Johns Hopkins Health Alerts - Healthy Living

Are Your Ears Ringing?

Wed, 03 Mar 2010 06:00:00 CST

Tinnitus is often described as “ringing in the ears” (the term is derived from tinnire, Latin for “to ring”). But tinnitus can take many different forms, including humming, whistling, hissing, machinelike noises, and even roaring. While there is no cure for tinnitus, many treatments are available, and new ones are being developed.

The cause of tinnitus is frequently in the inner ear. Lloyd Minor, M.D., Director of Otolaryngology -- Head and Neck Surgery at Johns Hopkins, explains, “Tinnitus often accompanies age-associated hearing loss, so we presume that it’s caused by damage to inner ear structures and hair cells in the cochlea, especially if the person is or was routinely exposed to loud noises. However, when a patient has tinnitus without hearing loss, we think it may have a central cause -- that the tinnitus is coming from the brain.”

An audiogram (hearing test) indicates the extent of hearing loss and helps determine if centrally located tinnitus is the more likely cause. A careful medical history also is important to find out if a coexisting medical condition or medication could be at work. Thyroid disorders and high blood pressure, for instance, and at least 200 medications, including common pain relievers, may cause tinnitus.

The search for tinnitus relief: A good first step is to cut out caffeine. “Many people who give up caffeinated beverages like coffee, tea, and soda and foods like chocolate find that their tinnitus symptoms improve,” says Dr. Minor. Giving up smoking and alcohol also may help.

Probably the most common treatment is to mask the internal noise with external noise. Dr. Minor notes, “Oftentimes people are only bothered by tinnitus when it’s quiet -- at bedtime, for instance. No masking device has been shown to help a large number of patients better manage their tinnitus. But people’s experiences with tinnitus and its treatment can vary widely. If a patient finds that a masking device helps, I wouldn’t discourage its use.”

The latest efforts: Early studies of a new therapy called transcranial magnetic stimulation (TMS), which sends an electric current into the brain, are encouraging, and clinical trials are under way. Some tinnitus patients have benefited from electrical cortical stimulation (ECS), which makes use of pacemaker-like implants to deliver electric impulses. Electric neurostimulation is noninvasive and also has few side effects. But more research is needed, and currently TMS and ECS aren’t available outside clinical trials.

Pill Splitting Advice

Wed, 28 Oct 2009 06:00:00 CDT

Prescription medication is expensive, so many patients split their pills to save money. Is this a good idea? Here’s advice from Johns Hopkins.

Pill splitting is a good way to save on the cost of prescription medication, since a 200-mg dose typically costs the same as a 100-mg dose of a particular drug.

But it is essential to ask your doctor and pharmacist whether your medication can be split safely, because it is very easy to split pills unevenly. For people with certain medical conditions, like epilepsy and some heart problems, an inadequate dose can be dangerous. Correct dosage is also essential for hormone medications. Other medication that shouldn't be split:

Extended-release pills that deliver medication over time

Combination tablets that contain more than one medication

Pills coated to protect the stomach from irritation

Pills that crumble easily or are awkwardly shaped

Pills that are difficult to swallow because of bitter taste

Powder or gel capsules

That said, other medications can be split, like sildenafil (Viagra), certain blood pressure medications, many antidepressants, and most statins. Pills that are scored to make cutting easier indicate approval from the U.S. Food and Drug Administration to split the tablets.

Don't split pills with your hands or a knife -- this could lead to inaccurate doses. Buy a pill splitter at your local drugstore. Most cost $5-10; ask your pharmacist for a demonstration.

Urgent Care or the ER – Which is the Right Choice?

Wed, 18 Nov 2009 06:00:00 CST

You've got a sore throat or a deep cut that needs medical attention now, but you don't think it warrants a trip to the emergency room (ER). Is going to an urgent care center a sound alternative?

"In these cases, call your primary care provider first," says Michele Bellantoni, M.D., Associate Professor of Medicine and Medical Director of Johns Hopkins Bayview Care Center. "This is particularly important for patients with chronic conditions, because a healthcare provider familiar with your medical history will be able to tell you whether a problem that appears small actually requires complex care. No matter where you seek medical attention, it's also necessary to keep your primary provider informed about any medical problems you're facing."

Urgent care centers are staffed with licensed physicians (and are not to be confused with retail clinics in pharmacies and chain stores, which are typically run by nurse practitioners and physician assistants who perform screenings and treat minor illnesses).

Many urgent care facilities offer services your doctor's office likely does not provide, including x-rays, on-site lab work, and suturing. Other major advantages of urgent care are speed and cost. In some states, the average wait time in the ER for a patient with a non-emergency ailment is more than four hours, and services typically cost $1,000-plus.

At an urgent care center, the bill may be five times less than the ER, and patients generally wait no more than an hour. That's why thousands of these facilities are springing up throughout the country. In fact, many are affiliated with hospitals (including Johns Hopkins), which have started offering urgent care to expand business and relieve busy ERs.

If you're not sure whether you or a companion is experiencing an emergency, play it safe and go to the ER -- particularly for symptoms of a heart attack (like chest pain) or a stroke (like sudden vision changes, slurred speech, one-sided weakness, or mental confusion).

Practicalities. Research urgent care facilities in your area so if you face a non-emergency problem, you'll know where to go. The website www.findurgentcare.com will give you a list of centers in and near your zip code. Find out which accept your insurance and when they're open. While urgent care centers have expanded evening and weekend hours, most aren't open 24 hours a day like ERs.

Info To Bring Along. Whether you're visiting an urgent care center or the ER, always bring a copy of your essential medical information. Make a list with the following items and keep it in an accessible place (like on the refrigerator), so you can grab it quickly before you seek medical attention:

The name, address, phone number, and fax number of your primary care provider

Your current medical conditions

Your current medications, along with dosages

Drug allergies

Chronotherapy: Taking Medications at the Right Time

Wed, 16 Sep 2009 06:00:00 CDT

Many individuals take their medications at times of the day that are convenient or easy to remember -- in the morning, at lunchtime, or before bed, for example. But this strategy may not always give you the most benefit. Instead, an approach called chronotherapy takes into account your body's rhythms to tailor the timing and dosage of your drugs so that they work better and produce fewer side effects.

The human body follows multiple natural rhythms to regulate physiological functions and behavior. The most important one for chronotherapy is circadian rhythm -- your body's daily biological clock that follows the sun's 24-hour cycle and regulates sleeping and waking. Circadian rhythm also affects important biological processes such as hormone secretion, cell growth, and metabolism.

Biological rhythms are known to influence health. For example, jet lag describes the unpleasant symptoms we experience after breaking with the normal circadian rhythm of sleeping and waking related to travel. Scientists have also discovered that biological rhythms play a role in disease and its treatment, since these rhythms cause symptoms to vary throughout the day. Consequently, chronotherapy times administration of a drug so that its peak concentration in the blood occurs around the time of day when the symptoms are worst -- not necessarily because the drug works any better at that time.

Studies to date suggest that by timing drug therapy to biological rhythms, it is possible to reap greater benefits with fewer downsides. For example, symptoms of allergic rhinitis, a condition that affects the mucus membranes of the nose and includes seasonal allergies (hay fever), are often worst in the morning when histamine levels in the body are elevated. That's why some allergists recommend that individuals take a long-acting antihistamine drug at bedtime so it will be in their systems when they wake up.

Chronotherapy is an active area of research, and its applications may extend to other health conditions. For example, researchers have discovered that cholesterol production in the liver appears to be higher in the evening, whereas many people take their cholesterol-lowering statin drugs in the morning. The timing of statin therapy and other drug treatments may change in the future if clinical trials show a benefit to watching the clock as we take our drugs. In the meantime, ask your doctor or pharmacist for the ideal time to take your prescription drugs. Most important, never change the timing of your drugs without first consulting your physician.

The Truth About Toenail Fungus

Wed, 09 Dec 2009 06:00:00 CST

If your toenails are discolored, thick, and brittle, chances are you have nail fungus, or onychomycosis, a common condition caused by an infection under the nail bed. Home remedies for nail fungus abound, but unfortunately none of them actually works. To really treat fungus, you have to take a trip to your doctor.

You can get rid of nail fungus -- but not with Vicks VapoRub, bleach, Listerine, tea tree oil, or vinegar, says podiatrist Zachary L. Chattler, D.P.M., an instructor in the Department of Orthopaedic Surgery at Johns Hopkins. All of these "cures" are myths. And don't waste your money on over-the-counter products; they may cure athlete's foot and other fungal infections of the skin, but they won't work on nail fungus.

Which treatment will work depends on the severity of the infection. If the fungus is caught early and has not spread to the entire nail, your doctor may recommend a prescription antifungal topical lacquer, ointment, or cream, like ciclopirox (Loprox).

However, these therapies probably will not get rid of fungus for good, says Dr. Chattler, since topical treatments wipe off easily and have trouble penetrating the toenail to reach the nail bed. The most effective treatments are oral antifungal medications like itraconazole (Sporanox) and terbinafine (Lamisil), which are available by prescription and taken daily for three months. These medications work by killing the fungus at the nail root, says Dr. Chattler.

After the medication regimen, the toenail cuticle should look clear, but it could take up to a year for the entire nail to be fungus free, says Dr. Chattler. Unfortunately, some people are never cured. If this is the case, you may have to just manage the fungal nail, he says. Regular visits to the podiatrist to cut and file down the nail will prevent it from irritating your foot. You may also consider having the nail removed.

Protecting Your Nails. Fungi thrive in warm, wet places, so good hygiene is the best defense, says Dr. Chattler. Make sure your feet are clean and dry, and keep nails clipped straight and short. Always disinfect nail clippers, and wear synthetic socks rather than cotton or wool, which absorb moisture.

Typically, toenail fungus is more of a nuisance than a health problem, the doctor continues. But this doesn't mean you can ignore it: Left untreated, fungus can spread to your fingernails and skin. And if you have diabetes or a circulatory disorder, you need to be more vigilant in treating the fungus -- a thick, long toenail could cut your foot, which can lead to an ulcer or skin infection.

Is White Wine Good For Your Heart?

Wed, 10 Feb 2010 06:00:00 CST

In this House Calls column from a recent issue of our Health After 50 newsletter, a reader asks: Is white wine as "heart healthy" as red wine? Here’s what you should know about the heart health benefits of white wine.

The answer is probably -- though researchers continue to debate the question. Some studies have indicated that red wine is modestly better for the heart than white wine (or beer or spirits) because it contains resveratrol -- a polyphenol (plant chemical) associated with cardiovascular benefits, including reduced risk of heart attack.

Resveratrol is found in the seeds and skin of grapes, which are crushed together with the pulp to make red wine. White wines, on the other hand, are made with just pulp and therefore contain very little resveratrol. But recent studies have shown that the pulp does contain other polyphenols that may be heart healthy.

Moreover, although red and white wines differ in polyphenol composition, both contain similar amounts of alcohol -- which is known to increase level s of HDL ("good") cholesterol and prevent blood clots. And observational studies have found that drinking any type of alcoholic beverage in moderation has the potential to reduce the risk of a heart attack. ("Moderate" generally means no more than two drinks per day for a man and one drink for a woman. In most studies, "a drink" is the equivalent of about 5 oz of wine.)

Remember, too, that most experts don't advise nondrinkers to start consuming alcohol to improve their heart health. There are better ways to accomplish that -- starting with diet and exercise to control your blood pressure, cholesterol, and weight. Drinking should never be a substitute for these measures.

Does Insomnia Run in Families?

Wed, 30 Dec 2009 06:00:00 CST

According to the American Academy of Sleep Medicine, about one-third of adults have symptoms of insomnia, the most common sleep disorder. In fact, insomnia is so common that many sufferers wonder if it could be inherited. Here’s what the research on insomnia and family ties shows.

From what we know so far, it looks like insomnia may very well run in families, just like diabetes and heart disease.

A study published last year in the journal Sleep reported that people who have experienced bouts of insomnia -- difficulty falling asleep and staying asleep or waking up too early -- are more likely than good sleepers to have a close relative with the condition.

About 12–15% of the population has chronic insomnia -- sleep problems that last a month or longer. In the largest study to date to evaluate insomnia and its family ties, 953 adults age 18 to 83 were surveyed multiple times about their sleep habits and the sleep habits of their parents, siblings, and children.

Just over half of the people who took the survey were classified as good sleepers, i.e., they did not report sleep complaints. About 33% experienced occasional symptoms of insomnia. Nearly 16% met all the criteria for the sleep disorder.

Participants who experienced past and current bouts of insomnia were significantly more likely than good sleepers (39.1% vs. 29%) to note that one or more family members also had experienced sleep problems.

Bottom line: So are genetics or relatives who behaviorally pass on bad sleep habits to blame? Probably a little of both. There is some evidence from smaller studies, including one that looked at twins, suggesting a genetic factor. That said, researchers are still a long way off from identifying a clear genetic marker for insomnia. There is also some evidence of a learned insomnia effect, i.e., people with bad sleep habits tend to transmit them to their children.

Should You Take Antibiotics Before Dental Work?

Wed, 05 Aug 2009 06:00:00 CDT

If you have a heart condition but your doctor or dentist neglects to give you an antibiotic prior to your next dental procedure, don't be alarmed. According to new guidelines published by the American Heart Association (AHA), few people with heart disease need to take this precaution.

The practice of taking antibiotics prior to dental procedures began decades ago to prevent infective endocarditis (IE), a rare but very serious heart infection that requires long-term treatment with antibiotics and, in severe instances, surgical valve replacement.

Getting your teeth cleaned or having a cavity filled causes small cuts in the gums that allow bacteria in the mouth to enter the bloodstream. It's very unlikely that these bacteria will cause IE. But because IE can lead to heart failure, arrhythmias, stroke, and death if untreated, antibiotics have been widely prescribed as a preventive measure prior to dental work for a broad group of people with heart conditions such as structural and valve-related heart defects that may make it easier for bacteria to get trapped in the heart's inner lining.

Why the change? Recently, the AHA convened a panel to review all IE studies published between 1950 and 2006. They concluded that only patients at high risk for serious complications from IE should continue taking preventive antibiotics -- a decision that amounts to a 90% reduction in the number of patients who will get prescriptions for antibiotics before going to the dentist.

A study published in the journal Heart looked at the death rates from endocarditis in France and estimated that even high-risk patients with artificial heart valves who do not take antibiotics prior to a dental procedure have only a one in 54,000 chance of getting IE. In fact, the risks of antibiotic use outweigh the benefits; people are more likely to have an allergic reaction to an antibiotic than to develop IE. Limiting unnecessary antibiotics will save patients money, reduce the number of medications they must take, cut the chances of allergic reactions, and help prevent antibiotic resistance. For most people, controlling the amount of bacteria in your mouth with good oral care -- brushing and flossing twice daily -- is the best way to prevent infection.

Who still needs antibiotics? The updated guidelines advise preventive antibiotics for high-risk patients only. This includes people with:

previous episodes of infective endocarditis (IE)

artificial heart valve replacements and repairs

valve problems after a heart transplant

congenital heart defects, both before and possibly after repair

Bunion Basics

Wed, 15 Jul 2009 06:00:00 CDT

Many people are plagued by pain from bunions, a deformity that forces the big toe out of alignment. But it's not a lost cause -- there are ways to relieve the pain.

