On the Best Timing to get Tested for Strep Throat

On the Best Timing to get Tested for Strep Throat

Just today, a parent in the practice asked, "When is the best time in the course of a sore throat to get tested for strep?"   And then added, "You should make this the topic of your next email."

I agree.  So here it is.

The problem is one faced by many, many families.   You have a child with a sore throat and fever, when is it best to bring them in for a throat swab and strep test?

Two errors can be made.  The first is getting tested for strep if you don't have it.

The second is not getting tested for strep if you do have strep.

Now, the actual question put to me was, when in the course of a sore throat is it best to be tested?  This implies that one is more likely to be subject to either error if you come in too early or too late in the course of the sore throat.

For example, if it was true that it took 2-3 days of being sick with strep throat before a strep test would reliably be positive, then coming in for a strep test on the 2nd day of being ill would cause the test to say you did not have strep, when you did.

But, it turns out it is not true that it takes 2-3 days of strep illness before the strep test turns positive.

The way it does work is as follows:

1. You are not infected with strep until the strep germ lands on your throat and begins to infect your throat.
2. From the moment the strep germ lands on and infects your throat, you have strep throat.  From that moment on, a swab of your throat will yield a positive strep test.
3. It does take some time for the germ, once landed and infected, to cause symptoms, usually something on the order of 1-2 days.  But even during this time, a throat swab could detect the presence of strep.
4. Once the first 24-48 hours are passed, symptoms begin to appear, and may include headache, stomach ache, neck ache, sore throat, fever, and even a fine red dotted rash.  The rapid strep test stays positive throughout the duration of the illness.
5. After a few days or a week, even if untreated, the infection begins to fade away.  The rapid strep test stays positive through the decline of the illness as well.

Bottom Lines

1.  The rapid strep test for the infection of strep throat can be done reliably at any point along the course of a strep throat infection.   Getting tested on the first day or a week later yields the same answer.

2.  If a family is wondering if their child has strep throat, it is OK to wait a day or two to see if the symptoms go away, as long as your child is not too ill or uncomfortable.

3.  Strep throat itself is fairly harmless, aside from the discomfort it causes.  The vast majority of strep throat infections do not even cause a sore throat, are missed, and never treated.  So the main reason to get tested is that if you have it, we can treat it and reduce the fever and pain.  That can be done at essentially any point along the course of the illness.

4.  The only timing issue that counts is that if strep is treated prior to 10 days of illness, a rare complication, rheumatic fever, is prevented.  So if strep is suspected, you have plenty of days to weight whether to get tested, but not more than 10 days.

To your health,

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.

Fidget to Learn- Some Children need to Fidget to Learn Better

Fidget to Learn- 

Some Children need to Fidget to Learn Better

Perhaps one of the most challenging aspect of our school-age years, is that everyone is obligated to do the same thing.  Everyone must sit in a classroom, everyone must study language, math, and science, and other subjects as well.  Everyone has the same homework.

This is so different than the rest of our lives, one could talk about three parts of the modern person's life- their life before they enroll in school, the school years, and their life after they leave school.

The life before entering the world of school is the one in which learning is the most geared to the particular child.  Toddlers and pre-schoolers get to do pretty much what interests them at the moment.  A roomful of 20 three year olds will often show a room of 20 different activities going on.

Much the same is true of us adults once out of school.  Some of us become teachers, or painters, or lawyers, even doctors.   But the point is a randomly sampled group of 20 adults will likely yield a wide range of what constitutes their daily activity.

Not so school.  There all children are asked to do what the school requires, not what they are interested in.

This fact has created a rather huge amount of trouble for kids across the country, so it was quite interesting to read that two studies published recently seem to suggest that some children's minds actually think better when they fidget.

Two of these studies were reviewed in the Wall Street Journal and New York Times (http://well.blogs.nytimes.com/2015/06/24/fidgeting-may-benefit-children-with-a-d-h-d/).

The findings were actually very straighforward:  if you take kids with ADHD and let them move or fidget during school work, their ability to think is actually improved.   If you have kids who do not have ADHD fidget, it offers no benefit to their thinking.

One of the papers' authors was Dr. Julie Schweitzer of the MIND Institute of University of California at Davis.  She notes that children with the primary form of ADHD (that is, their inattention is not due to some other problem other than being unable to attend), often have evidence of less brain activity in the cognitive parts of the brain, such as the prefrontal cortex.   But these children, even at rest, have higher levels of activity in parts of the brain that run muscle action, such as the cerebellum and basal ganglia.

