Tuesday, August 30, 2011

HPV (Gardisil) Vaccine and THE TALK

Do parents get squeamish when they have to bring up HPV vaccine during a checkup for their 12 year old?  Yes, it turns out, according to a recent study.   Investigators from the Univeristy of North Carolina at Chapel Hill recently presented their work at a national meeting of the Society for Adolescent Health and Medicine. 

When it comes to girls, they note that the recommended timing of the vaccine works nicely with the age at which conversation about topics related to sexuality should be happening frequently.  Subtle short discussions engaged in with some regularity are better heard than the "talk" which is often awkward for everyone involved.  The series of three vaccines over six months allows doctors and other providers to initiate conversation and answer questions about what exactly HPV is.  But it also should be an opportunity for providers to model an easy age-appropriate three-way conversation with the young patient and the parent.

As far as boys go, the findings were a bit different and may be enlightening for providers.  "Overall," said Abigail Lees, one of the researchers, "parents believed their sons to have a low susceptibility to HPV infection and its outcomes."  They figure that this disbelief is driven by the stigmatization and anxiety that people feel with respect to anal cancer ( "my son isn't gay") and oral cancers ("just the thought of so much oral sex makes me uncomfortable"), both conditions associated with HPV.   Of course it's not rational but we all know that denial is a powerful thing.

Is it that somehow cervical cancer in females is more "acceptable" even though it is, of course, also sexually transmitted via the HPV virus?   The researchers recommend (and are funded by Merck) that "awareness campaigns" focus more on the prevalence of HPV (over 75% of sexually active people are exposed to the virus in its many forms by age 20) and less on the gruesome pictures of lesions and sores that may just backfire on parents and teens alike.

Clearly Gardisil has a PR problem and it's interesting to see how US culture surrounding issues of sexuality continues to appear to be the root roadblock to wider acceptance and immunization rates. Talk early and often to your kids. Keep it simple.  Start where they are and don't make assumptions.

image from: noplacelikehome.org

Wednesday, August 24, 2011

Colleges: First Do No Harm

Bravo to David Skorton, the president of Cornell University for speaking out against hazing in the fraternity setting in today's New York Times.  Full disclosure: my son graduated in 2010 from Cornell and was a fraternity member there.  My son also lived through a rash of suicides at Cornell during his senior year (although they were not necessarily fraternity related).   It's not random that Dr Skorton is a medical doctor and so lends a more humanistic perspective to the issue.

Even though I usually visited the frat house the "morning after" once cleanup from the Saturday night events had begun, I am sure I joined many parents in their disgust and shock at how their sons could "live that way."

The culture of the frat, whether it is steeped in American tradition or not needs to reform.  There are many traditions that we have decided need to be relegated to the history books--slavery, segregated restrooms and classrooms, rape, injustice toward the disabled, and many others.  If only more of the egregious activities were revealed, much of what goes on during "pledge" week would go that way as well:
As a physician to teens and young adults, I often hear from my patients or their parents about the ostracism and disappointment that some feel when they have been "rejected" by this wayward culture.  As parents we need to send the message that these "clubs" are not necessarily where our children should be.  The social "rejection" can be a ticket to a much more meaningful and long-lasting alternative group of friends whose activities are not alcohol or party based. If the group photo of the frat looks like this:
....be sure to ask what goes on after the ties come off.

Thursday, August 18, 2011

A mom's adoration of her teenager

"She's a true beauty, and sometimes I just look at her in awe of all that she is.  I'm lucky to have her in my life."
quoted (with permission) from a mom's office questionnaire about her 14 year old daughter.

It's not that often that we hear parents saying really kind things about their children. Often it's about how insolent, quiet, demanding, self-involved, otherwise unconnected or just plain "adolescent" they are. Of course, this interpretation often stems from concerns about one's children or one's parenting. In order to allow parents to express their worries and pride about their kids, I have parents answer a standard questionnaire about my new patients. In addition to family and medical history it gives parents an opportunity to speak their minds.

Perhaps it is because we don't have enough opportunities for our kids to hear how we feel about them that one of the early scenes from the new movie, The Help, is particularly moving. Aibileen, the Mobley family's maid, played by Viola Davis, tells the overweight, forlorn and awkward young Mae Mobley, "You is kind, you is smart, and you is important." This mantra is repeated several times in the film, helping Aibileen imprint on this young child in the absence of her own mother's love or recognition.

Let's start the new school year reminding our children of their treasured qualities. There are so many opportunities to disparage them, whether in our thoughts, to their faces or to others. Let's make the time to say the good things so that these positive messages stick as surely as the negative ones.
image from manzine.org

Wednesday, August 10, 2011

Don't Fry Your Body in Pre-Season

Heat-related illness is the most common cause of illness and even death in athletes at this time of year.  Korey Stringer was a Minnesota Vikings player who died in August of 2001 from exertional heat stroke.   The Korey Stringer Institute at University of Connecticut is dedicated to the prevention of sudden death in athletes and is supported by Korey Stringer's widow. 

There are two basic physiologic processes that contribute to this problem. These are dehydration and hyperthermia:

Dehydration is the process of water loss leading to hypohydration. Usually measured by body mass loss, urine color, urine osmolality, urine specific gravity or via serum osmolality (gold standard).