The primary cause of bunions is your foot's structure, explains podiatrist Zachary L. Chattler, D. P. M., an instructor in the Department of Orthopaedic Surgery at Johns Hopkins. According to Dr. Chattler, bunions occur most frequently in feet that pronate -- meaning, as a person walks, the ankle rotates internally and the forefoot rotates externally. Bunions may result from this pronation, which causes an abnormal pull on the foot's tendons and bones.

But heredity isn't completely to blame; shoe choice does play a considerable role. Narrow or poorly fitting shoes, like high heels, can exacerbate bunions by pushing toes into an abnormal position and putting pressure on toe joints.

"That's why women seek treatment for bunions far more frequently than men, even though both genders develop the deformity. Shoes won't cause a bunion, but they can speed up the progress and make it worse," says Dr. Chattler. People with rheumatoid arthritis also may develop bunions, because of inflammation and swelling in the toes.

Simple solutions can soothe bunion pain.

Make sure your shoes fit properly. Trade in narrow, flat shoes or high heels for shoes with wider toe boxes and more support, like sneakers.

Are your shoes the correct size? Dr. Chattler stresses that many adults think their feet haven't grown since their teens; in truth, feet continue to get bigger as the ligaments loosen and arches flatten over time.

Orthotics can help. In addition to changing footwear, your doctor might also prescribe custom-made orthotics that fit in shoes and prevent the foot from overpronating. Some insurance plans may cover custom orthotics, which usually cost $300–500; however, Medicare does not.

Medications. To relieve pain and swelling, nonsteroidal anti-inflammatory drugs like ibuprofen are recommended. A steroid injection also may be prescribed.

For further short-term relief, podiatrist Bruce S. Lebowitz, D. P. M, an instructor in t he Department of Orthopaedic Surgery at Johns Hopkins, suggests keeping feet elevated and sticking to low-impact exercises like walking, water aerobics, or stationary biking, which will not aggravate the bunion as much as running or other high-impact activities.

Although bunions are permanent, most people find relief through conservative treatments. If not, surgery may be the next option. Many surgical procedures can correct the misaligned joint and remove the bump.

Surgery usually lasts about one hour with local anesthesia, and most patients leave the hospital that day. But healing can take eight to 12 weeks, and swelling can last up to six months. Although surgery will relieve bunion pain, bunions can grow back, especially if you continue to wear ill-fitting shoes. So choose the right footwear to stay pain free.

Energy Drinks: Beverages With an Unhealthy Boost

Wed, 03 Jun 2009 06:00:00 CDT

You've seen them in the grocery store refrigerated coolers, with fancy names, like Red Bull, Monster, Full Throttle, and Rockstar. They're the so-called "energy drinks" that come loaded with caffeine, sugar, vitamins, minerals, and other ingredients. But are they really good for you? Johns Hopkins reviews the data.

The popular high-caffeine, high-sugar beverages, typically sold in 8.3 oz aluminum cans (two-thirds the size of a standard size of Coca-Cola) contain about seven teaspoons of sugar and as much as two to four times the amount of caffeine (9 milligrams per fluid ounce) as Coke.

Caffeine is a drug and should be treated with caution. Some people are now suggesting that warning labels be placed on energy drink cans because of their high caffeine levels and their potential to raise blood pressure. Elevations in blood pressure were the point of small study presented at a recent American Heart Association meeting.

While the increases didn't reach dangerous levels in the healthy volunteers, the increases in blood pressure and heart rate could prove to be clinically significant in patients with heart disease or in those who consume energy drinks often, said James Kalus, Pharm.D., senior manager of Patient Care Services at Henry Ford Hospital in Detroit, Michigan, who led the study. "Individuals with high blood pressure and heart disease should be advised to avoid these drinks," he said.

Most energy drinks contain high levels of caffeine and taurine, an amino acid also found in protein-containing foods such as meats and fish. Both have been shown in some studies to effect heart function and blood pressure. In contrast, "sports drinks" like Gatorade and POWERade are simply mixtures of water, sugars, minerals, and salts, without chemicals aimed at increasing "energy" or alertness.

In Dr. Kalus' study, blood pressure and heart rate levels increased in healthy adults who drank two cans a day of a popular energy drink. According to Dr. Kalus, these changes occurred while the participants were sitting in chairs watching movies. "The increases in heart rate and blood pressure weren't enough for something to happen acutely," he said, "but a person on hypertension medication or who has cardiovascular disease may not respond as well. While energy drinks increase concentration and wakefulness, people with risk factors for heart disease could have a bad reaction. The subjects in this study were healthy, with low blood pressure."

Dr. Kalus feels that the increases in blood pressure and heart rate may be due to the caffeine and taurine in the drinks. The energy drink used in the study had as much caffeine as one to two cups of coffee, but some of the other energy drinks available contain much higher levels of caffeine.

Bottom line: "Energy drinks could affect some individuals if they didn't know they had a blood pressure problem in the first place," he said. "The study raises some concerns." Until further study, Dr. Kalus said people with high blood pressure or heart disease should steer clear of energy drinks because they could affect blood pressure and may even alter the effectiveness of hypertension medications.

Finding Relief From Allergies

Wed, 13 May 2009 06:00:00 CDT

With some 10% to 30% of adults suffering form allergic rhinitis, the condition can seem as ubiquitous as pollen on a dry spring day. Because it is so common and causes few obvious complications, sufferers often don't seek treatment for their condition. But lifestyle changes, medication, and even allergy shots can help many people find relief.

Allergic rhinitis is an immune response to an airborne allergen, and its symptoms occur in two phases -- a response immediately upon exposure and a delayed response. Immediate symptoms include an itchy, runny nose; sneezing; and itchy, watery eyes. The main delayed symptom is nasal congestion.

If untreated, allergic rhinitis may decrease quality of life even further by leading to chronic nose blowing, fatigue, sleep problems, and difficulties with learning and concentration. It may also contribute to asthma, inner ear or respiratory infections, and nasal polyps.

There are two types of allergic rhinitis: seasonal and perennial. Seasonal allergic rhinitis, sometimes called hay fever, is triggered by outdoor, seasonal allergens such as pollen from trees, grasses, and weeds as well as outdoor molds. Perennial allergic rhinitis is caused by allergens that can be in the home year-round -- for example, animal dander, indoor mold, and droppings from dust mites and cockroaches. Rhinitis can also be nonallergic -- in which case symptoms are caused by irritants in the air and do not involve an immune-system reaction.

Treatment Strategies -- Treatment for allergic rhinitis involves limiting exposure to specific allergens and often taking medication to control symptoms. Allergy shots may help those who don't respond adequately to these measures.

Limiting exposure. The first step is to try to avoid, if practical, your allergens. Steps may include keeping house and car windows closed and using air conditioning with a regularly cleaned filter system whenever possible if you are allergic to pollen; frequently dusting, vacuuming, and washing sheets and blankets to avoid dust mites; and limiting exposure to family pets to avoid pet dander.

Medications. Medications such as oral antihistamines and inhaled antihistamines are first-line medications for mild to moderate symptoms of allergic rhinitis. These medications are best at targeting immediate symptoms such as a runny nose, itching, and sneezing as well as allergic conjunctivitis. For patients with more severe symptoms, inhaled corticosteroids are considered first-line treatments.

Immunotherapy. Patients whose symptoms persist despite lifestyle and medication treatment may need immunotherapy ("allergy shots"). This treatment involves a series of injections (over three to five years) of a diluted form of the patient's particular allergens. Over time, an immunity should develop to the allergens, potentially decreasing reactions.

Whatever Became of the Annual Physical?

Wed, 22 Apr 2009 06:00:00 CDT

Once upon a time, an annual adult physical typically included a weight and blood pressure check; blood tests to measure white blood cell counts and cholesterol, iron, and thyroid hormone levels; a urinalysis; and diet and exercise counseling. For older adults, chest x-rays and electrocardiograms (ECGs) also were routine. How things have changed …

Since the 1980s, the United States Preventive Services Task Force (USPSTF) has argued against these traditional exams. The committee's review of available evidence on the standard screening tests revealed that they rarely detected or prevented underlying diseases in healthy adults who weren't experiencing symptoms.

So instead of the traditional annual physical, which can be time consuming and expensive, the USPSTF recommends that doctors provide preventive services only as needed based on age, gender, family history, and -- most important -- symptoms. In other words, blood tests that measure white blood cell counts aren't necessary unless you're experiencing symptoms that suggest an underlying infection, and ECGs are recommended only for patients with risk factors for or symptoms of heart disease. This "as-needed" approach means that you play an important role in managing your own preventive care.

To get a better idea of how patients and their doctors are using their time together, researchers writing in the Archives of Internal Medicine analyzed the medical records from more than 8,000 doctors. The investigators found that one third of all scheduled office visits were considered "annual physicals." The majority of the patients seen at these office visits received or were referred for recommended preventive services including mammograms, prostate specific antigen (PSA) tests, pap tests, cholesterol checks, smoking cessation counseling, weight loss counseling, and exercise and/or nutrition counseling. However, 11% of patients received a series of blood tests that the USPSTF labels unnecessary for asymptomatic adults.

By being proactive, you can avoid unnecessary tests and ensure you're up to date on appropriate screenings. Also, be aware of what vaccines you need:

Influenza: Every year

Pneumonia: At least once starting at age 65

Tetanus/diptheria: Every 10 years; after age 64, one booster should include pertussis (whooping cough)

Chickenpox: Once for anyone who's never had it

Shingles: Once after age 60

Some final advice:

Make your doctor visits work for you by bringing a list of concerns to your appointments.

Bring a list of the medications, vitamins, and other supplements you're taking.

Share your lists with your doctor at the beginning of the visit so you don't have to rush through important issues at the end of a hurried doctor's appointment.

How Long Do Medications Last?

Wed, 26 Aug 2009 06:00:00 CDT

Readers want to know: Are medications that have passed their expiration dates good to use, or should they be discarded? Here's the answer from Johns Hopkins.

Think of expiration dates -- which the U.S. Food and Drug Administration (FDA) requires be placed on most prescription and over-the-counter medications -- as a very conservative guide to longevity. The expiration date is a guarantee from the manufacturer that a medication will remain chemically stable -- and thus maintain its full potency and safety -- prior to that date. Most medications, though, retain their potency well beyond the expiration date, and outdated medications, whether prescription or over-the-counter, are not usually harmful.

In a study conducted by the FDA on a large stockpile of medications purchased by the military, 90% of more than 100 medications were safe and effective to use years after the expiration date. The drugs in the FDA study, however, were stored under ideal conditions -- not in a bathroom medicine cabinet, where heat and humidity can cause drugs to degrade.

If your medications have been stored under good conditions, they should retain all or much of their potency for at least one to two years following their expiration date, even after the container is opened. But you should discard any pills that have become discolored, turned powdery, or smell strong; any liquids that appear cloudy or filmy; or any tubes of cream that are hardened or cracked.

To help maintain potency, store your medications in a closet or cabinet located in a cool, dry room. Also, don’t mix medications in one container: chemicals from different medications can interact to interfere with potency or cause harmful side effects. If two or more medications have been mingled for any period of time, discard them.

A few medications, like insulin and some liquid antibiotics, do degrade quickly and should be used by the expiration date. Also, consider replacing any outdated medications that you’re taking for a serious health problem, since its potency is more critical than that of an over-the-counter drug you take for a headache or hay fever. If in doubt, consult a pharmacist.

Menopause Relief Without HRT

Wed, 18 Feb 2009 06:00:00 CST

Many symptoms of menopause -- such as night sweats, mood swings, and hot flashes -- lessen over time. In fact, they may go away in a matter of months without any medical intervention. However, other menopause symptoms, such as vaginal dryness, often do require some treatment. This article from the Johns Hopkins Health After 50 newsletter provides alternative treatments for women who are reluctant to go on hormone replacement.

Menopause is associated with a number of symptoms; however, these menopause symptoms vary considerably in frequency and intensity from one woman to another. For many women, menopause symptoms are mild and/or infrequent, and therefore tolerable. For other women, menopause symptoms are so severe that some form of intervention is necessary.

While most symptoms of menopause are relatively innocuous, the decline in hormone production can cause bone loss and alterations in cholesterol levels -- changes that can markedly increase the risks of two serious disorders, osteoporosis and coronary heart disease (CHD).

For women who are reluctant to go on hormone replacement therapy (HRT) to relieve menopause symptoms because of the associated risks, alternatives are available. These options are proven to work:

Off-label medications for menopause symptom relief. Selective serotonin reuptake inhibitor (SSRI) antidepressants given in small doses may be effective against hot flashes in some women. Gabapentin, a drug approved for the treatment of epilepsy, and blood pressure medications such as clonidine (Catapres) or methyldopa (Aldomet), also given in small doses, may help with hot flashes, too.

Self-management for menopause symptom relief. Dressing in layers, avoiding hot beverages and spicy foods, and limiting alcohol may help reduce hot flashes. Healthy eating and exercise may also work.

Vaginal lubricants for menopause symptom relief. Over-the-counter water-based lubricants are available. Prescription estrogen creams may also provide some short-term relief.

Other options are advertised to help relieve menopause symptoms, but research suggests otherwise:

Phytoestrogens for menopause symptom relief. These supplements can be purchased over the counter. They are derived from plant estrogen, which is usually synthesized from soy beans or yams . Some women have claimed that plant estrogens relieve hot flashes, but recent research contradicts these reports.
Approach these "natural" alternatives to estrogen with caution, because, like all supplements, phytoestrogens are not approved by the U. S. Food and Drug Administration, so their safety and efficacy have not been substantiated in rigorous clinical trials.

Black cohosh for menopause symptom relief. A study that was published in the Annals of Internal Medicine of 351 women found that this herbal medicine relieved hot flashes no better than placebo.

Do You Know What's in Your Medicine Cabinet?

Wed, 01 Apr 2009 06:00:00 CST

Do your medications increase your risk of falls? Listed in this Health Alert are 33 medications with side effects that are more dangerous to people over 65, like memory impairment, dizziness, drowsiness, and blurred vision. These medications should be avoided unless no other options exist.

A recent review by the Agency for Healthcare Research and Quality (AHRQ) found that older adults are still using many of the risky medications listed here. According to the AHRQ, 13% of adults over 65 used "always inappropriate" medications. This percentage was higher (25%) among older adults with disabilities.

Now researchers from the University of North Carolina (UNC) at Chapel Hill compiled a second list of dangerous medications. This new list includes medications that increase the risk of falls in people over 65 who take more than four medications.