I found this work fascinating for a number of reasons.

First, it presents science based evidence for what we have all known all along.  People learn the same facts in quite different ways from person to person.  In this example, clearly some kids need to move to learn, and for some kids moving offers not help at all.

Secondly, there is a fascinating connection between thinking and moving.   The basal ganglia are a set of structures of neurons deep inside the brain that are known to be very important in making sure our muscle motions are smooth, well-planned, and effective.   They do a lot of programming of motion, like walking, picking up items, catching things, etc.   But it turns out the basal ganglia are also the centers of dopamine-run nerve networks that are the source of much of our senses of pleasure.  We also know these same dopamine networks are involved in effective thinking.  So the nerves that make pleasure happen also coordinate our muscles so that we get tasks done, like writing this post.

We tend, culturally, to split great athletic prowess and bright thinking.   But the brain does both, and in many instances, using the same pathways.  This is yet another reason exercise is so good for you, purposeful, well-executed motion, helps the mind create purposeful, well-executed thoughts.

Bottom Lines

1.  The chief take away point is that every person learns in their own way.  School typically offers only one approach to learning.  This works for many, but not many others.

2.  So, the ideal school, the school of tomorrow that will be based on good neuroscience, will know how every student learns, and use the right approach for each student.

3.  In the meantime, we now know that some subset of kids really do learn subjects better if they can fidget and move.   Just think of how many of our children actually get in trouble for moving in class, and how many of them would have been much better students had they been allowed to.

To your health,

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.

Moles: What are They? When to Worry?

Moles:  

What are They?  When to Worry?

Everyone has them, increasingly people are worried about them.

So, what is a mole, why do we worry about them, when should we worry about them.

Some mole basics

The word mole comes a very old root from which other words meaning spot, or stain, or blemish arise.    And in common use today, the word refers to small, typically dark brown or black, spots or blemishes on the skin.

Nearly everyone has moles, and they are made up of the same type of cells, the melanocytes (muh-LAN-o-sites).

Melanocytes are cells with a unique function, they make a chemical called melanin, the key pigment of human skin.   The way it works is that each melanocyte has a network of little tubes, one tube going to from the melanocyte to a skin cell.  Typically each melanocyte is connected to about 50 skin cells.   As the melanocyte make their yellow pigment melanin, it is delivered through these 50 tiny tubes to 50 skin cells.

Nearly everyone has the same number of melanocytes, distributed in an even blanket across the skin, feeding nearly every skin cell with its melanin.   People with dark pigmentation have no more melanocytes than those of very little pigmentation.  The only difference is how much melanin is pumped out from one's melanocytes.  A very little bit or almost none will yield a person with very pale unpigmented skin.  More leads to olive or even slightly yellowish hues.  As melanin production increases, skin color tends towards the various shades of brown.

Almost everyone has a group of melanocytes accumulate somewhere on their skin, not the even sheet distributed across the skin described above, but a little ball of melanocytes.   This is a mole.

The average number is about 10-20.  It is thought the number of moles a person will develop, and where they will appear, is determined prior to birth in one's genes.

The number and place of moles is determined once one's genes are set, but these little balls of melanocytes, the moles tend to take many years to form. That's why most moles are not present at birth.  Many tend to develop during infancy and childhood and even appear during adulthood.
The little clumps or balls of melanocytes grow over time and so they may start flat and then grow to have some vertical elevation relative to the flat plane of the skin.

Moles tend to be some shade of brown.  They can be without any pigment, just flesh-colored, or very light brown,  Or, they can be darker brown, even to the point of looking black.  Some have a reddish hue as well.  Some have a little halo of decreased pigment or lighter skin surrounding them.

An enduring question about moles is, why do we have them?  No one has ever answered this question, so it remains in place.   My own sense is that they are present either because this a by-product of having a vast network of melanocytes across nearly all of our skin and sometimes they gather into clumps at random.  Or, they serve some function that we don't know about yet.

The main point about moles though, is that they are a normal part of the human body.  Nearly everyone has them, and unless they change in some radical way, they are 100%, completely harmless.

Why worry about moles?
If moles are a normal part of the body, why is there so much worry about them?

