug guanfacine.

Guanfacine was originally developed as a drug that could treat high blood pressure, but adults taking doses large enough to lower their blood pressure got quite sleepy.  The sedative properties of guanfacine led to it being used in lower doses to help quiet the raging behaviors of children with severely abnormal behaviors.  That version of guanfacine was called Tenex and it was fashioned to last about 4-6 hours per dose.  Now, children treated with Tenex often had problems with attention as well as extreme behaviors, and when they took Tenex an improvement in their ability to focus and pay attention was noted.

This led to the development of a form of guanfacine that was low enough in dosage to not sedate but enough of a dosage to improve attention and focus.  That is Intuniv, and one dose tends to last 12 hours.  It is a remarkably safe medication with few side effects aside from those relating to tiredness noted in many decades of use.

On October 6, 2011, the New England Journal of Medicine (365:14, p. 1346-7) published an article reviewing recent research describing what physically is causing the nearly universal loss of memory function as we get older.  That is, the normal loss of memory, not dementia.  What the article demonstrates is that the key type of thinking ability lost with age that explains the loss of memory is working memory.  This is yet another indicator of the central power of working memory to help the mind get tasks done.  Working memory is not really a type of memory, rather it refers to the ability of one's mind to hold more than one piece of information in the mind at one moment in time and do something with it.  

In this article, monkeys had the parts of their brain that creates working memory wired for measurement of activity, but also to allow various medications to be administered.  What they found was that when guanfacine was applied to the nerves that create working memory, older monkey's working memory was restored to that of young monkeys.  This, in turn, led to better ability to remember items, and to improved ability to get tasks done.

This is the first indication I have read of a medication demonstrating the ability to improve working memory.

As such, guanfacine, or Intuniv, works in a radically different way than stimulants such as Ritalin, Concerta, Adderal, Focalin, or Vyvanse.  The stimulants work by arousing the brain.  As we know a brain that is more alert works better.  That, after all, is what coffee is all about.  But Intuniv appears to work by actually changing the ability of the brain to create working memory function.

If this impact can be proven to be reliably present on use of Intuniv, and shown to be safe, it could make Intuniv a very interesting, powerful, and safe medication to consider when seeking to improve attention and focus.  It could yield changes that lie at the heart of attention deficits, without all the significant side effects of stimulants.

At the same time, it should be noted that there are interventions that have been proven to increase working memory without the use of any medication.  One of the most promising of such interventions is Cogmed, the product of serious neuroscience research and development in Sweden.  Cogmed, whose impact on working memory has been verified by independent laboratories, including the one, in England, that developed the concept of working memory, increases working memory significantly in 80% of those who complete the 5 week intervention.

Research into how the brain works is rapidly expanding our knowledge and our ability to help our minds work.  This recent report in the New England Journal of Medicine puts working memory once again at the center of how the mind gets tasks done.  It raises the possibility that a very safe medication, Intuniv, may be a specific intervention to boost working memory, and it increases the chance that interventions that require no drugs, e.g. Cogmed, are devoted to changing the right cognitive function.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

HPV in the News: A Review of the Basics

HPV in the News:  

A Review of the Basics

You never know when or which topic in science will become a hot topic in politics, but when science and politics mix, the facts usually take a beating.  This is not because politics sets out to wage war on facts, but rather that politics always has a goal in mind, and it typically is happy to twist a few facts to reach that goal.

We have seen this all in play during the recent explosion of interest in the HPV vaccine by those some politicians vying to become their party's nominee to be president.  The controversy surrounds a 2007 executive order as governor by one of the candidates mandating that all middle school girls in the state be immunized against HPV infection.  Other candidates reacted strongly to that decision in a recent debate, and suddenly HPV immunization leapt to the headlines.  Large numbers of people began registering their anger at the idea that government could force someone to be immunized, and bristled at the idea that families could be forced into decisions that could promote promiscuity.

Given the furor over HPV, we thought it would be timely to take a step back from the political excitement and think about just what this virus is, what the immunization does, and how to make a good choice for your family.

What is HPV?