Patients shouldn't avoid the medications on the UNC-Chapel Hill list, but if they're taking one of the UNC-Chapel Hill medications, they should talk to their doctors about reducing their risk of falling. To view the UNC–Chapel Hill list, go to:
uncnews.unc.edu/images/stories/news/ health/2008/drugslist.pdf

33 Medications To Avoid if You're Over 65

Always Inappropriate Medications

Barbiturates (amobarbital, butabarbital, pentobarbital, phenobarbital, secobarbital)

Flurazepam (Dalmane, Somnol, Novo-Flupam, Apo-Flurazepam)

Meprobamate (Equanil, Meprospan 200, Meprospan 400, Probate, ApoMeprobamate)

Chlorpropamide (Diabinese, Novo-Propamide, Apo-Chlorpropamide)

Meperidine (Demerol) • Pentazocine (Talwin, Talwin Nx)

Trimethobenzamide (Benzacot, Stemetic, Tebamide, Tigan, Tribenzagan, Trimazide)

Dicyclomine (Bentyl, Bentylol, Spas- moban, Formulex)

Hyoscyamine (Anaspaz, A-Spas-S/L, Cystospaz, Levbid, Levsin, Levsinex Timecaps, Symax SL)

Propantheline (Pro-Banthine)

Belladonna alkaloids/phenobarbital (Barbidonna, Donnatal)

Rarely Appropriate Medications

Chlordiazepoxide (Librium)

Diazepam (Valium)

Propoxyphene (Darvon, Darvon-N)

Carisoprodol (Soma)

Chlorzoxazone (Remular-S, Paraflex, Parafon Forte DSC)

Cyclobenzaprine (Flexeril)

Metaxalone (Skelaxin)

Methocarbamol (Robaxin)

Sometimes Appropriate Medications

Amitriptyline (Elavil)

Doxepin (Sinequan)

Indomethacin (Indocin)

Dipyridamole (Persantine)

Ticlopidine (Ticlid)

Methyldopa (Aldomet)

Reserpine (Serpasil, Serpalan, Novoreserpine)

Disopyramide (Norpace, Norpace CR)

Oxybutynin (Ditropan, Ditropan XL)

Chlorpheniramine (Aller-Chlor, Chlorate, ChloAmine, ChlorTrimeton)

Cyproheptadine (Periactin)

Diphenhydramine (Benadryl)

Hydroxyzine (Atarax, Rezine, Vistaril)

Promethazine (Phenergan)

Reported in the Journal of the American Medical Association, vol. 286, p. 2823

Doing Good and Feeling Good

Wed, 28 Jan 2009 06:00:00 CST

Volunteering doesn't just help others -- it may also benefit your health. Reviewers from the Corporation for National and Community Service (a government agency that promotes volunteerism) reviewed two decades of data from over 30 studies and found that volunteers had less depression, reported greater satisfaction with life, and lived longer than those who did not volunteer.

One two-year study found that adults over 75 who volunteered or worked for over 100 hours a year were one third less likely to report bad health and two thirds less likely to die over the course of the study. And according to other data in the review, people over 65 seemed to benefit more from volunteering than younger participants.

That volunteering has psychological benefits probably comes as no surprise to people who volunteer regularly -- doing good in turn leads to feeling good. But for older people, who are more likely to have retired or lost a spouse, volunteer activities are also a way to stay active and involved in their communities. The structure and social support that volunteer activities provide may help stave off depression that often accompanies chronic illnesses and major role transitions, including moves into long-term care residences.

According to an eight-year study of 1,137 adults, volunteering after the death of a spouse was associated with a decline in depression. And people who volunteered before their spouses died were less depressed after losing a spouse than those who hadn't volunteered before.

These emotional benefits may have a biological basis. According to Peter Rabins, M.D., Professor of Psychiatry and Health Policy and Director of the Division of Geriatric Psychiatry and Neuropsychiatry at Johns Hopkins, "Studies by my colleagues at the Johns Hopkins Older Americans Intervention Center have revealed that volunteering is associated with increased blood flow in certain areas of the brain, which might indicate more connections between brain cells in these areas. Their research also shows that volunteer work with children improves mood and morale. Perhaps better mood and blood flow are related."

Research has established that depression makes it harder both to recover from illness and to do things that are good for you, like exercise and eat well. Thus, the improved mental well-being that results from volunteering may also have an indirect impact on physical health.

For more information:

Corporation for National and Community Service, Senior Corps
202-606-5000
http://www.seniorcorps.gov

U.S. Administration on Aging
800-677-1116
http://www.aoa.gov/eldfam/Volunteer_Opps/Volunteer_Opps.aspx

Talking About A Difficult Subject -- DNR Directives

Wed, 07 Jan 2009 06:00:00 CST

A do-not-resuscitate (DNR) order often isn't discussed until it's too late. When reviewed before an emergency occurs, this document can guide your family and communicate your wishes to the people who carry them out: doctors, nurses, emergency medical technicians, and paramedics.

A DNR order is a legal document indicating that you should not be resuscitated in the event of a sudden cardiac arrest or pulmonary arrest. Most states have laws that require hospital staff and emergency medical workers to resuscitate patients in their care, however a DNR order overrides state laws to resuscitate.

The fact that it is legally binding differentiates a DNR order from advanced medical directives or living wills, which outline wishes concerning medical therapies like feeding tubes and ventilators or designate a healthcare proxy to make medical decisions on your behalf if you become incapacitated. Here are some points about DNR to keep in mind:

If you choose to complete a DNR order while you are hospitalized, the form will go into your medical record at that hospital. There are nationwide electronic DNR databases, but hospital participation varies.

If you live in a nursing home or an assisted-living facility and sign a DNR form, ask that a copy be kept on record. Residents who do not want to sign a DNR form should put their wishes in their official records, too.

Emergency situations are more complicated. In some states, emergency response teams will accept verbal DNR orders from a family member, but most states require official documentation to withhold resuscitation outside of the hospital.

Patients with signed DNR forms should keep a completed copy at home and might consider wearing an ID bracelet. Some family members who know that a loved one does not want to be resuscitated may delay calling 911 in an emergency. But bear in mind that hospital staff can determine if recovery is possible (e.g., recognize sudden cardiac arrest vs. a heart attack), and medical teams may be able to keep patients comfortable as they are dying.

In many instances, a DNR order is discussed with family members after a relative becomes incapacitated following an unforeseen event like an accident, heart attack, or stroke. If an advanced medical directive or living will does not designate a healthcare proxy or surrogate, a spouse or adult child can decide whether to sign a DNR form. But family members might not know what you want, or the emotional strain of the situation might keep family from acting on your wishes.

Bottom line:

The Facts on Super-Staph

Wed, 17 Dec 2008 06:00:00 CST

Worried about MRSA? In this Health Alert, Dr. Michele F. Belantoni explains why this antibiotic-resistant staph infection is so hard to treat and provides advice to help you avoid it.

Until recently, methicillin-resistant Staphylococcus aureus, or MRSA, had been confined mostly to health care facilities. But now, some healthy adults and children are contracting this potentially fatal staph infection, which can "eat" the skin and attack vital organs. According to estimates from the Centers for Disease Control and Prevention, MRSA killed more Americans than AIDS in 2005.

"When someone comes into contact with MRSA, it 'colonizes' the skin and inner nose," explains Michele F. Belantoni, M.D., Director of Johns Hopkins Bayview Care Center. "Generally, the staph infection causes no harm; however, when people exposed to the bacteria get deep cuts or undergo surgery, infections may develop."

Most staph infections start as painful pimples or boils. MRSA is difficult to treat because it produces more inflammatory toxins than other staph infections, and it doesn't respond to conventional medications like penicillins or several other antibiotics. Risk factors include hospitalization within the past year (particularly for surgery), residence in a long-term care facility, frequent antibiotic use, and casual contact with intravenous-drug users. Some people also have contracted MRSA from sharing gym equipment or playing contact sports.
To reduce your risk of the MRSA staph infection:

Keep abrasions on your skin clean, dry, and covered and avoid handling other people's wounds;

Don't share personal items like towels or razors;

Use flip-flops in public showers;

Put clean towels over the handle-bars of exercise machines;

Wash your hands or use an alcohol-based hand sanitizer several times each day; and,

Don't be afraid to ask healthcare providers to wash their hands and wipe their stethoscopes before treating you.

To prevent further development of antibiotic-resistant bacteria, avoid taking antibiotics unnecessarily for viruses like colds. Above all, don't panic: You should not stay away from the hospital to avoid the MRSA staph infection. It's been around for decades, and many drugs -- like tetracyclines, trimethoprim-sulfamethoxazole, rifampin, and linezolid -- can still kill the bacterium, particularly when detected early.

Diet and Longevity

Wed, 05 Nov 2008 06:00:00 CST

Here is diet advice from five leading scientific journals that can help you maintain your health, prevent disease, and enjoy a healthy lifestyle.

Diet tip 1: "Cutting carbs" may help trim your waistline and maintain your vision. Researchers at Tufts University analyzed the dietary habits of 4,099 people with age-related macular degeneration and found that participants who ate a diet with the most refined carbohydrates, such as cookies, candy, pasta, white bread, and crackers, were 17% more likely to go blind than those who consumed a diet with the least refined carbohydrates. Try eating complex carbohydrates like brown rice and wheat bread. From the American Journal of Clinical Nutrition, vol. 86, p. 1210.

Diet tip 2: Some research suggests that the antioxidant lycopene, which is found in abundance in tomatoes, may help prevent certain cancers. But after reviewing more than 140 related studies, the FDA gave its lowest "strength of evidence" rating to this claim. Don't give up on tomatoes, though. They are an excellent source of vitamins C and A, and eating a diet rich in antioxidants has other health benefits. From the Journal of the National Cancer Institute, vol. 99, p. 1074.

Diet tip 3: The key to weight loss may be old-fashioned calorie cutting and exercise -- plus realistic expectations. A review of 80 studies found that weight-loss programs that focused on only exercise were ineffective after six months whereas people who dieted and didn't exercise lost 5–9% of their starting weight within six months. Keeping the pounds off was another story: After four years, a modest 3-6% reduction was sustained -- and only through consistent dieting and exercise. From the Journal of the American Dietetic Association, vol. 107, p. 1755.

Diet tip 4: According to the Physicians Health Study, which recorded the dietary habits of over 21,000 male physicians for almost 20 years, men who ate whole-grain cereal every day were 28% less likely to develop heart failure over the course of the study than men who did not eat whole-grain cereal. The authors recommend that people look for "100% whole-grain" cereal that has at least 4 g of whole grain per serving. From the Archives of Internal Medicine, vol. 167, p. 2080.

• Diet tip 5: Excess uric acid, which causes gout and may play a role in chronic conditions like high blood pressure, may be linked to sugar consumption -- but only in men. A dietary study of 4,073 men and women over 18 years of age found that men who consumed the most sugary drinks had high levels of uric acid; notably, sugar did not boost levels in women, possibly because estrogen is protective. If you've got a sweet tooth, try fruit juice; it doesn't increase uric acid. From the journal Hypertension, vol. 50, p. 306.

Screening Tests After Age 50

Wed, 15 Oct 2008 06:00:00 CDT

In this excerpt from a recent Health After 50 newsletter article, Johns Hopkins explains the difference between screening and diagnostic tests and provides a handy list of screening tests recommended for adults aged 50 and older.

A screening test looks for signs of an illness before symptoms develop. A diagnostic test provides information about a known problem or looks for disease after an illness is suspected.

For example, a blood test for prostate specific antigen (PSA) may be used to screen men for prostate cancer. But if PSA is elevated, a biopsy (a diagnostic test) is needed. Similarly, mammography is used to screen women for breast cancer, but a biopsy is needed to evaluate suspicious findings. In some instances, the same tests are used for both purposes, as when mammography is ordered to evaluate a suspicious breast lump. Some tests, such as PSA, may also be used to monitor response to treatment.

Here is a listing of recommended screening tests for women and men after age 50:

Screening Tests For Women:

Pap test (cervical cancer) -- Every three years if results are negative for three consecutive years; annually if you smoke or have multiple sex partners.

Human papillomavirus (HPV) test (cervical cancer) -- May be done along with a Pap test; not enough evidence to recommend routine screening.

Mammography (breast cancer) -- Annually for all women 50 and over.

Thyroid-stimulating hormone (TSH) test (thyroid disease) -- The United States Preventive Services Task Force doesn't recommend screening asymptomatic women, but other groups do. Talk to your doctor.

Dual-energy x-ray absorptiometry bone density test (osteoporosis) -- Once every two years beginning at age 65. Women with risk factors, as determined by their primary care providers, should begin at age 60.

Screening Tests For Men:

Prostate specific antigen test and digital rectal exam (prostate cancer) -- Black men and men with a family history of prostate cancer should begin annual screening at age 40. Others should begin at age 50.

Abdominal ultrasound (abdominal aortic aneurysm) -- Once only for men 65–75 who've ever smoked.

Screening Tests For Everyone:

Blood pressure check (cardiovascular disease) -- Once every two years; more frequently for people over 60 or with readings over 120/80 mm Hg.

Cholesterol and triglyceride levels check (cardiovascular disease) -- Once every five years; more frequently for people with a family history of heart disease.

Colonoscopy (colon cancer) -- Once every 10 years beginning at age 50; more frequently for those at high risk.

Fecal occult blood test (colon cancer) -- Annually, although its unreliability leads many organizations, including Johns Hopkins, to question its usefulness.

Fasting blood glucose test (diabetes) -- Every two to three years; more often if you're at high risk.

Sexually transmitted disease screening test -- At least once a year if you have multiple partners.

Glaucoma screening test -- Every three to five years; more often for people with diabetes or family history of glaucoma.

Dental cleaning and exam -- Every six months.

The Hospitalist--A New Model of Patient Care

Wed, 24 Sep 2008 06:00:00 CDT

In this excerpt from a recent issue of our Health After 50 newsletter, Leonard Feldman, M.D., Assistant Professor and Hospitalist, discusses the role of the hospitalist – a physician employed by the hospital who spends most of his or her time treating hospitalized patients.

Health After 50: Why was the hospitalist specialty system created?

Dr. Feldman: It's very difficult for primary care physicians (PCPs) to keep up with office visits and still provide rigorous care to their sickest patients who are hospitalized. This is even more challenging when patients have multiple medical conditions.

One of the most important functions of a hospitalist is transitioning patients between healthcare settings. This transfer requires coordinating tests tests, lab work, and medicines and conferring with other doctors, specialists, social workers, and case managers. For instance, many of our patients at Johns Hopkins need physical rehabilitation or nursing-home care. Ideally, the hospitalist system is designed to deal with these transitions in a timely and seamless manner.

Health After 50: How do patients know if they are going to be treated by a hospitalist?
Dr. Feldman: Patients should ask their PCPs. Doctors often have different arrangements with various hospitals. At Johns Hopkins, for instance, very few local physicians have practice privileges at the hospital unless they're also employed by Hopkins. If you are treated here, then, you most likely will be cared for by a hospitalist. Some hospitals do not have any hospitalists, while others have a hybrid system in which both hospitalists and outside physicians provide care.
Health After 50: Can the quality of care suffer when patients are treated by someone other than their regular physician?

Dr. Feldman: Many people are initially concerned when they first encounter a hospitalist, but concern usually subsides once they see the level of care we provide to our patients.

Hospitalists are typically on-site 24 hours a day and can respond immediately to any new problems that may arise. Often when you are in the care of your PCP, you must wait for him or her to come in during afternoon rounds. Hospitalists see patients first thing every morning, so your needs are addressed sooner, and if you are getting better, the discharge process can often begin earlier. Overall, I think that hospitalists are able to respond to the acute needs of patients at a much faster pace.