It should come as no surprise, but moles are like many other normal parts of our body, their cells can turn cancerous.   Not all parts of the body can create cancers, heart cells and nerve cells cannot turn cancerous.  But many other parts of the body can, like other parts of the skin, lungs, pancreas, kidneys, white blood cells, the gut cells.

Of course, cancer is a scary property of our bodies, one of the scariest, so it makes sense for us to be worried about whether our bodies, and especially our children's bodies, will every turn to cancer.

But moles have a special place in our world of worry.  We don't tend to worry much, when feeling fine, about our lungs, or gut.  In fact, if pushed to think about the insides of our body, most of us tend to be very grateful our lungs and gut, and other parts are doing their job.

But since moles have no known job to perform, they seem to sit there as a constant reminder of what might go wrong.  Moles, more than any other normal part of the body tend to make us think of cancer.   No wonder we worry more about our moles than any other part of our body.

What is melanoma?
Every cancer comes from a normal cell.  Most cancers are named for their cell of origin.  Lung cells are the cell of origin for lung cancer, and colon cells are the cell of origin of colon cancer.  But some cancers have their own name, usually tied to the cell of origin by some Latin or Greek translation.
White blood cells, for example, are the cell of origin of leukemia.  The ancient Greek word for white is leukos, and the ancient Greek word for blood is haima.  So leukemia is a rough Greek translation of the phrase white blood, referring to the white blood cell.
Melanoma comes from the Greek word for black (melos) and tumor or mass (oma), so it means black tumor.   But the cell of origin for melanoma is always a melanocyte.
Now, interestingly enough, most melanomas come from those melanocytes evenly distributed around the skin, not from moles.  In fact, about 75% of melanomas do not come from moles.  Of course that means about 25% of melanomas come from moles.
Melanoma is an unusual cancer since when it occurs, it makes itself visible via changes in the skin.
And so it has the very wonderful property that if the change is seen early enough, and it is removed before it goes even 1mm deep into the skin, it is cured.  No spread, no recurrence, cured.
Sadly, if it is missed, and goes very deep, it spreads better than most cancers and can be very deadly.

When is a mole worth our concern?
Of course, the only reason to worry about a mole is if its melanocytes convert to cancerous melanoma cells.  No melanoma no worries.  Thankfully, moles, like other parts of the body do not tend to convert, they stay normal our entire lives.   And, if a mole stays a mole, there is truly nothing to worry about.

So, the only reason to worry about a mole is if it is turning from a mole into a melanoma.   The key signs of that happening all have to do with change.  No mole starts off as a melanoma, so to become worrisome, a mole must change.

But it is is very important to keep in mind there is one change in a mole that is always fine, and always expected- they grow with you.   A mole on your belly at age 3 grows as the 3 year old grows, and maintains roughly the same proportion of area on the belly when you are 20 as when you were 3.

The changes of concern are easy to remember, as easy as A-B-C:
Area-  as noted, moles grow as a person grows, so they do increase in area normally, but if the mole grows beyond it usual proportion of area, that is of concern.   Moles smaller than the diameter of the eraser on a pencil are considered a normal, small size.
Border-  the border of a mole should not change.  Typically the border is very sharp, if the usually sharp border gets fuzzy or zig-zagged, that is of concern.
Color- moles come in all colors, but once a mole has appeared, its color should not change.  So if a mole gets darker, or develops more than one color, that is of concern.

The Gray Zone of Dysplasia
We have noted that moles either are simply moles, harmless clumps of melanocytes that don't do anything; or, are melanomas.

There is one other way moles can be, they can be dysplastic.  When we look at a mole under a microscope, we can see the melanocytes arranged in very orderly patterns, all looking exactly alike.  That's the normal mole.  Or we can see cells transformed into wild out-of-control clumps of growing chaotic looking cells.  That's melanoma.

Dysplasia is a state where the cells aren't as uniform, tidily arranged, and orderly as in a normal mole. But they aren't as wild and out-of-control, and oddly shaped as melanoma cells.   Dysplastic moles have melanocytes that are a bit disorganized, a bit non-uniform.  These are not cancers.   

Dyplasia means that the cells of the mole are a bit disorganized, but not that they are cancers.  It doesn't even mean they will become cancers.   If a mole turned dysplastic, but never turned to melanoma, it could stay on the body your whole life and never cause any harm.

The problem when it comes to the cancer melanoma is that any melanocyte can turn into melanoma, whether in the normal skin, in a normal mole, or a dysplastic moles.  Dysplastic moles turn into melanoma more often than normal moles, but the vast majority of dysplastic moles never do change, and most melanomas do not even come from moles.

