Tuesday, February 15, 2011

Let's Do Right by Lindsey Vonn

It could have been a heart-breaking sort of Valentine's Day for Lindsey Vonn.  That's what Alan Schwarz meant to say in his New York Times article entitled "Concussion Protocols Fail Vonn" about her silver medal race in the world championship on Sunday.

Schwarz is a champion himself of safer protocols following head injury and his extraordinary reporting was recently profiled in the New Yorker and on this blog.

The problem is that Vonn was allowed to ski inspite of clear signals from her that she was not ready and was at risk for severe injury and even death if she were to sustain a new head injury.  Not to mention that competing at full tilt-even without any injury-- before complete healing will delay complete recovery, sometimes for months.  Lindsey was still "foggy" in her practice runs and admits herself that she was not ready to race.  But as Schwarz states:
...the United States Ski Team appeared to hit the trifecta of concussion no-no's:they called the injury mild, blindly followed so-called concussion tests, then discounted clear signs that her injury remained."
If an NFL player had been allowed to compete under these circumstances, says Schwarz, "the team (and the league itself) would be roundly flayed for endangering his health--and misleading young athletes about the risks of head injuries."

The lesson here is that anyone in the athlete's midst, starting most importantly with the athlete herself, should be able to trump any protocol, doctor, test or opinion if they believe the athlete is not performing or feeling up to speed.  We need to be reminded that even in uber-athletes like Vonn, the brain takes just as much time to recover and can be as unpredictable as in an untrained person.  What distinguishes the champion is the ability to perform in spite of sub-par conditions. But that does not make it right.

Thursday, February 10, 2011

Sex Ed Online?

New York magazine's provocative cover story, "Porn and Junior-High Culture" highlights the technologically enhanced exposure of young kids to online pornography. MTV's new series Skins is raising eyebrows about its depiction of underage and teenage actors baring bodies. So I began to wonder about the availability of quality sex education for kids, teens and young adults online.

According to a 16 year old quoted in the New York magazine article:
"You can learn a lot of things about sex. You don't have to use, like your parents sitting down with you and telling you. The Internet's where kids learn it from, most of the time."
So how good is the information out there on the web? I wondered if anyone had ever looked to see what kind of information is available? Along comes a 2010 article in the Journal of Adolescent Health which reviews 177 sexual health websites for quality and accuracy.

Each site was judged based on 15 quality criteria including authors' credentials and affiliations, sources and references, clear dating, disclosure of ownership, clear editorial policies, copyright notices, and internal search engines. Websites were further reviewed for false and inaccurate information.  Surprisingly, only 17% of sites had one or more inaccuracies but site quality was not correlated with accuracy. And domain extensions (.com, .gov, .edu, .org) did not seem to affect either the quality of the website or the level of inaccuracies. However, "web sites containing the most technically complex information (contraception, sexually transmitted infections) and controversial topics (abortion, penis size, emergency contraception) contained the most inaccuracies." In other words a site can look legit but have inaccuracies and errors.

The authors pose the question "...what can we do to aid young people in finding quality OSHI (online sexual health information)?" Like all other issues related to nearly infinite web resources, parents, teachers, health care workers and those who care about our kids need to step in and begin to figure out how to endorse and then disseminate quality, accurate, readable and age-appropriate information that is "sexy" enough that kids will get their learning from trusted sources rather than the entertainment industry. Anyone up for creating one with me?

Tuesday, February 8, 2011

Girl Power:Now More Than Ever!

I just received the newsletter from Her Honor Mentoring, a wonderful organization that I support.  With their permission, I am re-printing here a short essay on the power of girls to help move and change the world.  (Color emphasis is mine). Her Honor does this amazing work right in our backyard in Westchester County but that doesn't prevent them from thinking globally. Here it is:

The current unrest in Northern Africa has us thinking, now more than ever, that a meaningful revolution will require a true investment in girls. "Half the Sky - Turning Oppression into Opportunity for Women Worldwide" by Pulitzer Prize winners Nicholas Kristof & Sheryl WuDunn brought this issue to our attention and now Time magazine has echoed these sentiments in their article; "To Fight Poverty . . . Invest in Girls". Here is an excerpt:

"There are countless reasons rescuing girls is the right thing to do. It's also the smart thing to do. Consider the virtuous circle: An extra year of primary school boosts girls' eventual wages by 10% to 20%. An extra year of secondary school adds 15% to 25%. Girls who stay in school for seven or more years typically marry four years later and have two fewer children than girls who drop out. Fewer dependents per worker allows for greater economic growth. And the World Food Programme has found that when girls and women earn income, they reinvest 90% of it in their families. They buy books, medicine, bed nets. For men, that figure is more like 30% to 40%. "Investment in girls' education may well be the highest-return investment available in the developing world," Larry Summers wrote when he was chief economist at the World Bank. Of such cycles are real revolutions born.