Hyperthermia is a body temperature elevated above 39°C or 102°F.

And here, from the Korey Stringer website are some other definitions, in descending order of severity:

Exertional Heat Stroke (EHS)- a medical emergency involving life-threatening hyperthermia (rectal temperature > 40°C, 104°F) with concomitant central nervous system dysfunction; treatment involves cooling the body.

Heat Exhaustion- Inability to continue exercise in a hot environment due to cardiovascular insufficiency usually in combination with prolonged heat exposure, cutaneous vasodilation, muscular exertion, and dehydration.

Heat Syncope- A brief fainting episode in the absence of salt, water depletion, fluid loss or
hyperthermia, often subsequent to prolonged standing.

Heat Cramps- Painful spasms of skeletal muscles, usually after exercise in a hot environment.

For some really frightening stories about illness and two recent deaths on the football field check out this blog, Training and Conditioning

Here are some basic guidelines laid out for athletes by the Korey Stringer Institute:

1. Listen to your body- if you do not feel well, back off (lower your intensity) and seek help if you continue to feel lousy.

2. Hydrate yourself- try to keep your urine color like lemonade and not like apple juice.

3. Listen to your thirst- if you are thirsty, you need fluids.

4. Phase in exercise in the heat- called heat acclimatization, the first 7-10 days should gradually include an incremental increase in intensity, duration, equipment, etc.

5. If your teammate, child, athlete, friend, colleague, look like they are struggling in the heat, seek shade/ice/fluid/rest for the person. If they do not start to do better immediately, call 911.

6. Be sure that an athletic trainer is employed by your high school to take care of the prevention, recognition, and treatment of emergency situations in sport.

7. Be sure to educate coaches and athletes about these tips and the common signs and symptoms of heat illnesses.

8. Realize that your performance will be about 10-15% worse in the heat as compared to cooler climates. Adjust pace, intensity, and effort accordingly.

9. Be sure you are getting enough salt in your diet/sports drinks/sport foods. Sodium assists with the hydration process and you lose a lot in your sweat during intense exercise in the heat.

10. If someone is suffering exertional heat stroke, cool them immediately using cold water immersion, the amount of time hyperthermic (not the temperature obtained) is the key to outcome being life or death.

Most school athletic departments have guidelines that encourage coaches and trainers to pay attention to the Heat index and the Real Feel Temperatures when they are practicing.  Of course, they need to remember that the index at noon is very different from what they will feel later inthe afternoon.   Schools should have policies that call for cancelling practice when the Heat Index is over 95 degrees Farhenheit. Here is a website for New York State that charts the correct actions to take based on the Heat Index.  And here is a fairly good explanation of the difference betweeen Heat Index (essentially a mix of heat and humidity) and the (Accuweather) Real Feel Index (more complex that takes cloud cover, wind and other factors into account).

Knowing that the country is in the grips of a severe weather system, there is no reason to believe that the temperatures and humidity will vastly improve before pre-season starts.  It's a good idea to start acclimatizing by spending time in the heat and humidity and beginning to work out under the hot conditions to get the body accommodated.   Although water is generally good enough to hydrate most athletes, when there is a great deal of sweating, electrolyte containing drinks are going to be much better.

image from beautyangle.com

Thursday, August 4, 2011

Mom: Your Brain is Really OK

The older graduates are coming home, raiding the refrigerator and using the kitchen computer to look for a job (wouldn't want it any other way) and the youngest are sorting through extra-long twin sheets and supply lists while everyone scrounges for the last frozen pizza for a SNACK, and the laundry keeps cranking through the machines (small prayer here to the appliance gods).   I am impressed by my own ability to juggle it all while I listen to Adele and run to the grocery store for more milk and juice and go to work.

Funny thing because I was just thinking about how my mind was getting old and I keep losing my keys or my parking spot or forget that I already told the kids that story from my own freshman year.  And just in time a book was recommended to me that explains how the middle aged brain can actually do all these things, i.e. forget and accomplish so much.  The Secret Life of the Grown-Up Brain:the surprising talents of the middle-aged mind by Barbara Strauch, science and health editor at The New York Times, is a primer on the current psychological and neuroscience research into the ways in which my mind and those of many friends and parents of patients are functioning.  Trust me, it's a godsend.

Next time I get reprimanded for re-telling a stupid joke or forgetting a friend's name or the plot of a movie (or that I even saw it before) let me remind people that Strauch says we are better at problem-solving, integrating, social expertise, judging character and situations, multi-tasking (oh yeah!) and wisdom.  Used to be that wisdom came with "old age" but it turns out no one really studied healthy middle-aged people so much before.  And contrary to decades of "wisdom" it turns out that the brain can make new cells and most importantly, new connections.

So I say, bring it on that middle age stuff.   Reading this book I felt empowered to recognize how we have traversed so much life and are really experts in our own little corners.   Like the Kali, the multi-limbed Hindu goddess associated with eternal energy and motherhood (and also violence since the world is not so simple), we have many arms and they are all moving, keeping the worlds we inhabit in balance.