The Current Craze to Remove and Biopsy
Now we come to current habits of how we all respond to the moles we all seem to have.

As noted above, we live in an era in which moles are far more scary than other parts of our body, even though so many parts of our bodies can turn into cancer.  It seems as though the fear of cancer, which is a very reasonable thing to dread, comes to the surface when it comes to moles.

Most would agree that any mole that poses a serious risk of being a melanoma needs to be removed and studied to see if it is.

The more interesting question is what about removing normal looking moles?  How to decide whether to worry about one, remove it and study it.

The answer turns out to be quite different for kids and older adults.   That is because the usual melanoma takes many, many years to transform its once normal melanocyte cells into melanoma cells.

To put this into some perspective, consider the how many people get diagnosed with melanoma a year.  For kids 0-14 years of age, that number is 1-3 out of every million kids.  For adults that number is 216 out of every million adults, about 200 times more common!!

This leads to perhaps the most interesting number I have come across when it comes to what happens to all the moles removed from kids.   This number is astounding, and was presented to me at a conference on pediatric dermatology not long ago.  The dermatologist stated that currently only 1 in every 100,000 moles removed in children turns out to be actual melanoma.  

That means that under current rates of mole removal, there are 100,000 moles removed that are perfectly harmless for every one that is.   There are no other procedures in medicine I know of where so many surgeries are done to that many people with no problem, for every one that is.

Which moles should be removed in childhood

There are a set of very unusual moles called large congenital nevus.  This is a very large mole, typically over 8 inches across, and present at birth.   These convert to melanoma at a higher rate than any other mole at any age, and need to be removed.

Otherwise, if a mole is present in childhood, is small, uniform in color, with sharp borders, has no spontaneous bleeding, the only reason to remove it is if it changes in those characteristics.  Removal for any other reason would be for appearance.

That means the typical mole should be removed for these reasons:
1.  Change in color
2.  Getting larger than expected with normal growth proportionate to the child's health
3.  Developing a fuzzy border,
4.  Changing in shape.

A good set of pictures contrasting typical, harmless moles, with worrisome moles is at
http://www.skincancer.org/skin-cancer-information/melanoma/melanoma-warning-signs-and-images/do-you-know-your-abcdes#panel1-5

BOTTOM LINES
1.  Moles are a normal part of the normal human body, almost everyone has some, often as many as 100.
2.  Like other parts of the body, moles can become the cell source for cancers, in their case, melanoma.
3.  Even if everyone got all their moles removed, about 75% of melanomas would still occur, since most melanocytes are distributed across all our normal skin.
4.  The risk of melanoma developing from a melanocyte goes up with age, melanoma is quite rare in childhood.
5.  Well beyond the vast majority of moles removed in childhood turn out to be harmless, not cancerous.   If you took 100,000 moles removed from children, on average only one of them would turn out to be dangerous.
6.  A dysplastic mole in childhood is not a cancerous mole.   There is no direct way to know if a specific dysplastic mole will ever convert to a melanoma, just as there is no direct way to know if any spot of skin will at some time.
7.  Putting it all together, aside from the very rare instance of a large congential nevus (a mole >8inches across), the only clear medical reason to remove a mole from a child is if the area, symmetry, color, border, are worrisome as a result of it being too big, too asymmetric, changing, or bleeding.  Simple appearing moles that don't change or bleed or erode are very, very likely to be safe to leave alone.

To your health,
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.

Edible Health- Our New Column in Edible Cleveland

Edible Health- 

Our New Column in Edible Cleveland

We are pleased to announce that the extraordinary magazine, Edible Cleveland, had invited Dr. Lavin to write a regular column, Edible Health, starting with their current issue, Summer 2015.

www.ediblecleveland.com

Edible Cleveland is our region's premiere magazine about eating well, eating locally in a gorgeous, celebratory style.   It is one of over 50 regional magazines that make up the Edible Communities publishing juggernaut.   Edible Communities is the world's largest publisher of information about local food resources. They print over 5 million issues a year across the US and Canada which are read by more than 5 million readers.  We are very fortunate to have Edible Cleveland, an Edible Communities publication, highlighting the extraordinary offerings of our local region in such a spectacular presentation.  Many thanks to the Publisher Noelle Celeste and Jon Benedict, the Editor, for assembling the impressive group of writers, illustrators, and photographers and making this phenomenal publication available to all of us.  

