Are Doctors Short on Empathy?

By Dena Rifkin, MD

A number of news outlets have picked up an article, published in last week’s Archives of Internal Medicine, which suggests that physicians “miss” opportunities to express empathy and compassion in discussions with cancer patients. The researchers noted 384 “empathetic opportunities,” but only about 10% of those received an empathetic response.
The article was fascinating, but I think the press coverage was a bit overstated. The study looked at less than 30 interactions at one medical center, but generated headlines such as: “For Some Doctors, Empathy Is in Short Supply.” Read More

Most Patients Don’t Want to See Me

By Dena Rifkin, MD

I’m the only person in my immediate family who works in the medical profession. And when I visited with my extended family last weekend, I was reminded of how much they dislike even thinking about medicine.

My older relatives have reached their 70s with relatively few health problems and only see doctors when absolutely necessary. To them, doctors take up valuable time, poke and prod them in uncomfortable ways, and (worst of all) have the potential to deliver bad news. My relatives don’t understand why I would want to do those sorts of things all day long. Read More

When Doctors Don’t Have All the Answers

By Dena Rifkin, MD

I recently ran into a colleague who was returning from an internal medicine review course. These expensive and elaborate affairs consist of a week or so of lectures, tips, and new techniques, usually taught by well-known academics. Many doctors take these courses before taking the medical board exam in their specialty, and some doctors repeat the course every few years, to keep up with new developments or prepare for recertification exams. To be “board-certified” in a specialty, doctors must take exams every 10 years, so I’ll be attending a course next week to review kidney diseases.

A key part of the course is problem-solving. Just like when the audience votes in “Who Wants to Be a Millionaire,” the 400 doctors in the room press buttons to answer multiple-choice questions. The number of people who give each answer is displayed on a big screen. Read More

Saying Good-Bye to Patients

By Dena Rifkin, MD

Next month I’ll be finishing the final year of my fellowship in kidney disease and transitioning into my new role as attending physician, with mainly in-hospital rather than outpatient responsibilities. So I’m saying good-bye to some patients I’ve been seeing in clinic for the past two years.

These patients won’t be left scrambling to find a new doctor. The attending physician who followed them for years before I showed up, and who supervised me, will see them from here on, albeit with another fellow. This pattern repeats itself every two or three years in our clinic. Read More

Doctor-Patient Talks Affect Use of Breast Reconstruction Surgery

(HealthDay News) -- A lack of patient-doctor discussion may contribute to socioeconomic, age and race-related disparities in the use of breast reconstruction after mastectomy, says a study by researchers at Brigham and Women's Hospital and the Dana-Farber Cancer Institute in Boston.

The study also found that breast reconstruction was more likely to occur after a surgeon discussed options with a patient, which suggests the need to increase and improve these conversations, the researchers said.

They analyzed data on 626 patients who underwent mastectomy for breast cancer. Of those patients, 253 (40.4 percent) received breast reconstruction, and 249 (39.8 percent) had a documented discussion about the option with a doctor.

About 70 percent of those who had a discussion about breast reconstruction had the procedure. But the researchers found that increasing age and lower levels of education were associated with lower rates of a documented discussion. Hispanic patients, those born outside of the United States, and those whose primary language wasn't English were less likely to undergo reconstruction after discussing it with a doctor.

The study was published in the April issue of the Journal of the American College of Surgeons.

The decision to have breast reconstruction is a complex one that's influenced by access to care, patient preference and a doctor's interaction with the patient, the researchers noted.

"Patient preferences should be respected, but an informative discussion of reconstruction is required to help patients understand and weigh the risks and benefits of this procedure," Dr. Caprice C. Greenberg, Instructor of Surgery in the Center for Surgery and Public Health at Brigham and the Center for Outcomes and Policy Research at Dana Farber, said in a prepared statement. "We learned that physicians need to improve communications with all women undergoing a mastectomy, regardless of age, race or socioeconomic status."

She and her colleagues said doctors should systematically address the issue of breast reconstruction with all patients undergoing mastectomy. Doctor-patient discussions could include interpreters and educational materials to ensure an informative discussion regardless of a patient's primary language, ethnicity or education level.

More information

Will We Soon Be Storing Our Medical History on Facebook-Like Pages?

That’s what some big companies believe. I’m not so sure
by Scott Mowbray

Count me skeptical about the Microsoft and Google forays into personal medical information storage. The idea is good: We travel through life throwing off data about our health, which scatters like dust into doctor’s computers, hospital computers, HMO computers, and pharmacy computers. That data should be organized into a personal profile and accessible—like a password-protected Facebook page—but right now the computers don’t talk to each other.