The benefits are so obvious, you have to wonder why we haven't paid attention. Less than 2¢ of every development dollar goes to girls — and that is a victory compared with a few years ago, when it was more like half a cent. Roughly 9 of 10 youth programs are aimed at boys. One reason for this is that when it comes to lifting up girls, we don't know as much about how to do it. We have to start by listening to girls, which much of the world is not culturally disposed to do. Development experts say the solutions need to be holistic, providing access to safe spaces, schools and health clinics with programs designed specifically for girls' needs. Success depends on infrastructure, on making fuel and water more available so girls don't have to spend as many as 15 hours a day fetching them. It requires enlisting whole communities — mothers, fathers, teachers, religious leaders — in helping girls realize their potential instead of seeing them as dispensable or, worse, as prey."

Thursday, February 3, 2011

Still wary about HPV vaccine for your teens?

If so, you are not alone.  A recent study in Pediatrics which surveyed parents on this topic showed that HPV (Human Papilloma Virus) vaccine (marketed as Gardisil or Cervarix) is the most often refused vaccine in the pediatrician's arsenal against disease.  Reasons cited for refusal by parents include belief that there has not been enough research (80% of those refusing); that it "challenges their belief system"(51%); that they believe their children are not at high risk for contracting the STD (59%)  and that they do "not believe the vaccine is effective in preventing the disease" (37%). 

In my practice I have found that if I take the time to address these concerns with parents and patients, most are convinced of the benefit of the vaccine.  It's worth mentioning in my anecdotal experience that most kids are convinced of the value of the shot (probably due to intensive and teen-oriented marketing) but will usually acquiesce to parents' wishes to avoid the needles.  A number of my patients with skeptical parents have opted independently to get shots once they reached age 18.

What exactly does the vaccine prevent?

There are over 100 "types" of human papilloma virus.  The vaccines prevent over 70% of all cases of cervical cancer and Gardisil in particular also protects against the most common causes of genital warts. In addition to these dread diseases (click here for a photo of the pesky and tenacious genital wart), HPV is now linked to a number of head and neck cancers (due to more oral sex?) and of course can cause months of undue anxiety when Pap smears or biopsies show abnormalities due to HPV infection-even if they are temporary and ultimately vanquished by the body's immune system.

How do we contract HPV?

HPV is contracted through sexual intercourse for sure. But it is also contracted through intimate touching;  "third base", oral sex, fingering and other forms of "outercourse" bring risk of infection with them.  And let's remember that most teens progress through months to years of these "lower risk" activities (can't get pregnant after all) before engaging in intercourse.  Many 13, 14, and 15 year olds are there already even though parents underestimate the likelihood that such activity is going on.

Why vaccinate an 11 or 12 year old?

There is excellent data showing that the earlier we vaccinate the better the immune response.  I once heard a pediatrician say "We don't wait for them to step on a rusty nail to give them tetanus vaccine, do we?"  Vaccinating with HP, according to Pediatric News,  is "not about sexual readiness" rather about the prevention of cancer.

Is it safe?

According to the CDC on this subject, over 32 million doses of Gardisil were ditributed in the US from the time the vaccine was licensed in 2006 until September 2010.  The Vaccine Adverse Event Reporting System has investigated all serious event reports and has not found a pattern to suggest the vaccine is causing a serious problem.  True confession (that most teens will confirm): The HPV shot DOES hurt a bit more than most vaccines, but it is a brief 60 second ache.  This pain may explain a slightly higher than average incidence of post-shot fainting in the doctor's office.  Contrary to early YouTube videos, it DOES NOT make people walk backwards!

How long is it good for?

With each passing year since licensure we see strong data that extends the length of time we know the vaccine provides protection.  As of now we know it will last at least 7.5 years and most manufacturers and researchers think it will extend far beyond this as it contnues to be studied.  By the time the young vaccinees get into young adulthood, we will know whether a booster is necessary (as we have discovered for whooping cough, tetanus, meningitis, polio and many other illnesses).

What about boys?

Boys are the group getting the least extensive coverage in spite of it being approved and recommended for them as of last year.    When a parent or a young man asks me "Why should men get it?"  I just pause and look at them a little funny and say: "Let's stop and think about where the virus is coming from when girls get it through sexual activity."  And if that isn't convincing enough I say: "Would you like to see a picture of penile warts? (see above)"  It is worth noting that men having sex with men are at increased risk of warts and penile cancer and should definitely be vaccinated as early as possible.

I fully endorse vaccination against HPV.  I am also fully aware that there are political and economic issues surrounding the vaccine.  For one, most of the folks who speak about it publically are on the Merck payroll (the sole manufacturer of Gardisil).  And the steep price of this immunizaiton raises a moral quandary about whether it is really just a boutique vaccine and much less readily available in the rest of the world.  Nonetheless, insurance companies seem to have done their calculus and since they usually err on the side of withholding treatments and are not known for their support of preventive medicine I say we should be grateful for what we have.