HPV stands for human papilloma virus.  This is the virus that causes all warts.  The word papilloma is the Latin way to say wart.  So the HPV is the virus that causes warts in humans.  

The HPV is different sort of virus.  Most viruses make you sick, but with one exception, HPV does not.

All infections with HPV cause an infection isolated to the one spot the virus has landed.   At that spot the skin is goaded into making more skin, causing a lump of skin material to form, the lump that we call a wart.  That lump of material, with one exception, causes no harm.  Often the virus can sit in the skin without any lump appearing, but with lump or no lump, the virus can sit in its spot under the skin for a very long time, sometimes for decades.  It looks like it can sit there for such long times precisely because it is very quiet about its business.  Often not spreading to other spots in the skin, and really not doing much where it sits.

Consider how strikingly different this is from the usual virus, say the virus that causes the common cold, the rhinovirus.  Once the rhinovirus lands in your nose, it starts a real fire.  It burns off the lining of the nose, and in  rapid sequence goes on to burn the lining of the throat, all the sinuses, and then the entire lung.  The burning only stops once all the linings are burnt.  Luckily for us, the burn is very shallow, so it is not dangerous, but it causes all the suffering of a cold- fever, feeling lousy, achiness, cough, and a river of mucus wherever the virus has been- nose, eyes, throat, and lungs.  The whole infection causes an uproar in the body with a big response from our immune system that kills the invader and ends the infection.  The whole drama is over in 1-2 weeks.

HPV does none of that.  As we noted, it does not spread well, wherever it sits it causes little harm, and it can stay in its quiet, isolated spot for decades, not weeks.

There is one exception to this peaceful portrait of HPV.  That is the ability for infection with HPV in the area of the cervix to start a sequence that can end in cancer.  The cervix is the neck-shaped end of the uterus that lies at the top of the vagina.  HPV infection of the cervix by certain subtypes of HPV, can start a process that allows cells there to start growing in a disorganized fashion, and sometimes that can end up with a cancerous tumor called cervical cancer.

It is worth repeating that HPV infection is not rare.  Essentially every single person will come into contact with the skin HPV's.  The skin HPV's are spread by simple contact, and appear to be a nearly universal experience.  The genital HPV's spread by sexual contact, but are nearly as common, causing infection in as many as 75% of all humanity.  As such HPV is, by far, the most common sexually transmitted disease (STD).

So HPV causes three types of warts.  The common warts of the external skin.  Genital warts in men and women.  And the special genital warts of the cervix that can become cancer.  Since each type is caused by a separate type of HPV, an immunization against one type of HPV will protect against the infection that type causes.

Of course, only the HPV that causes serious disease, the subtypes that can lead to cervical cancer, has been targeted with an immunization that can prevent HPV infection.  That means the HPV shot only prevents infection with the HPV's that cause infection in the cervix of the uterus, not the ones that cause common skin warts.

This is a smart choice.  After all would one rather have a shot that prevents harmless skin warts, or one that prevents a type of cancer that kills more young women in the world than any other?

What is the HPV Immunization?

What does the HPV shot try to do?   Prevent cervical cancer

Of the many types of HPV that cause infection of the cervix and that can then lead to cancer, the HPV immunization prevents infection from the HPV's that are most likely to lead to cervical cancer.  That is not all HPV's and it not all the HPV's that cause cervical cancer.

So the first thing to say about the HPV immunization is that it does not protect against all HPV infections and cannot prevent all cervical cancer.  But it does protect against the HPV infections that are responsible for roughly 70-80% of all cervical cancer.   Not a bad start.

Does the HPV shot work?  Yes

The next question is how well HPV immunization works.  The answer is that it works very well.  If you get HPV immunization before you are exposed to cervical HPV, that is before sexual activity begins, it will block infection with the HPV subtypes in the shot.  And it looks like it lasts.  Since the HPV's are so widespread, people get exposed to them for a very long time and this acts like a booster for the shot, helping it provide protection for many, many years.

Is the HPV shot safe?  Yes
As those familiar with Advanced Pediatrics know, we take do not allow any representatives of the drug industry to be in our office and accept no materials from them, all in effort to be sure when asked about their products, that we can offer the most trustworthy observations that science can provide, as free as possible from market influences.