FOR MORE INFORMATION:

Society of Hospital Medicine
www.hospitalmedicine.org
800-843-3360

The Johns Hopkins Hospitalist Program
www.hopkinsmedicine.org/gim/training/hospitalist.html
410-955-5000

Will a Pedometer Help Me Stay Fit?

Wed, 23 Jul 2008 06:00:00 CDT

Should you use a pedometer when you exercise? Johns Hopkins provides advice.

Pedometers have become increasingly popular in the last few years, particularly in the wake of the American Heart Association’s (AHA) Start! campaign, which provides participants with discounted pedometers and other tools to promote exercise.

The most recent evidence supporting their use comes from a study in the Journal of the American Medical Association. Data pooled from 26 studies totaling 2,767 participants found that people who used pedometers walked about one mile more per day than those who did not use pedometers. Other benefits included a 27% average increase in physical activity, a 3.8–mm Hg drop in systolic blood pressure, and a 0.38- point decrease in body mass index.

But pedometers alone didn’t boost activity. The participants who benefited most also recorded their progress benefited in “step diaries” and set step goals, such as 10,000 per day. To achieve this goal, the AHA recommends adding 1,000 steps each week to your walking routine until you reach 10,000.

All pedometers are not created equal. According to a study from the University of Tennessee, piezoelectric pedometers (also called accelerometers) count the steps of overweight adults more accurately than less-expensive spring-levered pedometers, especially at slower walking speeds. Extra inches around the waist can cause pedometers to tilt and skew results in spring-levered models.

How Safe Are Sleeping Pills?

Wed, 03 Sep 2008 06:00:00 CDT

Sleeping pills help millions of people with insomnia -- but for some, a good night’s sleep can turn into a nightmare. In this excerpt from a Health After 50 newsletter article, David Neubauer, M.D., Associate Director of the Johns Hopkins Sleep Disorders Center reviews the risks of sleeping pills.

You may have heard that the sleeping pill Ambien (zolpidem) has been linked to odd and potentially dangerous behavior -- users don’t just sleepwalk, they drive, make phone calls, eat large amounts of food, and strip off their clothes, all while “asleep.”

In response to these reports, the FDA has ordered the manufacturers of Ambien -- along with manufacturers of over 10 other popular sleeping pills -- to add a warning to product labels about these risks.

If you’re using sleeping pills to combat insomnia, the recent reports and subsequent warning required by the FDA may seem threatening. Yet David Neubauer, M.D., Associate Director of the Johns Hopkins Sleep Disorders Center and the author of Understanding Sleeplessness (Johns Hopkins University Press), says, “These dramatic sleeping pills side effects are really quite rare.”

In addition, not all the sleeping pills on the FDA’s list are equally as likely to cause side effects. “The FDA attached this warning to a very wide range of medications that work in different ways. For example, Rozerem (ramelteon) affects melatonin receptors in the brain and doesn’t cause memory difficulty, nor are there reports of its causing these kinds of strange behaviors,” Dr. Neubauer says. However, it has not been available as long as the other sleeping pills, so rarer side effects may not have yet come to doctors’ attention.

Bottom line advice on sleeping pills: To lower your already low risk of experiencing side effects from sleeping pills, Dr. Neubauer advises that you take no more than your prescribed dose of medication, avoid alcohol when using sleeping pills, and, most important, take your medication when you’re already in bed.

People taking sleeping pills should keep in touch with their doctor for regular reevaluation of progress and should also tell their doctor about any side effects that occur. And keep in mind that sleeping pills may not always be the solution to sleeplessness. Insomnia may be related to an underlying and/or undiagnosed medical condition such as depression, chronic pain, Alzheimer’s disease, or digestive problems. In some instances, treating an underlying disorder may put an end to sleepless nights.

The Sleeping Pills That Made the FDA Warning List:

Ambien (zolpidem)

Butisol (butabarbitol)

Carbrital (pentobarbital and carbromal)

Dalmane (flurazepam)

Doral (quazepam)

Halcion (triazolam)

Lunesta (eszopiclone)

Placidyl (ethchlorvynol)

Prosom (estazolam)

Restoril (temazepam)

Rozerem (ramelteon)

Seconal (secobarbital)

Sonata (zaleplon)

Avoiding Hepatitis When You Travel

Mon, 21 Jul 2008 06:00:00 CDT

Hepatitis is a virus that causes inflammation in the liver. Approximately 42,000 new cases of hepatitis A, 56,000 new cases of hepatitis B, and 20,000 new cases of hepatitis C occur each year in the U.S. How can you avoid hepatitis when you travel abroad? Here's advice from Johns Hopkins.

Hepatitis B and C are spread by exposure to infected blood or sexual contact with an infected person, so the risk is of contracting hepatitis when you travel is low. The exception is in countries with intermediate or high rates of chronic hepatitis B and C, where travelers should be cautious about contaminated injections and healthcare equipment, blood transfusions, and unprotected sex.

Hepatitis A is the greater threat, since it is spread through the saliva and feces of an infected person -- meaning that food and water can easily become contaminated. The risk is very low in North America (except Mexico), Japan, Australia, New Zealand, and Western Europe -- the same as if you were traveling within the United States -- but much higher in Africa, South and Central America, Eastern Europe, and Asia. (Look up your destination at wwwn.cdc.gov/travel/destinationlist.aspx.)

There is no vaccine for hepatitis C, but the hepatitis A and B vaccines are recommended for all unvaccinated people traveling to countries at intermediate or high risk. You should receive two or three shots starting as soon as travel is considered. And while traveling to higher-risk countries, be sure to avoid beverages that aren’t sealed or boiled, ice cubes, uncooked shellfish, and fruits or vegetables that you haven’t peeled or prepared yourself.

If you do get sick with hepatitis or another disease while you're out of the country, you can obtain lists of local clinics where English is spoken by:

Contacting the local U.S. embassy

Visiting the International Society of Travel Medicine website (www.istm.org) or the International Association for Medical Assistance to Travelers website (www.iamat.org).

You may want to check these sites before you travel and print out the contact information for clinics in the countries you’re planning to visit. You also may wish to purchase travel health insurance. Your usual health insurance won’t cover airlifting to a medical facility if you become very ill or get injured while traveling outside of the United States. For information on policies, visit www.insuremytrip.com.

What Works for Mild to Moderate Hearing Loss?

Wed, 02 Jul 2008 06:00:00 CDT

The National Institutes of Health estimates that only 1 in 5 people who need a hearing aid gets one. Resistance to hearing aids remains high, partly because of their perceived stigma. Many people who try hearing aids are also disappointed by the quality of sound. Fortunately, hearing aid technology is always advancing to better meet patients’ needs. Johns Hopkins specialist Dr. Charles Limb reviews your hearing aid options and offers advice.

Hearing aids help by amplifying sound. With the proliferation of digital technology, new hearing aids can do a lot more in a smaller package. Compared with older “analog” models, new digital hearing aids are less conspicuous. They also have more sophisticated, programmable features like noise reduction and automatic adjustment to different environments.

However, one simple rule still holds true for hearing aids: The smaller the device, the less amplification it has. Some people with moderate to severe hearing loss find that small digital devices simply do not have enough power. Of course, louder does not always mean clearer. For people who still hear low-pitched sounds well, amplification can create a “muddle” if these low-pitched sounds become too loud. A digital hearing aid that can be programmed for specific frequencies is a good choice if you can still hear certain pitches reasonably well.

“The type of aid that is best for each person depends entirely on the pattern of hearing loss,” explains Charles Limb, M.D., Assistant Professor, Johns Hopkins Department of Otolaryngology-Head and Neck Surgery. “The more complex the nature of hearing loss, the more useful a programmable digital device will be. Someone with selective hearing loss at middle-range frequencies, for instance, would benefit from a digital hearing aid because it can be set to correct for the specific frequency."

“People who don’t benefit from digital or traditional analog hearing aids can consider a bone-anchored hearing aid, or baha,” adds Dr. Limb. Abaha is a titanium device that is implanted behind the earlobe and transmits sound through the bone, thus bypassing any damage in the middle ear. “It can be extremely helpful for people who are deaf in one ear or have conductive hearing loss -- when sound is not adequately transmitted through the ear canal owing to a blockage like the buildup of scar tissue.”

Bottom-line advice: If you are buying a hearing aid for the first time, see an audiologist, who is trained to test your hearing. This specialist will provide follow-up testing and hearing-aid adjustments to make sure the device is functioning well for you. And do not put off another visit to an audiologist or otolaryngologist if you think that your hearing aid is not meeting your needs. Medical evaluations are essential to get the best results.

Breast Cancer Screening Gets Better

Wed, 09 Apr 2008 06:00:00 CDT

It’s common knowledge that a yearly mammogram can be a lifesaver, but recent news suggests that a mammogram isn’t always enough. The American Cancer Society (ACS) now recommends the use of magnetic resonance imaging (MRI) as an additional screening tool for breast cancer for selected high-risk individuals. In addition, new mammography technology, such as digital mammography, is increasingly available.

A mammogram is an x-ray of your breast tissue. And for most women, an annual mammogram beginning at age 40 is enough to ensure that breast cancer, if it develops, is caught early, when it is most treatable. The mammogram, however, is not perfect: It may not detect up to 20% of breast cancers (particularly if a woman’s breasts are dense). In some instances, the more sensitive MRI test is recommended.

Unlike the mammogram, which picks up images of tumors in the breast, MRIs can discern blood vessel activity in tumors, thereby detecting tumors that a mammogram might miss. MRIs are not recommended for all women for the same reason. Says Nagi Khouri, M.D., Associate Professor of Radiology and Oncology at Johns Hopkins and Director of Breast Imaging at the Johns Hopkins Avon Foundation Breast Center, “The test is so sensitive that it produces a lot of false-positive diagnoses of cancer. These false positives lead to unnecessary anxiety and to invasive biopsies that uncover noncancerous tissue.”

MRIs aren’t the only new option for breast cancer screening.

Ultrasound. “Ultrasound is another extremely helpful tool," says Dr. Khouri. "Many patients may end up having a mammogram, an MRI test, and an ultrasound test.” Ultrasound testing uses sound waves to create an image of the breast and is especially useful for women with dense breast tissue.

Computer-aided detection. Another technological advance that allows improved evaluation of suspicious findings detected by mammograms is the use of computer programs to examine x-rays. This process is called computer-aided detection (CAD).

Digital mammography. A digital mammogram is another option. “Currently only 10–12% of imaging centers in the United States use digital mammography, but we think it is the wave of the future,” says Dr. Khouri. A digital mammogram creates an electronic image of the breast tissue that can be stored on a computer, where the image can then be adjusted for contrast and magnified. By altering the image, radiologists may be able to find “hidden” tumors.

Screening Recommendations from the American Cancer Society (ACS)

Mammogram
The ACS recommends a yearly mammogram for all women starting at age 40.

Magnetic Resonance Imaging (MRI)
An MRI is recommended in addition to a mammogram for women with a lifetime risk of breast cancer of 20% or greater. Factors that can put you at high lifetime risk include:

Strong family history of breast cancer (multiple relatives who have had breast cancer, particularly a mother or a sister)

A mutation in the BRCA1 or BRCA2 gene or a parent, child, or sibling with a mutated BRCA1 or BRCA2 gene

Hormonal, menstrual, and childbirth histories and results of a prior biopsy may suggest a higher risk

Radiation treatment to the chest for Hodgkin’s disease between the ages of 10 and 30

Is It Time To See a Geriatrician?

Wed, 11 Jun 2008 06:00:00 CDT

In this article from our Health After 50 newsletter, Michele Bellantoni, M.D., Associate Professor of Medicine, Medical Director of Johns Hopkins Bayview Care Center, describes the unique type of care that geriatricians provide.

What is a geriatrician?
Geriatricians are doctors with specialized training in medical conditions and health care issues of older adults. As people age they tend to develop a number of coexisting health problems, which often require treatment with a variety of medications and frequent visits to different specialists. Geriatricians are trained to treat multiple health problems, keep track of multiple medications, and help patients who cannot function well to stay as independent as possible. We do this, in part, by creating a healthcare plan in coordination with other medical specialists and practitioners.

Who should see a geriatrician?
Generally it is the older adult with multiple medical conditions. For instance, patients may have heart disease or peripheral artery disease and neurological conditions, or they may have arthritis, diabetes, and vascular conditions that limit mobility. My patients range in age from the late 70s to 107. The oldest and most impaired don’t come to see me, since many can only walk a couple of steps, so I visit them in their homes.

What are the advantages to seeing a geriatrician?
We are particularly good at assessing physical function and are specially trained to recognize potentially adverse drug reactions and interactions in older people who metabolize medications differently and tend to take more of them. Also, we often have a health care team available to us that general practitioners and specialists do not have. For instance, we rely heavily on case managers, social workers, and nurses to follow up on the care plans that we’ve established in coordination with patients’ other doctors.

How can people find a practicing geriatrician?
Unfortunately, it is not easy to find a geriatrician. By all estimates there is and will continue to be a shortage of geriatricians in the United States. One reason is the sole practice of geriatric medicine does not pay as well as a medical practice that includes surgeries or invasive procedures.

The good news is that we are beginning to take steps to ensure that older people get the health care they need -- even if we continue to have a shortage of geriatricians. Medical schools now require students to receive training in geriatrics, and nursing schools are beginning to do the same. And many primary care doctors are not geriatricians but received continuing medical education in treating older patients with multiple medical conditions.

FOR MORE INFORMATION
• American Geriatrics Society (800) 563-4916 www.americangeriatrics.org • American Board of Family Medicine (877) 223-7437 www.theabfm.org • American Board of Medical Specialties (847) 491-9091 www.abms.org

Snoring Remedies

Wed, 21 May 2008 06:00:00 CDT

What can you do to quiet nighttime snoring? Johns Hopkins provides nine practical strategies.

Snoring occurs when the muscle that keeps open the airways carrying air from the nose and throat to the lungs relaxes during sleep. This causes the airways to collapse, requiring more forceful inhalation to breathe. Hence, the nocturnal foghorn blasts.

Adults generally start to snore in their late thirties and forties, and the incidence increases when they pass the age of fifty. Snoring predominantly plagues adults but children between the ages of three and thirteen will snore when they have large tonsils and adenoids, or when they have a heavy cold.

If snoring annoys your bedmate, try these techniques to stop it:

Snoring Tip 1 -- Avoid heavy meals and alcohol within three hours of bedtime. Eating heavily and drinking alcohol before turning in cause greater than normal relaxation of the throat muscles, and this may cause even a “nonsnorer” to snore.

Snoring Tip 2 -- Avoid tranquilizers and antihistamines before bedtime. Like alcohol, most of these medications suppress neck muscle tone and can cause snoring.

Snoring Tip 3 -- Lose weight, if you are overweight. No one is certain why weight gain causes snoring. It may be linked to increased fat in the structures around the throat, which diminishes the size of the air passages through which you breathe.

Snoring Tip 4 -- Avoid sleeping on your back. This position may lead to snoring because the tongue falls back and presses against the top of the airways. It’s preferable to sleep lying on your stomach or on your side. However, for heavy snorers, sleep position has no effect -- they will snore in all positions.