And so we are so grateful that Edible Cleveland, after careful consideration of health care experts in our region, selected Dr. Lavin to be their medical writer.   In the column Edible Health, exciting topics relating to health and eating will be explored and presented in a compelling format.

The magazine is published every season, so 4 issues a year.  You can pick up a free copy at Mitchell's Ice Cream and other outlets, or go to www.ediblecleveland.com to subscribe at a very reasonable cost, or to peruse their abundant online resources, including back issues.

Our first column is all about how the speed at which we eat can determine if we will be thin or overweight.  Compelling research from Stockholm presents evidence that eating rapidly can increase your waistline, while eating too slowly can actually lead to being too thin.  Details are in our inaugural column.  This fall, the Edible Health will present the fascinating story of why we chew, when we develop this demanding instinct, and how it impacts our lives.

So, once again, many thanks to Edible Cleveland for the opportunity to be part of this incredible publication.   We will be a distribution site for issues, but do go online as well.  We hope you enjoy our column and this great magazine.

To your health,

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.

Getting Thinner- It's all about our Food, Exercise has a much smaller role

Getting Thinner- It's all about our Food, 

exercise has a much smaller role

On June 15, 2015, The New York Times published a review of many years of study on the question: what helps us lose weight more- eating less or exercising more?

http://www.nytimes.com/2015/06/16/upshot/to-lose-weight-eating-less-is-far-more-important-than-exercising-more.html

As many who have discussed this question in our practice already know, diet trumps exercise, to a surprisingly great degree.

The key benefits of exercise all rest in helping any organ in our body work better.  People who are physically active experience better function of their lungs, their heart, their bones, and their brains.  They tend to live longer.  But they do not tend to be thinner.

One's weight is determined far more by what one eats than how much one moves.  That is because our bodies are so efficient.  It takes very few calories to move our body around, even quite a bit.

One of my favorite illustrations of this amazing fact has to do with the comparison between the energy it takes to run a full marathon compared to the energy in a common hamburger sold.

It turns out the energy burned to run a full marathon actually equals the energy in a Big Mac from McDonald's.

Imagine that, you could run to the point of utter exhaustion, over 20 miles, and if you eat a Big Mac afterwords, it is as if you did not eat anything or run at all, it comes out as a zero change in energy status.  Incredible.

Many years ago, the PBS science show NOVA did a piece on a group of 20 or so older adults, none of whom had exercised at all for many, many years.  Over a one year period, the study got all of these volunteers up to running at least 5 miles a day, and capped the year by running a full marathon.  Of all these people whose level of exercise increased so very dramatically, only one lost any weight during the year.  That would be the one person who took the opportunity to change what she ate, she was the only one of those running at least 5 miles a day, and training for a marathon, to lose any weight.

So, I hope you find the article interesting.  The level of evidence on this point is now quite convincing.

http://www.nytimes.com/2015/06/16/upshot/to-lose-weight-eating-less-is-far-more-important-than-exercising-more.html

Which means, if you want to lose weight, or if you are growing would like to gain weight more slowly, then drink only water (not juice, milk, or soda), limit snacks to only fruits and vegetables, and eat smaller portions.

To your health,
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.

The Live Immunizations- Why They do Not Need Boosters but Still Need more than One Dose

The Difference between a Live and Dead Immunizations:

One Needs Boosters, the Other May Not

A lot of colleges are now requiring entering students to have 2 chickenpox vaccines, and this has led to many questions about why some vaccines require regular repeat dosages (boosters), why some don't.  This essay is a bit technical, but explains why this is so.

It turns out that not all immunizations are the same sort of immunization.

One aspect that all immunizations share is that they present the body with the illusion that it is being infected with a germ, the body responds by creating its defenses, and as along as those defenses remain in place, the real germ is kept from creating a real infection.  For example, the polio immunization tricks the body into thinking a real polio infection is happening.  The body's response leaves the body fully defended from real polio germs, and if they come by, cannot cause polio.

So, all immunizations use this approach and strategy, but some are living, and some are not, and that can impact on how many doses you need to create and maintain the protection.

Non-Living Immunizations

Nearly all immunizations routinely used for American children are not live, but made out of non-living materials derived from a once alive germ.  These include the very familiar immunizations for diphtheria, tetanus and pertussis (the DTaP for young kids and TDaP for older people), all the meningitis shots, the HPV vaccines, the polio vaccine, and hepatitis A and B.