Worst case, a doctor has to make an urgent treatment decision without knowing some very recent, possibly live-saving medical history (see “My Patient Can’t Tell Me Where It Hurts”). In the future, the data optimists say, all the important information will be available through a secure link, and the patient grants access (or, if he’s unconscious, has presumably worked it out ahead of time). Continue reading »

Prostate Cancer Treatments Often Compound Existing Health Problems

(HealthDay News) -- More than a third of prostate cancer patients may receive treatments that are inappropriate because of problems they are already having with urinary, bowel or sexual function, a new study suggests.

These mismatches might occur, because patients don't give enough information to their doctor or because their doctor favors a particular type of treatment, according to the report in the Nov. 26 online edition of Cancer.

"We found an awful lot of patients whose treatment seemed to be contraindicated by urinary, bowel or sexual problems they had before they got treated," said lead researcher Dr. James Talcott, from the Center for Outcomes Research at Massachusetts General Hospital Cancer Center in Boston. "That's pretty good evidence that information wasn't transmitted or didn't factor in with the treatment decision."

Unlike other cancers, there are several treatment options for prostate cancer. The treatment that is best for an individual patient is based on several factors, including stage at which the cancer is diagnosed, age of the patient, and existing problems with urinary, bowel or sexual function that the patient has.

Treatments include external radiation therapy; brachytherapy, in which tiny radioactive particles are implanted into the prostate gland, and the surgical removal of the prostate gland.
Although these treatments are effective, each has a different set of side effects. External radiation can lead to bowel dysfunction, brachytherapy can cause urinary problems, and surgery can damage nerves involved in sexual function.

Treating patients who already have problems in these areas with a procedure that could exacerbate their problem is usually not recommended.

For example, treatment designed to preserve normal functions, such as nerve-sparing, prostate-removal surgery, is not appropriate for patients who have already lost sexual function, Talcott said.

To find the extent of treatment mismatches, Talcott's team collected data on 438 prostate cancer patients. Patients were asked to complete questionnaires that included questions about urinary incontinence and other urinary problems, and bowel and sexual dysfunction.

The researchers found that 89 percent of the patients had some level of urinary, bowel or sexual problem before starting treatment. Among these patients, 34 percent of those with one serious symptom had a mismatched treatment, as did 37 percent who had a less serious symptom. Moreover, 40 percent of those who had several symptoms also received contraindicated therapy.

In addition, among patients with significant dysfunction in all three areas for whom no treatment would be recommended, only 5 percent chose watchful waiting. In this strategy, patients are not treated but are followed closely.

These mismatches appear to occur because doctors and patients don't communicate well. Patients are often reluctant to talk about urinary, bowel and sexual problems, Talcott said. "And, sometimes patients override their doctor's recommendation," he added.

Talcott also thinks that physicians can be wedded to a particular treatment at the exclusion of others. "Surgeons believe in surgery, and radiation oncologists believe in radiation," he said. "That may be part of the problem."

To counterbalance physician bias, patients should get another opinion, Talcott said. "Patients should always get a second consult," he said. "It's a good idea to talk with a surgeon, a radiation oncologist and possible a medical oncologist."

One expert thinks that patients need to make an informed decision about which treatment is best.

"The kind of doctor that you see often predetermines the treatment you receive," said Dr. Durado Brooks, director of prostate and colorectal cancer at the American Cancer Society. "Urologists are much more likely to have a surgical solution, and those who see a radiation oncologist are more likely to have radiation."

Patients need to be well-informed about their condition and the possible treatments and their side effects, Brooks said. "Patients need to arm themselves with as much information as possible about what their treatment options are, and what some of the contraindications of particular treatments are," he said.

Men also need to know what all the treatment options are, Brooks said. "Men need to be aware that, in some cases, depending on their overall medical condition and the stage of their cancer, that it is, at times, appropriate not to have any active treatment," he said. "Watchful waiting is a legitimate option in a significant proportion of men."

"In addition, doctors need to work with their patient to choose the best treatment option, Brooks said.

"If one takes the time to have a discussion, educate the patient and not rush them into a decision, then you may be able to allow them to get past their emotional response and make a more educated, logic-based response," Brooks said.

Brooks noted that because there are so many treatment options in prostate cancer, patients may insist on a particular treatment even though it's not the best choice for them.

"Where treatments are contraindicated in other places in medicine, doctors don't provide a treatment for a patient just because that's what they say they want," Brooks said. "You explain that that treatment is simply the wrong treatment for you, and therefore, we are not going to take that approach."