Snoring Tip 5 -- Try the tennis ball treatment. At bedtime, strap on a fanny pack with a tennis ball in it and position it in the hollow of your back. Alternatively, tape a tennis ball to the back of your pajamas. (A rolled-up pair of socks will also do the trick.) Every time you roll over on your back, you’ll become uncomfortable and roll back on your side.

Snoring Tip 6 -- Tilt the head of your bed upward. Place telephone books or bricks under the legs at the head of the bed. This may help relieve chronic snoring.

Snoring Tip 7 -- Seek treatment for allergies and upper respiratory problems that cause nasal obstruction. Congestion due to allergies and colds cause the air passages to narrow. When air flows through a narrow airway, it’s more turbulent and causes the throat tissues to vibrate. Contact an allergy specialist for testing and treatment. If you have nasal congestion due to a cold, use a decongestant.

Snoring Tip 8 -- Make sure there is a good flow of fresh air in the bedroom. When the room is hot and dry, nasal passages become clogged during sleep, and this often leads to snoring. Keep your windows open and, if necessary, use a humidifier to keep your nasal passages moist.

Snoring Tip 9 -- If you smoke, quit. Along with its many deadly health consequences, smoking has an irritant effect that causes mucus buildup, inflammation and swelling of the pharynx, and bronchial congestion, all of which can contribute to snoring.

Questions on Resistance Training and the Diet Pill Alli

Wed, 19 Mar 2008 06:00:00 CST

Each issue of our popular Health After 50 newsletter includes House Calls, a lively question and answer column in which Johns Hopkins doctors answer readers’ questions. Here’s a sample.

Q. I’m 72 and reasonably healthy, but I have never lifted weights. Should I start now?

A. Absolutely. Resistance training, which refers to weight lifting and other strength-building exercises, is essential to good health for both men and women at any age and despite many existing medical conditions -- but always talk to your doctor before starting an exercise routine.

If you are healthy, you can partake in a fairly vigorous strength-training program. One example comes from a small study in the International Journal of Sports Medicine. Researchers analyzed the effects of strength training on 24 healthy men and women who were over 75. Participants used a combination of weight machines, dumbbells, and exercise bands to work a variety of muscle groups twice a week for the first three weeks. Then one workout was added per week until exercisers were up to four weekly workouts. After three months, participants lost an average of 8 lbs. of body fat, increased their oxygen uptake by 12%, and increased their strength up to 37% in some muscle groups.

Q. I am about 15 lbs. overweight. Do you recommend the new over-the-counter diet pill Alli?

A. Alli is FDA approved and therefore safe to try to lose weight, but be aware of several things. Alli is made of the same ingredients as prescription Xenical (orlistat), only at half the dose. Orlistat prevents the enzyme lipase from breaking down fat within the intestine, thereby blocking the absorption of approximately 25% of the fat you consume.

However, unpleasant side effects can result when fat lingers in your digestive tract, including frequent, loose bowel movements, foul-smelling stools, flatulence, urges to rush to the bathroom, and oily discharge. Thus, people taking orlistat must also eat a low-fat diet in order to keep undigested fat at a minimum. In stopping the breakdown of fat, orlistat also blocks the absorption of essential, fat-soluble vitamins, which must be replenished by taking a daily multivitamin. And there is the potential for drug interaction with the blood-thinner Coumadin (warfarin), diabetes medications, and immunosuppressant drugs.

Owing to its possible side effects, orlistat may not be ideal for you or others who are otherwise healthy and are looking to drop a small amount of weight -- in those cases, reduced caloric intake and regular exercise will do the trick. Doctors therefore usually recommend orlistat only for people with body weight indexes (BMIs) greater than 30 -- which is considered obese -- or for those who risk weight-related health problems due to diabetes, high blood pressure, or heart disease.

Do Commercial Weight-Loss Programs Actually Work?

Wed, 27 Feb 2008 06:00:00 CST

Can you stick with it? Research shows that the longer you can stay in a commercial weight-loss program, the more weight loss you’re likely to achieve.

Successful weight loss requires a three-pronged approach: changing your behavior, altering your diet, and increasing your physical activity. Permanent alterations in your lifelong attitudes toward diet and exercise are the keys to successful weight management. You must be motivated enough to change habits not for a few weeks or months, but for a lifetime. The importance of this cannot be underestimated. The desire to lose weight must come from within.

Commercial weight-loss programs can be effective tools for weight loss, but you do need to stick with the program for at least three months to see benefits. That was the conclusion of a one-year study of men and women enrolled in the Jenny Craig Platinum program.

After a month, 73% of the 60,164 people who joined the program were still enrolled. The number dropped to 42% at three months and 22% at six months. Only 7% remained at one year.

For those who stuck it out, weight loss was substantially greater. Men and women who lasted a year lost 13–16% of their initial body weight, compared with only a 1% loss in those who dropped out in the first month. Men and women who stayed in the program for at least three months lost about 8% of their baseline weight.

A loss of 5–10% of body weight can lead to significant reductions in blood pressure, cholesterol levels, and other conditions associated with overweight or obesity. But there’s a good chance that the three-month dropouts gained back the lost weight by the end of the year. Nonetheless, the longer you can stay in a commercial weight-loss program, the more weight loss you’re likely to achieve. The study was funded by an unrestricted research grant from Jenny Craig and reported in the International Journal of Obesity (online edition June 6, 2006).

Is Exercise a Weapon Against Cancer?

Wed, 06 Feb 2008 06:00:00 CST

If you have cancer and are undergoing chemotherapy, exercise is one of the best ways to combat treatment-related fatigue, and may even increase the body’s ability to recover from the effects of chemotherapy.

Several groundbreaking studies suggest that exercise doesn’t just help combat treatment-related fatigue, it may help fight against cancer. And obsessive exercise isn’t needed to see a benefit. Depending on the intensity of the activity, you may need to exercise only a few hours a week.

Researchers measured how much energy exercisers expended in metabolic equivalent task (MET) hours. One MET hour is the equivalent of the energy expended by the body during one hour of rest. You can rack up several MET hours of exercise during one “real-time” hour. For example, one hour of moderate walking is the equivalent of three MET hours and one hour of doubles tennis or slow jogging is the equivalent of 5 MET hours.

The first study, published in the Journal of the American Medical Association, followed 2,987 women with breast cancer. Women who exercised more than three MET hours a week after diagnosis were less likely to die of their cancer.

In another study of 573 women with colon cancer, women who exercised more than 18 MET hours a week after diagnosis were 61% less likely to die of cancer-specific causes than women who exercised less than three MET hours a week. And exercise was protective no matter the patient’s age, stage of cancer, or weight. Furthermore, patients benefited even if they hadn’t been physically active before their diagnosis.

A third study, in the Journal of Clinical Oncology, found similar results after examining the effects of exercise on 832 men and women with stage III colon cancer.

How does exercise help fight cancer? Researchers theorize that exercise can regulate production of certain hormones that, unregulated, may spur tumor growth.

What You Should Know About Kidney Disease

Wed, 26 Dec 2007 06:00:00 CST

People at risk for kidney disease can protect kidney function by treating diabetes, hypertension, losing weight, not smoking, and having regular screening tests.

The number of people with chronic kidney disease has doubled over the last decade. Experts attribute this rise, in part, to the increase in type 2 diabetes -- a condition that takes a toll on the kidneys. Uncontrolled hypertension also may play a role. Kidney disease, hypertension, and type 2 diabetes form a cluster of age-related conditions, and developing one puts you at risk for the others. More important, this cluster of conditions puts you at very high risk for cardiovascular disease. Even people in the early stages of chronic kidney disease are at a greatly increased risk for coronary heart disease.

Without treatment, kidney disease progresses and eventually leads to organ failure, which requires dialysis or a kidney transplant. Kidney failure -- also known as end-stage renal disease (ESRD) -- can be fatal. Most people with kidney disease are unaware that their kidney function is impaired because symptoms only appear after the kidneys have suffered significant damage. The high risk of heart disease is one more reason that early identification and treatment are essential.

Small declines in kidney function pose no health problems. In fact, it is possible to function well at half of normal kidney capacity, provided function remains stable. However, serious problems result in anyone with kidney disease whose functional capacity drops by more than half.

Early symptoms may include headache, fatigue, and dry, itchy skin. As more function is lost, people may need to urinate more (or less), lose their appetite, or experience nausea and vomiting. Sometimes the hands and feet swell, and fluid may back up in the heart and lungs, prompting heart failure -- or worsening it if it is already present. High blood pressure and anemia may also develop. These problems become serious when function declines to about 20%. ESRD is diagnosed at 10–15% of capacity; at this point dialysis or transplantation is necessary.

Essential Tests for Kidney Disease: Everyone should be screened for hypertension and diabetes -- and treated for these conditions if they are present -- to protect both the heart and the kidneys. But according to the National Kidney Foundation guidelines, people with diabetes, hypertension, or a family history of kidney disease are at high risk for kidney disease and require two additional laboratory tests: a urine test for extra protein (proteinuria) and a blood test for creatinine (a waste product created by normal muscle activity).

The urine test measures albumin, a protein that appears in urine when kidney function is impaired. Results of creatinine testing permit calculation of the glomerular filtration rate (GFR), an estimate of how efficiently the kidneys are functioning. Research is currently being conducted on the optimal interval for screening. Meanwhile, the American Diabetes Association recommends yearly urine and blood testing for most diabetes patients -- a good guideline for those in other high-risk groups. If kidney disease has already developed, testing should also be done every year -- or more often if GFR is below 60 mL/min, an indication of more advanced disease.

Stretching Away Plantar Fasciitis

Wed, 05 Dec 2007 06:00:00 CST

A recent study of plantar fasciitis patients reveals that stretching the plantar fascia may reduce pain more than stretching your Achilles tendon.

Rising in the morning, you put your feet on the floor and immediately feel a sharp pain in the inside of your heel … or after exercising your heel aches and swells … or your heel hurts anytime you stand up after sitting for a while.

These pains are typical of plantar fasciitis, a common foot condition. Although it's not dangerous, plantar fasciitis can curtail your activities and alter your gait, which can cause foot, knee, hip, and back pain. Plantar fasciitis occurs when the plantar fascia, a fibrous band of connective tissue that attaches your heel to your toe bones, becomes irritated. Plantar fasciitis becomes more common with age.

Most people with plantar fasciitis use pain relievers, splints, and orthotic shoe inserts that redistribute pressure on the affected foot. In severe cases of plantar fasciitis, corticosteroid injections can help with plantar fasciitis pain. A less common option to relieve the pain of plantar fasciitis is extracorporeal shockwave treatment. During treatment, an ultrasound device aims sound waves at the plantar fascia. Shockwave therapy may stimulate healing, but thus far, studies show conflicting results. About 5% of people with plantar fasciitis go on to have a surgical procedure, such as detaching the plantar fascia.

Stretching your Achilles tendon is often recommended for additional pain relief of plantar fasciitis; however, directly targeting the plantar fascia may have better results. A study published in The Journal of Bone and Joint Surgery evaluated 82 chronic plantar fasciitis patients who were given a three-week supply of Celebrex (celecoxib), orthotics, and instructions for an Achilles tendon stretch or a plantar fascia stretch. After eight weeks, participants who stretched their plantar fascia felt less pain and could perform more activities than patients who stretched their Achilles tendon.

When the study ended, the plantar fascia stretch was taught to all the participants. Two years later, 66 of the original patients were re-examined; 94% of these patients reported feeling no pain or less pain than they had experienced before the study, and only 30% had undergone further treatment with a physician or physical therapist.

Stretches for plantar fasciitis: The plantar fascia stretch requires pulling the toes to create tension in the plantar fascia.

Step 1. Cross your legs so that the foot you will be performing the stretch on rests on top of the opposite knee.

Step 2. Hold the base of the toes in your hand and pull back towards the shin. You should feel a stretch in the bottom of your foot.

Step 3. To check that you’re performing the stretch correctly, touch the bottom of your foot with your other hand. You should be able to feel the plantar fascia tense under the skin.

In the study, the stretch was done 10 times, three times a day.

Should Your Doctor Be Board Certified?

Wed, 24 Oct 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Should Your Doctor Be Board Certified

Each issue of our Health After 50 newsletter includes House Calls, an informative question and answer section. Here’s a sample.

Q. Should my doctor be board certified?

A. Doctors do not have to be board certified to practice; approximately 85% of M.D.s are. Generally, doctors test for certification after completing residency training.

According to Health After 50 Board Member Edward Wallach, M.D., Professor of Gynecology and Obstetrics at Johns Hopkins, "Board certification should be one of the top considerations in choosing a doctor. Certification is a sign that the doctor has had his or her credentials reviewed, has up-to-date licensure, has kept up to date on new medical innovations after residency, and is participating in a continual learning process in his or her specialty.”

To become board certified, a doctor must pass exams administered by one of the 24 specialty boards of the American Board of Medical Specialties (ABMS), a nonprofit organization composed of leading medical specialists. Subspecialty certificates can be obtained after additional training within a particular field (e.g., a board-certified radiologist may test for a subspecialty certificate in neuroradiology). A similar process is in place for medical doctors with osteopathic degrees (D.O.s) through the American Osteopathic Association (AOA) specialty board. D.O.s may also train and sit for board certification by ABMS specialty boards. Most specialties require recertification testing every 10 years.

Some doctors advertise themselves as "board eligible,” but this term means only that they are eligible to begin the certification process, not that they are actively working toward it. Younger doctors may use this term while they are taking their exams or waiting for examination results, but the term doesn’t guarantee quality. Your insurance provider may note whether its participating doctors are board certified. Alternatively, search the ABMS database at www.abms.org/ newsearch.asp or call (866) 275-2267. For a board-certified osteopath, call AOA Member Service Center at (800) 621-1773.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Should Your Doctor Be Board Certified

Ask the Doctor about Constipation

Wed, 14 Nov 2007 06:00:00 CST

Johns Hopkins Health Alerts | Healthy Living After 50 |

Ask the Doctor about Constipation

Each issue of our Health After 50 newsletter includes House Calls, an informative question and answer section. Here’s a recent sample.

Q. When should I try a laxative to treat constipation?

A. The National Institutes of Health defines constipation as having bowel movements less than three times a week; however, frequency isn’t as important as whether you experience constipation symptoms, such as painful stools, bloating, or cramping.

Drinking more water, eating foods rich in fiber, and exercising more can usually help alleviate chronic constipation. If not, you can try laxatives for constipation. There are four different types of laxatives, some available over the counter, others only by prescription. Bulk, lubricant, and hyperosmotic laxatives make stools easier to pass by absorbing water into the stool. Over-the-counter types of bulk, lubricant, and hyperosmotic laxatives include Metamucil, Epsom salts, and Miralax (previously a prescription product and now available over the counter). Stimulant laxatives prompt intestinal contractions—Ex-Lax is an over-the-counter type of this laxative. While bulk laxatives are safe for long-term use without significant side effects, lubricant, hyperosmotic, and stimulant laxatives should be used under a physician’s supervision.

Recently, the medication Amitiza (lubiprostone) was approved to treat chronic constipation. But H. Franklin Herlong, M.D., Associate Professor of Medicine at Johns Hopkins, says, "Since the long-term safety of this drug isn’t established, it should be considered only after other therapies have failed."