The key property of non-living, or dead immunizations, is that the body does not totally believe that a real infection has taken place.  Most of the defenses that allow us to survive and triumph over an infection take place after immunization with inert material, but not all.  So after getting an immunization with non-living material, you are protected, but the protection wanes, and after some period of time, disappears.   So, if after you are born you get one tetanus shot, you will have protection against tetanus for 2 months, but that's it.

The other property of non-living immunizations, is that if you repeat the dose, the time the protection lasts gets longer.  Taking the tetanus example, if you get one shot every two months for a total of 3 tetanus shots, you will be protected for one year, and after a fourth dose at the end of that year long interval, you will be protected for 7 years!

So almost all non-living immunizations require an initial series of immunizations, to keep protection in place, and to lengthen how long you are protected between repeat doses.  But even once you achieve protection for 10 or more years, one typically sees protection weaken.  That is why all of these types of immunizations typically require boosters, or repeat dosages over long periods of time.

Three exceptions to this rule are the Hepatitis A and B, and HPV immunizations, which do not require boosters over time.

Living Immunizations
There are not many living immunizations, and they all are for diseases whose germs are viruses.

There are very, very few live immunizations containing live bacteria.

The reason for both these facts has to do with the central challenge of a live immunization.   How do you put a live germ in someone and avoid causing the infection?

No one has figured out how to weaken a bacteria to the point it won't make you ill, but still keep it live enough to provide immunity.

But that has been figured out for a variety of viruses.  It turns out you can grow viruses in a way that renders them very, very weak, but still capable of reproducing a few times in your body before dying off.   This allows for some immunizations to deliver a very, very weak form of the germ, so weak you don't get ill, but still alive enough to really convince the body it is experiencing a real infection.

If the body thinks a very real infection has occurred, then it goes all the way in defending against it and creates mechanisms to produce protection for the rest of the person's life.  This is called life-long immunity, and is typically the result of live immunizations.

The first live immunization was for smallpox, and was achieved by a very clever, and very simple trick.   It was noted that milkmaids who got cowpox never got smallpox, so by giving cowpox to everyone, smallpox was eradicated.  The Latin word for cowpox is vaccinia, and to give someone cowpox was to vaccinate them, the source of the word vaccine and vaccination.  Technically to vaccinate someone only refers to preventing smallpox, which is why I use the word immunization.

The permanent protection against smallpox via vaccination was so effective that smallpox has been eliminated as a disease from the entire planet for over 40 years.

The next live immunization created was for polio.  We are nearing the extinction of polio.  Across the entire world in 2015, so far, only 26 cases of polio have occurred- 24 in Pakistan and 2 in Afghanistan.   The virus is thought to still be alive in Nigeria as well.  But that's it.  India is now polio free for 3 years.   The eradication of polio is close enough the US switched to the non-live form of polio immunization many years ago, so it is not a live vaccine in the US.

The three live viral immunizations we use routinely in Advanced Pediatrics are:  the MMR, the varicella, and the influenza immunizations.

MMR
The MMR is the only form of immunization available in the US to prevent the infection measles.  MMR stands for measles, mumps, and rubella.  The MMR contains a very weakened version of all three of these viruses.  Once placed in the body, each of these viruses replicate for a few cycles, die and are completely eliminated from the body.   But, if the immunization works, if the body creates a response to these viruses, that leaves the body permanently protected.

For measles, the MMR works at least 95% of the time.  That means if 100 people get 1 dose of the MMR, then 95 will not be able to get measles for the rest of their lives.   For any individual that is pretty good level of protection, but in large groups, such as colleges, that still leaves about 1 in 20 able to sustain an epidemic.  Hence the recommendation that everyone get two MMR's.  The second dose may provoke permanent protection in some of the 5% who did not respond to the first dose.

So the second dose of the MMR is not a booster, it is simply a second chance to have a response.

We support the two dose strategy, it has worked well. Populations that have two doses of MMR do not have measles.  Those that do not, do have measles.

I will also mention that the allegation that MMR can cause autism has been definitively disproven, and the intensity of belief in this idea has weakened dramatically in the last year or so.

Varicella or Chickenpox Immunization
Varicella is the Latin word for chickenpox, and zoster is the Greek word for shingles.