It is with this commitment and approach in mind that we took a look at the facts of how safe this vaccine is.

The data are very strong and compelling that this is a safe vaccine.

The list of possible side effects are limited those seen with any shot- irritation, allergic reactions, fever, headache, and fainting.  That's about it.

Like with any intervention, however, when upsetting events happen after the intervention, one cannot help but believe the intervention caused it. This is the power of guilt by association.  A good example would be getting a haircut and then right afterwards getting into a car accident.  The accident did immediately follow the haircut, and so is definitely associated, but did the haircut cause the accident, clearly not.
Just so, there have been stories circulating that a person became mentally impaired after getting this shot, but there is no evidence that this shot causes any sort of mental impairment.  The impairment may have started on the day of the shot, but there is no reason to believe the shot caused it.

A wide body of study has looked carefully at whether the HPV immunization causes serious problems, and the observations are strong, consistent, and reassuring, the HPV immunization does not cause serious problems.

How to be immunized against HPV?
Immunization to prevent HPV infection takes three shots.  The second dose has to be 1-2 months or more after Dose 1, and the third dose 6 months or more after Dose 1.

It is best to be immunized before you get exposed to HPV, meaning before sexual activity begins.  If people are immunized in middle school or early high school, that seems to provide the best timing.

Keep in mind that human papilloma viruses (HPV's) can cause three types of infection in people- common skin warts, genital warts, and cervical warts.  Only the cervical wart infection can lead to cancer.  And that is why the HPV immunization only protects against the HPV's that cervical wart subtypes.

This is good to remember, because it introduces a difference in benefit between boys and girls getting HPV immunization.  Boys can only get two of the HPV infections mentioned, skin and genital wart infections.  So even if a boy gets an infection with a subtype of HPV that can cause genital warts, that virus cannot physically ever lead to cervical cancer, boys do not have a cervix.   Girls, of course, can and do get all three type of HPV infections.

As a result, if a girl gets the HPV immunization, she may prevent developing cervical cancer someday.  No boy will ever have that benefit.

So why immunize boys?  For the same reason we immunize everyone for rubella (German measles).  Rubella is a very harmless infection for children and adults, but deadly and deforming to the developing fetus.  We actually never immunize those really at risk for rubella, the fetus.  Instead, we immunize everyone else, all children and adults who need it.   That immunization offers essentially no benefit to those immunized, but since we all agree to be immunized, no fetus can be exposed.  This strategy has led to the nearly complete disappearance of all fetal rubella infections, a stunning triumph.

Just so with immunizing boys against HPV.

Remember, as many as 75% of all humanity, is infected with genital HPV.  It is literally everywhere.
Boys carry it as much as girls.  So it does help to immunize all girls, but it is not enough to prevent all the cervical cancer that we can.  If boys get immunized too, it greatly strengthens the defence against these HPV infections.

So we recommend boys get immunized, knowing that they will never gain the benefit of cancer prevention, but knowing that if they do get immunized it will help prevent cervical cancer in half of humanity. And, the boys will have fewer genital warts, offering some benefit.

BOTTOM LINE
American presidential politics have thrusted HPV immunization into the nation's spotlight.  As is to be expected, the discussion has promoted the temptation to throw facts out and let strong feelings carry the argument.

But when it comes to your child's health, it makes sense to take a step back, a bit of a breath, and try to base decisions on facts.

The salient facts are these:

• The human papilloma viruses (HPV) cause warts on our skin, genitals and the cervix of the uterus.
• HPV infects nearly all of us.   The skin types are likely present in all people at some time.  About 75% of people,  men and women, are infected with genital HPV.  The genital HPV in women is the major cause of cervical cancer.
• HPV immunization can prevent infection with the subtypes that cause cervical cancer in women.
• The HPV vaccine works and is safe.
• Sadly, politics is having some of its way with science, obscuring facts, trying to raise fears, hopefully the facts can help you keep your focus on keeping your children healthy.

Dr. Arthur Lavin

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