Some people worry that laxatives are addictive, but that’s not exactly the case. Dr. Herlong states, "Many individuals believe that a daily bowel movement is necessary for ‘good health’ and may use laxatives to maintain a regular schedule even if they're not constipated. As a result, the natural urge for defecation may wane, and these people end up taking laxatives most of the time.”

Johns Hopkins Health Alerts | Healthy Living After 50 |

Ask the Doctor about Constipation

Being a 'Good' Patient

Wed, 22 Aug 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Being a "Good" Patient

Studies show that adherence is one of the most important factors in prevention, health maintenance, and recovery from illness. Yet many patients don’t do what the doctor recommends.

Although this advice might sound simplistic, your good health really does begin with you -- the patient. All the modern medicines, high-tech devices, and highly trained healthcare professionals can’t help if you don’t help yourself by being a good patient.

Unfortunately, too many people do not take their patient responsibilities seriously. Studies consistently show that a large percentage of patients -- 50% or more in some cases -- either don’t take their medication at all or don’t take it as prescribed. Many patients don’t even bother to fill the first prescription. And the track record for following recommended lifestyle changes -- diet, exercise, weight loss, and smoking cessation -- is probably even worse. Missed or cancelled doctor’s appointments, lack of regular health checkups, and failure to get recommended preventive care -- such as blood pressure and cholesterol measurements -- also are commonplace.

Following instructions, however, is only one aspect of being a good patient. A good patient is also informed and involved. Here’s what this means.

A good patient stays informed -- openly communicating with your doctor or other healthcare provider:

Answer questions honestly and completely. If you don’t understand a question, say so.

Volunteer information about your health if you’re not asked about it. Something that might seem trivial to you could be meaningful to your doctor.

Don’t be reluctant to ask questions.

Don’t be afraid to seek a second opinion.

A good patient stays involved -- taking responsibility for your healthcare. For example:

Appointments. Show up on time and be prepared to discuss your health with your doctor (for example, have a list of your symptoms, medications you are taking, and questions you want answered).

Tests. Ask your doctor for the results of any measurements tests performed in his or her office (such as your blood pressure). If your doctor requests lab work, x-rays, or other types of tests, promptly make an appointment for the tests and be sure to keep the appointment. Follow up with the doctor’s office to learn the results.

Medications. Whenever you get a prescription for a new medication, your doctor or other healthcare provider should tell you what the medication does, how to take it, and the possible side effects.

Always let your doctor know about any other medications you are taking, including prescription and nonprescription medications as well as vitamins and supplements.

Take medication as directed, paying careful attention to the number of daily doses required, the time of day the medication is to be taken, and the need to take the medication with food or liquids.

Ask your doctor if the medication comes in a form that can be taken less frequently if you find the dosing schedule complicated or you are taking multiple drugs.

Let your doctor know if another health condition is interfering with your ability to take medication.

Do not hesitate to tell your doctor if a medication is too expensive for your budget. Your doctor might be able to prescribe a less expensive drug, a generic version of the drug, or a larger dose so that you can split the pills.

Let your doctor know right away if you have any bothersome side effects.

Never abruptly stop taking a medication without first asking your doctor.

Never take another person’s medication and never give your medication to someone else.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Being a "Good" Patient

Unraveling the Mystery of Frailty

Wed, 12 Sep 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 | Unraveling the Mystery of Frailty

Geriatrician Dr. Linda Fried explains that frailty is not a disease in the classic sense, but a syndrome -- a constellation of symptoms that characterize a certain condition.

Though there’s no shortage of warnings about the dangers of obesity, older people should also be concerned about frailty. According to research spearheaded by geriatrician and epidemiologist Linda Fried, M.D., M.P.H., Founder and Director of the Johns Hopkins Center on Aging and Health, frail people are more likely to fall, be hospitalized, be disabled, or suffer from a variety of diseases and chronic conditions.

Because frailty makes it more difficult to cope with or recover from these major life stressors, frailty also tends to be associated with a significantly higher mortality rate. Knowing the warning signs of frailty may help you to shore up your strength as you grow older.

According to Dr. Fried, "Older adults know who is frail, they are concerned about it, and they don’t want it to happen to them.” But until recently, frailty did not have a medical, or clinical, basis. This changed in the late 1990s, when Dr. Fried set out to discover a way to recognize frailty early and therefore prevent the worst of its consequences.

Over the course of seven years, Dr. Fried and her colleagues examined the health of over 5,000 men and women ranging from 65 to 101 years of age. They found that the weakest, most physically disabled people shared a unique set of observable symptoms that together suggested frailty. They defined a phenotype of frailty by classifying people with three or more of the following characteristics as clinically frail:

Unintentional weight loss, including sarcopenia (loss of muscle mass), of 10 lbs. or more within one year.

Exhaustion that prevents normal or enjoyable activities.

Weakness characterized by significant reduction in grip strength.

Slow walking speed.

Low physical activity (burning less than 3,830 calories per week for men and 2,700 calories per week for women).

Johns Hopkins Health Alerts | Healthy Living After 50 | Unraveling the Mystery of Frailty

Relief for Carpal Tunnel Syndrome

Wed, 01 Aug 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Relief for Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common disorder that may affect up to 10% of the population. And women are three times more likely than men to develop carpal tunnel syndrome.

If you have experienced pain, tingling, and numbness in your hand and wrist for a long time, don’t ignore these symptoms: You may have carpal tunnel syndrome. Carpal tunnel syndrome is caused by compression of the median nerve, which enters your hand through the carpal tunnel -- a narrow passageway formed by bones and ligaments. If tendons in the carpal tunnel become inflamed and swell, they can squeeze the nerve and produce the typical symptoms of carpal tunnel syndrome.

Early recognition of carpal tunnel syndrome is important because prompt treatment can help you avoid potential long-term problems such as loss of feeling in some fingers and permanent weakness of the thumb.

People with jobs or hobbies that involve repetitive movement, such as assembly-line workers, grocery checkers, carpenters, or violinists, are more likely to develop carpal tunnel syndrome. Computer use has been thought to be implicated, but a Mayo Clinic study found that even heavy computer use (up to 7 hours a day) did not raise the odds.

If your carpal tunnel syndrome symptoms are mild, resting your hand and wrist for at least two weeks and avoiding, or doing less of, a repetitive movement may be all that is needed. Using a lightweight plastic wrist splint to support your wrist in a neutral position may also help because it can give the affected nerves and tendons time to recover. Your doctor may advise wearing the splint 24 hours a day for several weeks, but some people obtain relief by wearing the splint just at night.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and aspirin may help control the pain of carpal tunnel syndrome. If these over-the-counter pain relievers don’t help, a low dose of an oral corticosteroid, such as prednisolone, for two to four weeks can improve symptoms, but prolonged use of such drugs can have serious side effects.

If these measures do not ease your symptoms, your doctor may inject a corticosteroid directly into the carpal tunnel. This approach can provide immediate, dramatic relief, and a study in Arthritis & Rheumatism found that steroid injections were as effective as surgery for long-term (at least one year) relief of symptoms.

If you have been experiencing carpal tunnel syndrome symptoms for up to a year or so despite conservative therapy or if you have severe symptoms, such as persistent loss of feeling in your fingers or hand or weakness in your thumb, you may require surgery. In a procedure called open release, the surgeon will cut the transverse carpal ligament that lies over the median nerve to reduce pressure on the nerve and relieve symptoms.

In a newer procedure, the surgeon makes a small incision, inserts a tiny camera and a knife through a lighted tube called an endoscope, and cuts the ligament. Because this endoscopic procedure disturbs less tissue than open surgery, it does not leave a large scar, and recovery time is cut in half.

For more Alerts and Special Reports, please visit the Healthy Living Topic page.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Relief for Carpal Tunnel Syndrome

Don't Underestimate Anemia

Wed, 11 Jul 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 | Don't Underestimate Anemia

Because the symptoms of anemia can seriously undermine your quality of life and may point to an underlying illness, it is important to know the facts about anemia.

Hemoglobin (Hb) is the protein in red blood cells that picks up and transports oxygen throughout the body. A deficiency in the oxygen-carrying capacity of blood is called anemia. The risk of anemia generally increases with age, but it often goes unnoticed. Symptoms of anemia include weakness, fatigue, trouble concentrating, sexual dysfunction, shortness of breath, and dizziness.

Getting a proper diagnosis for anemia is important. Studies show that anemia may exacerbate the symptoms of underlying heart disease and may be a risk factor for frailty. Through simple tests your doctor can determine the cause of your anemia and, in turn, recommend treatment to boost your Hb levels and restore vitality.

A serum ferritin blood test for iron levels is the first step in diagnosing anemia. Hb needs iron to function and bind to oxygen. The chemical interaction between oxygen and iron-rich Hb makes blood red (think of how oxygen interacts with metals to create rust). Iron-deficiency anemia can result from a decreased ability to absorb nutrients from food -- not uncommon for people over 50. It can also result from malnutrition or a strict vegetarian diet, as meat is an important source of iron.

If your iron levels are low, your doctor will prescribe supplements. Never take over-the-counter iron supplements just because you feel tired. Too much iron can cause hemochromatosis, a rare but dangerous condition in which toxic levels of iron collect in the pancreas and liver. And self-treating with supplements may improve symptoms while their cause -- for example, colon cancer -- goes undiscovered.

Iron-deficiency anemia is often caused by a loss of red blood cells during chronic, low-level gastrointestinal bleeding. Internal bleeding can result from prolonged aspirin or nonsteroidal anti-inflammatory drug use, colon polyps, stomach ulcers, and gastrointestinal cancer. Thus, doctors will typically perform a fecal occult blood test on people diagnosed with iron-deficiency anemia. If blood is found in the stool, an endoscopy is done to check for colon cancer.

You can have normal iron levels and still suffer from anemia. Anemia caused by chronic disease, the most common form of anemia in people over 50. This kind of anemia is not caused by an iron deficiency, but by chronic inflammation from an underlying illness, which signals the immune system to release a steady supply of anti-inflammatory proteins that interfere with the production of red blood cells.

Chronic infections, rheumatoid arthritis, kidney disease, and certain cancers may all lead to this type of anemia. Iron supplements will not help, since the heart of the problem is the source of inflammation. Your doctor may give you injections of erythropoietin, a hormone produced in the kidneys that boosts Hb production, but in most cases anemia of chronic disease is reversed by treating the source of infection or inflammation.

For more Alerts and Special Reports, please visit the Healthy Living Topic page.

Johns Hopkins Health Alerts | Healthy Living After 50 | Don't Underestimate Anemia

Is It Dangerous to Cook with Plastics?

Wed, 28 Mar 2007 06:00:00 CST

Johns Hopkins Health Alerts | Healthy Living After 50 | Is It Dangerous to Cook with Plastics

Johns Hopkins professor Rolf Halden talks about the myth of dioxins and plastic water bottles.

The Internet has been flooded with email warnings to avoid freezing water in plastic bottles so as not to get exposed to carcinogenic dioxins. One hoax email has been erroneously attributed to Johns Hopkins University since the spring of 2004. The Office of Communications and Public Affairs discussed the issue with Rolf Halden, PhD, PE, assistant professor in the Department of Environmental Health Sciences and the Center for Water and Health at the Johns Hopkins Bloomberg School of Public Health. We sat down with Dr. Halden to set the record straight on dioxins in the food supply and the risks associated with drinking water from plastic bottles and cooking with plastics.

Question: What do you make of this recent email warning that claims dioxins can be released by freezing water in plastic bottles?

Answer: No. This is an urban legend. There are no dioxins in plastics. In addition, freezing actually works against the release of chemicals. Chemicals do not diffuse as readily in cold temperatures, which would limit chemical release if there were dioxins in plastic, and we don’t think there are.

Question: So it’s okay for people to drink out of plastic water bottles?

Answer: First, people should be more concerned about the quality of the water they are drinking rather than the container it’s coming from. Many people do not feel comfortable drinking tap water, so they buy water in plastic bottles instead. The truth is that city water is much more highly regulated and monitored for quality. Bottled water is not. It can legally contain many things we would not tolerate in municipal drinking water.

Having said this, there is another group of chemicals, called phthalates that are sometimes added to plastics to make them flexible and less brittle. Phthalates are environmental contaminants that can exhibit hormone-like behavior by acting as endocrine disruptors in humans and animals. If you heat up plastics, you could increase the leaching of phthalates from the containers into water and food.

Question: What about cooking with plastics?

Answer: In general, whenever you heat something you increase the likelihood of pulling chemicals out. Chemicals can be released from plastic packaging materials like the kinds used in some microwave meals. Some plastic drinking straws say on the label “not for hot beverages.” Most people think the warning is because someone might be burned. If you put that plastic straw into a boiling cup of hot coffee, you basically have a hot water extraction going on, where the chemicals in the plastic straw are being extracted into your nice cup of coffee. We use the same process in the lab to extract chemicals from materials we want to analyze.

If you are cooking with plastics or using plastic utensils, the best thing to do is to follow the directions and only use plastics that are specifically meant for cooking. Inert containers are best, for example heat-resistant glass, ceramics and good old stainless steel.

This interview with Dr. Halden is an excerpt from a Johns Hopkins Medicine press release. To read the entire interview, go to http://www.jhsph.edu/publichealthnews/articles/halden_dioxins.html

For more Alerts and Special Reports, please visit the Healthy Living Topic page.

Johns Hopkins Health Alerts | Healthy Living After 50 | Is It Dangerous to Cook with Plastics

Therapy for Kidney Stones

Wed, 30 May 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 | Therapy for Kidney Stones

What, other than drinking water, can help flush out a kidney stone? Brian Matlaga, M.D., M.P.H., Director of Stone Disease at Johns Hopkins Bayview Medical Center, responds.

Caused by the buildup of salts within the kidneys, kidney stones afflict 1.3 million Americans a year. The most common treatment for kidney stones is to drink lots of water and wait for the kidney stone to pass out of the body. Typically, 2-3 quarts of water a day are advised, along with painkillers to ease discomfort. About 85% of kidney stones pass in this fashion, most within 2-3 days. If the kidney stone still doesn’t pass, further treatment, such as extracorporeal shockwave lithotripsy or surgery, may be warranted.

"The treatment of kidney stones has become increasingly refined and less invasive," says Brian Matlaga, M.D., M.P.H., Director of Stone Disease at Johns Hopkins Bayview Medical Center. "And for some patients, treatment is advancing to the point where we can dispense with other methods altogether and instead effect kidney stone passage with medication." A recent review in The Lancet found that kidney stone patients given alpha-blockers or calcium channel blockers were 65% more likely to pass their stone than patients who didn’t take these medications.

Alpha-blockers and calcium channel blockers are commonly used to treat hypertension, but both drugs also appear to flush out kidney stones by relaxing the ureter and increasing liquid pressure. Dr. Matlaga recommends alpha-blockers rather than calcium channel blockers because the former have fewer side effects. "Rarely, patients may report light-headedness, which resolves once the medication is discontinued. Calcium channel blockers are associated with more side effects, such as a drop in blood pressure when standing up and cardiac effects."

There is a catch. All but one of the trials reviewed in The Lancet examined patients with kidney stones in the distal ureter -- the part of the ureter nearest the bladder. According to Dr. Matlaga, if your kidney stone is nearer the kidney, other treatments may still be necessary. How long will you take medication? "In most cases, my patients try medical therapy for up to a month. If the kidney stone has not passed in that time, surgical removal allows the patient to rid themselves of the kidney stone definitively and get on with life," says Dr. Matlaga.