Varicella in Latin means little pox, since chickenpox is a lesser pox than smallpox.  Zoster in Greek means belt, since the rash of shingles is often in a belt-like pattern.

The same virus causes chickenpox and shingles:  Herpes varicella-zoster.  This is no surprise since shingles is simply the recurrence of chickenpox.  The way it works is that if you get a case of chickenpox, the virus goes dormant in cells along your spinal cord the rest of your life.  You won't get chickenpox again, but your own dormant chickenpox virus can re-activate and erupt down a nerve fiber from the spinal cord, appearing in a patch on the surface of the skin at the end of that nerve, hence the patch (shingle) or belt-like (zoster) of the rash.

The varicella or chickenpox (same thing) immunization is a live virus, and contains a very, very weak version of the living Herpes varicella-zoster virus.   One dose of this immunization renders nearly everyone permanently immune to severe chickenpox.   If you've had only one dose and get exposed to a case of chickenpox, you have a 10% chance of developing chickenpox, but essentially all such cases are incredibly mild, with 1-10 red dots, and perhaps not even contagious.   So, one dose nearly eliminates all chance of serious chickenpox disease permanently.

Since that protection is permanent like other live immunizations, there is no need for a booster.

But, a second dose is desirable to further reduce the chance of developing any chickenpox illness, even very mild, and thereby stopping the spread.

We support the recommendation that all children have two varicella or chickenpox immunizations prior to Kindergarten.  For older youth and young adults who got their varicella or chickenpox immunization when it once was a one shot routine, the rationale for getting a second makes sense but is not urgent.   Staying with one is a reasonable choice, and exposes the person to only the 10% risk of very mild cases of chickenpox.

The flu mist, or nasal influenza immunization

The third routine live immunization we recommend is the influenza immunization.   It is the only nasal immunization we routinely offer.  It works because the influenza virus naturally lives in the nose and so can do its work by nasal administration quite well.

If you have followed the difference between live and non-live immunizations, you might wonder, why is a live immunization like the nasal flu immunization given every year if live vaccines last all one's life and do not require boosters?

That would be a great question, and if you asked it you would be right, if you get a nasal flu immunization, your protected against those subtypes of influenza virus for life.

The problem is that the subtypes change every year, so last year's lifelong protection does nothing to protect against this year's viruses.

Not routinely used live vaccines
There are three other live immunizations that we do not use routinely that should be mentioned:
1.  Polio- as noted above, live polio immunization is not used in the US, only the non-live version.
2.  Typhoid- the oral typhoid immunization is used for those traveling outside of the US/Canada/Western Europe/Israel/New Zealand/Japan areas.   This is the only live bacterial immunization we use in the office.  It works because the typhoid germ naturally infects the gut, so it can be weakened to avoid causing illness and still administered orally and offer protection.
3.  Rotavirus- this live oral immunization is also for a germ that infects the gut.  We do not recommend its use for three reasons.  First, the illness it prevents is harmless in the overwhelming majority of children in the US.  Second, the immunization is associated with a small but measurable increase in the risk of causing intestinal obstruction.  Third, the widespread use of this immunization has caused the number of rotavirus infections to go down, but another cause of viral stomach flu has taken its place, the noravirus, so this immunization program has had little impact on the chance of a child getting the stomach flu.

Bottom Lines

1. Immunizations all work by getting the body to think a harmless version of a germ has caused a real infection, to lead to real protection from the real thing.
2. Immunizations always contain the germ, in some the germ is not alive, in others it is.
3. Non-living immunizations tend to offer protection that weakens over time, and so boosters are necessary to remain protected.
4. Living immunizations tend to offer life-long protection, so boosters are not necessary, but more than one dose could be useful to improve the chance the immunization works, or to respond to a virus that changes type yearly.
5. Details on living immunizations that we recommend are noted above.

To your health,

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.

Congratulations to Dr. Julie Hertzer and Dr. Arthur Lavin for Top Doctor Award

Congratulations to Dr. Julie Hertzer and Dr. Arthur Lavin

Selected as Top Pediatricians for 2015

The Consumer Research Council of America (CRCA) has awarded the designation of Top Pediatrician in America to Dr. Julie Hertzer and Dr. Arthur Lavin in their national lists for 2015!

Our main concern, of course, remains being available to help you and your children, but it is very nice to be recognized.

So, we are sharing this bit of good news, along with our deepest gratitude for the trust you place in us.

Advanced Pediatrics

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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.