For more Alerts and Special Reports, please visit the Healthy Living Topic page.

Johns Hopkins Health Alerts | Healthy Living After 50 | Therapy for Kidney Stones

Testosterone for Women

Wed, 18 Apr 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 | Women and Testosterone Replacement Therapy

If a woman’s sexual problems are biological rather than psychological, testosterone therapy may help.

Men may have grabbed the sexual spotlight with Viagra (sildenafil citrate) and erectile dysfunction (ED), but women are equally prone to have concerns about their sex lives. While there may not be a woman’s equivalent to Viagra, if you are concerned about sex, take comfort in knowing that you are not alone. Upwards of 43% of women report some degree of dissatisfaction with their sexual health -- and help is available.

Experts believe that in women, the physical aspect of desire is governed by the male sex hormone, testosterone. Men and women produce both sex hormones, though not in equal amounts. By menopause, a woman produces 50% as much testosterone as she did in her 20s. The loss of testosterone occurs gradually over many years and is unrelated to menopause; however, its impact on desire becomes most evident around menopause, when estrogen production drops off completely. Many experts believe that boosting women’s testosterone levels will improve their libido.

The International Journal of Impotence Research recently reviewed 12 trials comparing testosterone replacement with placebo in postmenopausal women taking estrogen and concluded that testosterone therapy stimulates sexual desire and improves sexual satisfaction. The North American Menopause Society (NAMS) has come to similar conclusions and recommends testosterone to treat hypoactive sexual desire disorder (HSDD).

Currently, though, the only testosterone product approved by the FDA for women is Estratest, a combination of estrogen and methyltestosterone (a type of testosterone that can be taken orally). It is approved only to relieve hot flashes. Still, many doctors prescribe the treatment “off-label” -- outside of its FDA-approved use -- for low desire. Testosterone products approved for men also are sometimes prescribed off-label for women. Less commonly, doctors may use testosterone injections.

The FDA is reviewing the long-term safety of Intrinsa, a testosterone skin patch available in Canada and Europe made specifically for women. There are some safety concerns with long-term testosterone use. A large epidemiological study of postmenopausal women published in the Archives of Internal Medicine reported an association between an increased risk of invasive breast cancer and the use of testosterone and estrogen. NAMS recommends women use testosterone along with estrogen, as it is used in most clinical trials, but that they use it for no more than six months.

Despite these concerns, Leonard DeRogatis, Ph.D., Director of The Center For Sexual Medicine at Sheppard Pratt and a Hopkins faculty member says, “It is highly unlikely that testosterone contributes to breast cancer.” The biggest problem with transdermal (through the skin) versions of testosterone is the potential for facial hair growth and transient acne. In severe instances methyltestosterone can cause liver toxicity, but these effects can be avoided by careful monitoring. “The testosterone patch is probably the most effective delivery system; however, it is not yet available in the United States,” says Dr. DeRogatis.

Although Dr. DeRogatis believes that women will someday benefit more fully from testosterone, he says they should expect to see effective nonhormonal therapies for HSDD in the future: “Some are in the making and development is likely to be pushed along as a result of women beginning to demand more options to improve their sex life.”

Taken from the March 2007 issue of the Johns Hopkins Medical Letter: Health After 50. For more information about Health After 50, please go to the BOOKSTORE.

Johns Hopkins Health Alerts | Healthy Living After 50 | Women and Testosterone Replacement Therapy

Exercise and Cancer Update

Wed, 09 May 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Exercise and Cancer Update

New research points to the benefits of exercise as a weapon against cancer.

For cancer patients who are undergoing chemotherapy, exercise is one of the best ways to combat treatment-related fatigue. “It’s not recommended that you begin an intense, new exercise regimen while undergoing chemotherapy, but if you exercised before your cancer diagnosis, try and maintain some level of activity,” says Deborah Armstrong, M.D., Associate Professor of Oncology, Gynecology, and Obstetrics at Johns Hopkins, “If you haven’t been exercising, try low-level exercise, such as walking or swimming.”

Several groundbreaking studies suggest that exercise doesn’t just help combat treatment-related fatigue ¬for cancer patients, it may help fight against cancer. And obsessive exercise isn’t needed to see a benefit. Depending on the intensity of the activity, you may need to exercise only a few hours a week.

Researchers measured how much energy exercisers expended in metabolic equivalent task (MET) hours. One MET hour is the equivalent of the energy expended by the body during one hour of rest. You can rack up several MET hours of exercise during one “real-time” hour. For example, one hour of moderate walking is the equivalent of three MET hours and one hour of doubles tennis or slow jogging is the equivalent of five MET hours.

The first study, published in the Journal of the American Medical Association, followed 2,987 women with breast cancer. Women who exercised more than three MET hours a week after their cancer diagnosis were less likely to die of their breast cancer.

In another study of 573 women with colon cancer, women who exercised more than 18 MET hours a week after their colon cancer diagnosis were 61% less likely to die of cancer-specific causes than women who exercised less than three MET hours a week. And exercise was protective no matter the patient’s age, stage of cancer, or weight. Furthermore, patients benefited even if they hadn’t been physically active before their colon cancer diagnosis.

A third study, in the Journal of Clinical Oncology, found similar results after examining the effects of exercise on 832 men and women with stage III colon cancer.

How does exercise help? In the case of chemotherapy, Dr. Armstrong suspects that exercise may increase the body’s ability to recover from the effects of chemotherapy. Researchers also theorize that exercise can regulate production of certain hormones that, unregulated, may spur tumor growth.

Healthy Living Topic page.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Exercise and Cancer Update

The Ins and Outs of Outpatient Surgery

Wed, 14 Feb 2007 06:00:00 CST

Johns Hopkins Health Alerts | Healthy Living After 50 |

Outpatient Surgery

Serious complications of outpatient surgery are rare, but it’s important to be prepared.

Research shows that most outpatient procedures are safe and effective, but there are important differences among outpatient facilities that may make one type of facility a better -- and safer—option for your surgery.

Simple surgery, like hernia repairs or cataract surgery, are the most common outpatient procedures, but the widespread use of less invasive technologies has resulted in more complicated operations being performed on an outpatient basis. Outpatient hysterectomies, laparoscopic colon surgery, and gastric bypass surgery, for example, are now done through tiny keyhole incisions in the abdomen. With smaller incisions; less operating time, bleeding, and risk of infection; and shorter recovery periods, patients may leave the facility the same day of their surgery.

Outpatient procedures are performed at one of three locations: outpatient hospitals, ambulatory surgery centers, and doctors’ offices. Outpatient hospitals are affiliated with, and usually directly attached to, a major hospital. Surgeons and medical staff are hospital employees and the outpatient facility has access to hospital administrative and medical resources, including the hospital’s wide range of specialists.

In contrast, ambulatory surgery centers are privately owned, freestanding surgical facilities. Many ambulatory surgery centers are dedicated to one surgical specialty, such as eye or orthopedic surgeries. Most are staffed with board-certified surgeons and nursing staff. Although your ambulatory surgery center’s surgeon may also be affiliated with a hospital, the ambulatory surgery centers and hospital may not be directly affiliated.

Your surgeon will help you determine if the ambulatory surgery center or the hospital is a better choice for your procedure. Since 85% of ambulatory surgery centers receive Medicare funds, most are frequently inspected by the federal government and subject to the same stringent federal requirements as any hospital; however, because the ambulatory surgery center is not affiliated with a hospital, the staff may not be “on call.” Moreover, if you develop complications and require emergency services or hospital admittance after your operation, hospital staff may have difficulty getting information from the ambulatory surgery centers as quickly as they could from an affiliated outpatient facility.

Your doctor will also help you determine where to schedule your surgery. Keep in mind that your surgeon’s schedule may impact the decision. You may want to meet with your surgeon beforehand to discuss any health concerns. Finally, you can check the accreditation and safety records of your intended facility at:

American Association for the Accreditation of Ambulatory Surgery Facilities Phone: (888) 545-5222 www.aaaasf.org

Joint Commission of Accreditation of Healthcare Organizations Phone: (630) 792-5000 www.jointcommission.org

Accreditation Association for Ambulatory Health Care Phone: (847) 853-6060 www.aaahc.org

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Johns Hopkins Health Alerts | Healthy Living After 50 |

Outpatient Surgery

New Weapon Against Psoriasis

Wed, 24 Jan 2007 06:00:00 CST

Johns Hopkins Health Alerts | Healthy Living After 50 |

Biologic Therapies for Psoriasis

Should you try Remicade, Enbrel, or one of the other new biologic therapies for psoriasis?

In the past few years, there has been a surge in new treatments for psoriasis. These new psoriasis treatments include biologic therapies, which use portions of the body’s natural immune system to treat a disease. Since 2003, four biologic therapies that target immune system cells and chemicals implicated in psoriasis have been approved for moderate to severe psoriasis. These drugs are Amevive (alefacept), Enbrel (etanercept), Remicade (infliximab), and Humira (adalimumab). In addition, Embrel, Humira, and Remicade are also approved for psoriatic arthritis.

Normally, skin cells mature and are shed from the skin’s surface every 28 days. In psoriasis, however, skin cells mature every three to four days. As a result, they pile up on the skin surface and form the visible lesions of psoriasis: patches of reddish skin covered with silvery scales. It is now clear that an abnormal immune response spurs the overproduction of skin cells by activating T cells, white blood cells that normally protect the body against infection. Once activated, the T cells migrate into the skin and release cytokines -- chemicals used by the immune system to communicate messages. In psoriasis, cytokines induce skin cells to reproduce and mature at an accelerated pace.

Improved understanding of the underlying causes of psoriasis has led to new biologic therapies that specifically target immune factors implicated in psoriasis. For example, Amevive and Raptiva target the activated T cells that stimulate overproduction of skin cells, while Enbrel, Remicade, and Humira home in on cytokines. The biologic psoriasis therapies can often produce a rapid, dramatic improvement in people who have failed to respond to the older psoriasis therapies. Remicade and Humira are FDA approved for only psoriatic arthritis, but your doctor can prescribe them “off-label” for psoriasis if he or she believes they will help. A large controlled trial published in The Lancet showed that Remicade was highly effective in severe psoriasis, including difficult-to-treat nail disease. After 10 weeks, 80% of patients taking Remicade had achieved at least a 75% improvement, compared with 1% of those in the placebo group.

Although the biologics are more precisely targeted than older immunosuppressive therapies, they are not risk free. They may raise the risk of serious infections such as tuberculosis, and little is known about possible long-term side effects. They are also quite expensive, and health insurance coverage is individualized -- some plans offer full coverage, while others are very restrictive. In addition, because not everyone responds to all the biologics, a trial and-error approach is usually necessary to determine which drug is most effective in a particular patient. Yet biologic therapies have produced excellent results in cases of psoriasis that were not adequately controlled by traditional psoriasis medications. Thus, if you have moderate to severe psoriasis, you might want to ask your dermatologist whether you might benefit from one of the new biologics.

For more Alerts and Special Reports, please visit the Healthy Living Topic page.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Biologic Therapies for Psoriasis

Are You Thirsty Yet?

Fri, 29 Dec 2006 06:00:00 CST

Johns Hopkins Health Alerts | Healthy Living After 50 |

Warning Signs of Dehydration

Dehydration can sneak up on you, especially during exercise. Here's advice to help you get the 48 ounces of liquid you need, today and every day.

Thirst is the body’s way of telling you that you need more fluids. Water is required for virtually every bodily function, from respiration to the most minute biochemical reaction. However, the thirst response system diminishes as we age; older people may not feel thirsty even as dehydration sets in.

This was illustrated in a clinical trial that compared the fluid intake of men aged 51–60 with that of men aged 20–28 after a strenuous, 10-day hill walking trip. As reported in the Journal of Applied Physiology, the older men experienced less thirst and became progressively dehydrated while the younger hikers kept drinking plenty of fluids.

The age-associated risk of dehydration may be attributable to age-related diseases, such as kidney disease, diabetes, and thyroid disorders. All these conditions can cause the body to excrete more water and increase the risk of dehydration. Older people also are more likely to take medications that cause dehydration. These include antihypertensives, such as diuretics and angiotensin-converting enzyme (ACE) inhibitors, and antipsychotic drugs and cholinesterase inhibitors, which are used to treat Alzheimer’s disease and other dementia-related illnesses.

Researchers at Tufts University have devised a food pyramid for older people which recommends at least eight 6-oz. servings (48 oz.) of any liquid per day. Hydration can therefore come from a variety of sources, including fruit or vegetable juice, nonfat milk, and low-sodium soup. Even coffee, tea, beer, wine, or mixed-alcohol drinks are acceptable in moderation, since all contain large amounts of water. Drinking straight hard liquor, on the other hand, can cause dehydration and is not recommended. Many fruits and vegetables, such as watermelon, berries, grapes, peaches, tomatoes, and lettuce, are almost 100% water. Even meat is chock full of water. Water from foods typically accounts for 20% of your recommended total fluid intake.

Most people get enough water from the foods and drinks they enjoy without having to worry about dehydration, but certain situations call for more care. Instances where you should increase your fluid intake beyond the recommended eight servings to avoid dehydration include:

While you exercise. For an hour of light to moderate exercise, 2–3 cups of fluid are recommended to stave off dehydration.

If it is unusually hot. You will naturally lose more fluid and will require extra replenishing.

If you’re constipated. Increasing fluid intake adds moisture to the large intestine, which helps your body eliminate waste. Also, laxatives can cause dehydration.

If you’re prone to urinary tract infections and kidney stones. Fluids may prevent urinary tract infections and stop kidney stone formation.

If you’re sick. High fever, vomiting, and diarrhea can cause rapid dehydration, a condition that can be life threatening.

Warning signs of dehydration: If you notice that you’re urinating less than usual or if you don’t feel thirsty very often, check the color of your urine. It should be the color of straw if you are properly hydrated. If it’s much darker, it’s a sign that you need more fluids. Other warning signs of dehydration include dry mouth, decreased salivation, dizziness, sunken eyes, rapid pulse, and a loss of skin elasticity.

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Johns Hopkins Health Alerts | Healthy Living After 50 |

Warning Signs of Dehydration

Ask the Doctor About Flaxseed and Triglycerides

Tue, 31 Oct 2006 06:00:00 CST

Johns Hopkins Health Alerts | Healthy Living After 50 |

Flaxseed and Triglycerides

Johns Hopkins doctors explain the risks and benefits of consuming flaxseeds and other foods high in omega-3 fatty acids to improve your cholesterol profile.

Q. I take ground flaxseed to help control my cholesterol. But I read that the alpha-linoleic acid (ALA) in flaxseed increases the risk of prostate cancer. Is this true? Does the risk differ between ground flaxseed and concentrated flaxseed oil in capsules?

A. No real evidence has yet emerged to support the idea that ALA in flaxseed increases the risk of prostate cancer. According to a study in the Journal of Nutrition, however, "The association between high intake of ALA and prostate cancer is of concern and warrants further study."

ALA, an omega-3 fat similar to the fat in fish, is heart-healthy. Flaxseeds are one of only a few foods that provide ALA. Others are canola oil (from rapeseed), walnuts, and soybeans. Flaxseeds also contain compounds called lignans, which are thought to have anticancer effects. An article in The Journal of Urology reviewed 11 studies of ALA and prostate cancer. Some studies did suggest an association, but the researchers found the evidence unconvincing. They called for more research but emphasized that it was too early to make any recommendations.

Flaxseeds (in capsule or ground form), canola oil, soy, and walnuts can be part of a healthy diet—and their heart benefits are not in question. But don't go overboard: Very small amounts of these foods (one tablespoon of flaxseed or 1/2 oz. of walnuts daily) are enough to produce a beneficial effect. And for now, experts believe that flaxseed will not increase your risk of prostate cancer or worsen prostate cancer if you have it.

Q. How can I lower my triglycerides?

A. Like cholesterol, triglycerides are a type of naturally occurring lipid, or fat, present in the blood—and elevated levels of triglycerides increase your risk of heart disease. A desirable level of triglycerides is less than 150 milligrams per declilter (mg/dL), As numbers increase beyond that level, so does heart disease risk. Very high triglyceride levels—over 500 mg/dL— may predispose you to pancreatitis.

Treatment for high triglycerides is similar to general cholesterol treatment. Eating foods high in omega-3 fatty acids can help lower your triglyceride level. Fatty fish, like salmon, mackerel, and herring, are good sources, as are certain vegetable oils, nuts, and soy products. Also try cutting down on alcohol and sugary and starchy foods. Regular aerobic exercise and cutting calories help to lower triglyceride levels. If you smoke, quitting may improve both your triglyceride and total cholesterol levels.

If you can't get your triglycerides down on your own, your doctor may suggest fibrates, like gemfibrozil (Lopid) or fenofibrate (Lofibra, Tricor), which lower triglycerides while building up helpful HDL cholesterol. Or your doctor may prescribe a statin by itself or with a fibrate, although the risk of side effects rises with this combination. Niacin also lowers triglycerides, although it can affect glycemic control if you have diabetes.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Flaxseed and Triglycerides

Sunscreen Protection Basics

Thu, 29 Jun 2006 10:42:33 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Sunscreen Protection Basics

Taking steps to prevent melanoma – the least common and most deadly form of skin cancer

Summer is here, which means it's time to take extra precautions against the sun's harmful effects --particularly UVA and UVB rays. The experts at Johns Hopkins want everyone to understand the difference between UVA and UVB rays, as well as how to choose the right kind of sunscreen and use it correctly to protect yourself from skin cancer.

UVA is strongly associated with tanning, wrinkles, and melanoma (the most serious form of skin cancer). UVB is closely associated with sunburn and basal and squamous cell carcinoma (two other types of skin cancer). Although it is not known how sun-associated skin damage occurs, some researchers think that UV (ultraviolet) rays attack the body’s immune system and increase the production of enzymes that break down collagen, a protein in the connective tissue located underneath the dermis (the layer of skin below the outer layer, or epidermis). Whether you're fair-skinned and freckly or dark-skinned and not prone to burning easily, it’s important to take precautions. Here's what you need to know to protect yourself against skin cancer.

Sunscreen basics

UVB rays are more intense during the summer and cause tans and sunburns. UVA rays are the same intensity year-round and unlike UVB rays, penetrate deep into the skin's layers. For maximum sun protection against the risk of skin cancer, your sunscreen should block both UVB and UVA rays.

Always look for an SPF (sun protection factor) against UVB rays of 15 or higher.

Read the product label to check whether your sunscreen is formulated to block UVA rays. Look for terms such as full spectrum, broad spectrum, and UVA protection on the sunscreen lotion. Also look for titanium dioxide or zinc dioxide in the ingredient list. Better yet, make sure the ingredients include the chemical blocker Parsol 1789 (avobenzone).

Avoid direct sunlight between 10 a.m. and 4 p.m. Seek the shade; wear a wide-brimmed hat, long sleeves, and long pants. And don't forget to wear sunglasses as UVB rays can sometimes cause cataracts.

Apply sunscreen 15 to 30 minutes prior to sun exposure -- even on cloudy days. Remember to apply sunscreen liberally to your ears, hands, toes, and lips. Reapply regularly.

And don't worry about a vitamin D deficiency. You get enough UV light through incidental exposure, like walking to your car, for your body to manufacture adequate vitamin D. So there's no excuse for skimping on sunscreen. Rub on sunscreen liberally and enjoy those hot, sizzling months smartly.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Sunscreen Protection Basics

4 Healthy Living Updates on Erectile Dysfunction, Exercise and Dementia, and more!

Thu, 30 Nov 2006 06:00:00 CST

UPDATE

As part of our ongoing effort to ensure that this website is up to date, we have determined that the information in the article 4 Healthy Living Short Takes is no longer current, and has therefore been removed.

If you would like to read related articles about healthy living, please go to the Healthy Living topic page. Thank you.

Taking Control of Vertigo

Fri, 29 Sep 2006 11:28:55 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Symptoms of Vertigo

If you have ever had an attack of dizziness, you know how frightening it can be. Almost everybody has felt faint, but many people experience a spinning or falling sensation—vertigo—and attacks may recur. Vertigo is often caused by problems with the body’s sense of balance.

Your body uses three kinds of information to determine balance: visual, tactile, and internal signals from the vestibular structure in the inner ear, which acts as the body’s “level.” Fluid moves through the vestibular structure, bending tiny hairs that send signals to the brain. Several conditions can throw the vestibular structure off balance, such as migraines or inner ear infections. Dizziness or vertigo can also be the first symptom of a stroke or other disorders, or it may be a side effect of some medications, particularly high blood pressure drugs such as angiotensin-converting enzyme (ACE) inhibitors. (You will need medical advice to rule these out.)

Often, however, vertigo is caused by some malfunction of the vestibular structure, including a condition known as benign paroxysmal positional vertigo (BPPV). This occurs when calcium carbonate crystals inside the vestibular structure break down and collect inside the semicircular canals. BPPV is the most common type of vertigo, with over 50% of people in their 70s experiencing at least one episode of vertigo.

Many people put off going to a doctor after suffering an attack of vertigo. But according to Lloyd Minor, M.D., Director of the Laboratory of Vestibular Neurophysiology at Johns Hopkins, “It’s not normal to have spontaneous episodes of vertigo, so it’s reasonable to get an evaluation after one occurs.” Your doctor may refer you to an otolaryngologist (ear and throat specialist). Once you discover the exact cause of your vertigo, you can start on a course of treatment, which usually consists of vestibular rehabilitation exercises supervised by a physical therapist.

Did You Know? Here Are Some Healthy Living Short Takes to Help You Maintain Your Health.

Tue, 01 Aug 2006 11:21:46 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Healthy Living Tips to Help You Maintain Your Health.

Read these healthy living tips on saving teeth enamel, alternative therapy for stress incontinence, and overactive bladder.

Healthy Living Short Take #1: Saving your tooth enamel. Acidic foods and drinks such as fruit juice, soft drinks, pickles, yogurt, and wine can soften tooth enamel for a short time. Brushing while enamel is soft can wear away this protective coating and make your teeth more vulnerable to decay. Saliva restores the pH balance in the mouth but it can take longer to work after acidic foods or several soft drinks are consumed. The Academy of General Dentistry suggests chewing sugar-free gum to stimulate saliva flow or rinsing your mouth with water for 30 seconds after eating a heavily acidic meal.

Healthy Living Short Take #2: Alternative therapy for stress incontinence. Although surgery is the most effective treatment for stress urinary incontinence (leakage caused by a cough or exertion), collagen injections may be a better option for women with health problems or commitments that preclude a lengthy convalescence. After one year, the success rate of collagen was 19% lower than that of surgery, but immediately following treatment, women who received collagen were happier with their treatment, perhaps owing to fewer side effects: 63% of women reported at least one side effect after surgery compared with 36% of women who received collagen.

Healthy Living Short Take #3: Overactive bladder. Contrary to popular belief, the bladder does not shrink with age. Researchers found that there was no difference in the bladder capacity of 90 women between the ages of 22 and 90. The results suggest that the increased need to urinate as you get older may be caused by overactive bladder, a condition linked to aging in which bladder muscles go into spasm before the bladder has completely filled. Overactive bladder can be treated with bladder retraining exercises, less fluid intake, and medications.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Healthy Living Tips to Help You Maintain Your Health.

Cancer Prevention -- Protecting Your Bladder

Thu, 31 Aug 2006 10:36:40 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Reduce Your Risk for Bladder Cancer

Bladder cancer is common, it is a major public health concern, and it is strongly linked to cigarette smoking.

Bladder cancer isn’t nearly as well known as lung cancer, but it should be: Bladder cancer is common, it is a major public health concern, and it is strongly linked to cigarette smoking.

Most people diagnosed with bladder cancer are aged 60 or older. Carcinogens in the urine increase the risk of bladder cancer. Cigarette smoking is strongly implicated; other risk factors for bladder cancer include chronic bladder infections and treatment with cyclophosphamide (a chemotherapy medication). People regularly exposed to hair dyes in their occupation (such as hair dressers) are at increased risk for bladder cancer, but no association has been proved for people who dye their hair.

You can take these steps to lower your risk of bladder cancer:

Don’t smoke. Smokers and former smokers (the risk never declines to completely normal) are more than twice as likely to develop bladder cancer as people who have never smoked. It is thought that cancer-causing compounds in tobacco smoke are absorbed into the blood and eventually collect in the urine, where they damage the cells lining the bladder. However, giving up cigarettes does not seem to produce as dramatic a drop in risk for bladder cancer as for lung cancer and heart disease.

Drink enough fluid. Adequate intake of water and other fluids promotes urination and help to flush carcinogens from the bladder. The American Cancer Society recommends drinking several glasses of water or other nonalcoholic beverages a day.

Eat plenty of cruciferous vegetables. A diet that routinely includes several weekly servings of broccoli, cabbage, cauliflower and other cruciferous vegetables appears to be protective.

Limit exposure to workplace chemicals. Chemicals used in the making of dyes, rubber, leather, textiles, printing materials, and paint products have been implicated in bladder cancer.

Treat bladder infections. People with chronic or frequent infections have higher rates of bladder cancer than those who are not prone to such infections.

Johns Hopkins Health Alerts | Healthy Living After 50 |

Reduce Your Risk for Bladder Cancer

Varicose Veins—Now You See Them, Now You Don't

Wed, 31 May 2006 10:27:49 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 |

Reduce Risk of Varicose Veins

Only a surgical procedure or sclerotherapy (injection of a special solution to shrink the vein) can eliminate varicose veins.

Varicose veins are distended, bulging blood vessels that are typically located on the inside of the legs and the back of the calf. Many older adults are embarrassed to show their legs because of varicose veins or smaller dilated capillaries (spider veins) that lie closer to the skin surface, thinking that they are unsightly. Though some spider veins and varicose veins pose primarily a cosmetic problem, they can also cause severe leg discomfort with symptoms such as burning, swelling, cramping, and leg fatigue. More serious problems, such as blood clots, may also occur if varicose veins are left untreated.

Although certain predisposing factors for varicose veins such as age, heredity, and gender cannot be changed, you can take several practical steps to help reduce your risk for varicose veins:

Exercise regularly, including walking, jogging, bicycling, and swimming, to improve blood circulation in your legs and help prevent pooling.

Reduce your weight if you are overweight.

Wear low-heeled shoes and avoid tight-fitting clothes.

Elevate your legs above your heart several times a day by lying on your back and resting your feet on some pillows.

Avoid prolonged periods of sitting or standing, and move your legs frequently.

Periodically flex your ankles to help pump blood out of the legs.

All of these measures can also help keep existing spider or varicose veins from getting worse. In addition, wearing elastic support stockings, which compress the veins and help move blood more efficiently, can keep excess fluid from seeping out of the veins and pooling in the lower legs and ankles.

None of these steps, however, can eliminate varicose veins—only a surgical procedure or sclerotherapy (injection of a special solution to shrink the vein) can do that. If you are troubled by the appearance of varicose veins or spider veins or are experiencing symptoms, consult your doctor about the most appropriate treatment, which can usually be performed in a doctor’s office or a hospital outpatient setting.
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Johns Hopkins Health Alerts | Healthy Living After 50 |

Reduce Risk of Varicose Veins

Using Acetaminophen -- A Fine Line Between Safe And Harmful

Mon, 17 Apr 2006 13:52:56 CDT

UPDATE

As part of our ongoing effort to ensure that this website is up to date, we have determined that the information in the article Using Acetaminophen -- A Fine Line Between Safe And Harmful is no longer current, and has therefore been removed.

If you would like to read related articles about healthy living, please go to the Healthy Living topic page. Thank you.

Living Longer Through HDL Cholesterol

Mon, 17 Apr 2006 21:24:35 CDT

Johns Hopkins Health Alerts | Healthy Living After 50 | Boosting HDL Cholesterol to Live Longer

Now there is intriguing evidence that having a high HDL level can even boost a person’s overall longevity.

You’ve heard how important it is to maintain a high level of high density lipoprotein (HDL, or “good”) cholesterol to protect yourself against heart disease and stroke. And recent research suggests that a healthy HDL level may also be key to warding off Alzheimer’s disease. Now there is intriguing evidence that having a high HDL level can even boost a person’s overall longevity.

The very protective HDL cholesterol is one component of the lipid profile—a group of tests that is often ordered to determine a person’s risk of coronary heart disease. Other components include total cholesterol, low density lipoprotein (LDL, or “bad”) cholesterol, and triglycerides. HDL exerts its good effects on the heart by removing dangerous fats from the blood vessel walls, thereby reducing the risk of atherosclerosis.

Research recently published in the Journal of the American Medical Association determined that many people who live exceptionally long, healthy lives—average age of study participants was 98 years—share a particular gene mutation that leads to higher levels of HDL cholesterol as well as larger particles of HDL and LDL cholesterol than those seen in the general population.

It has been suggested that larger LDL particles may be protective against cardiovascular disease because such large particles cannot readily penetrate the walls of arteries and contribute to atherosclerosis. The gene mutation responsible for high HDL levels and bigger HDL and LDL particles appears to protect against many chronic diseases associated with aging, such as heart disease, stroke, and diabetes.

Although we are not all lucky enough to inherit the “longevity gene,” there is much that we can do to raise our HDL level on our own—and perhaps increase our odds for a longer and healthier life. The American Heart Association and the American Diabetes Association currently recommend that HDL levels be above 40 mg/dL for men, and an HDL of above 50 mg/dL for women. However, the greatest benefits seem to come when a person’s HDL level is over 60 mg/dL.

If your HDL is below these levels, there are numerous lifestyle changes you can make to help raise it. These include quitting smoking, exercising regularly, losing excess weight, and, in your diet, replacing trans fatty acids (found in margarines and many baked goods) with healthier monounsaturated fats, such as olive oil and canola oil, because they can help preserve HDL levels. If lifestyle changes alone are insufficient to raise your HDL level, there are several medications you can add to help improve your HDL level, and more are being tested in clinical trials.

Johns Hopkins Health Alerts | Healthy Living After 50 | Boosting HDL Cholesterol to Live Longer