More information
For more on prostate cancer, visit the American Cancer Society.

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Doctor-Patient Bond Frays After Medical Mistake

(HealthDay News) -- Serious medical errors don't just affect the health of the patient, they can quickly destroy the patient's relationship with his or her doctor, too, experts say.

Too often, a health care mistake causes shame and fear in the physician responsible, leading to stilted, unsatisfying conversations with -- or avoidance of -- the affected patient, say the authors of an article in the Oct. 25 New England Journal of Medicine.

All of this can quickly move patient and doctor into an adversarial or litigious position.

But that's not always necessary, said one of the article's co-authors.

"Trust is an enormously important part of medicine -- if people aren't straight with you, you do not trust them," said Dr. Tom DelBanco, a professor of general medicine and primary care at Harvard Medical School.

"So, being upfront and honest, indicating that you want to do something about what happened, makes all the difference in the world," said Delbanco, who co-wrote the article with Harvard colleague Dr. Sigall Bell.

In many cases, doctors who frankly admitted their mistake and told patients how they would safeguard against future errors avoided litigation by doing so, Delbanco said. Those doctors also maintained strong, long-lasting bonds with the patient and the patient's family.

According to Delbanco, several patients interviewed for the article (and a related film) said that, " 'We don't expect you to be perfect, everybody makes mistakes. We just want you to be honest when it happens. We can deal with that.' "

In fact, "There are now some malpractice [insurance] companies that teach doctors to be honest and open," Delbanco noted. "There is slowly growing evidence that it may actually prevent lawsuits."

Medical errors have gotten a lot more attention recently, ever since the U.S. Institute of Medicine issued its 1999 report, To Err is Human. That report estimated that the deaths of more than 100,000 Americans each year are tied to some form of medical mistake.

In the wake of such errors, doctors often feel shame and guilt, as well as fear linked to the looming threat of lawsuits. For legal reasons, "I think that doctors are very confused about what they can and cannot say" to patients after an error comes to light, Delbanco said. That includes the use of simple words such as "mistake," "error," or even "I'm sorry."

"It depends on their institutions' views, it depends on the lawyers that they may or may not talk to," Delbanco said. "Very often, they are not only confused, but depressed, because they feel like they cannot say what they really feel like saying."

People who care deeply for a patient affected by a medical mistake often shoulder their own level of guilt after the incident. "Family members, in particular, can feel extraordinary guilt," Delbanco said, and often berate themselves, thinking, " 'If I had done this, this wouldn't have happened,' 'If I had been there, I would have prevented it,' 'If only I had been more forceful, the doctor wouldn't have done this.' "

Such was the case for those close to a young man with sickle cell anemia, mentioned in the NEJM article. The unnamed patient received morphine while in the hospital -- despite a well-documented allergy to the painkiller. He slipped into kidney failure and coma soon after, and his sister said she felt as if she "failed her family in terms of 'I should have been there.' That's a guilt that everyone shares."

Doctors who acknowledge that a mistake has happened, and outline steps to prevent such mistakes going forward, can ease a lot of distress for themselves and the patient, experts say.

But, in many cases, physicians have "a lack of confidence in their communication skills -- they just aren't sure how to have these conversations," said Dr. Thomas Gallagher, associate professor of medicine at the University of Washington School of Medicine, in Seattle.

Gallagher said Delbanco's and Bell's article echoes the findings of studies he has led, which revealed profound differences in the ways doctors and patients communicated after a serious medical error.

But he also believes the landscape around medical errors is changing. Already, about 30 states have enacted so-called "I'm sorry" laws, which, to a certain degree, make a doctor's apology for an error inadmissible in a court of law.

That should help ease patient-doctor conversations. But Gallagher said many of these laws still "provide very little protection for clinicians. They allow you to say 'I'm sorry,' but they don't allow you to make any expression that a mistake happened or to admit liability."

And, he said, it's not entirely clear that admitting to mistakes always wards off a lawsuit. "It's not a magic bullet," Gallagher said. "There will clearly be some cases where disclosure is what precipitates a lawsuit."

So, work remains to be done in finding strategies that allow patients and doctors to remain close even after a mistake occurs.

For his part, Delbanco said he is currently screening his film for third-year students at Harvard Medical School -- at the request of the school's dean -- to help them become better physicians. "Traditionally, there's been little coaching in this area," he said. "That's changing."

His advice to patients: If a serious medical error occurs, "be very aggressive in asking for communication. Patients should not be afraid of opening their mouths." And if that communication is not forthcoming, "Ask why and with whom can they speak?" he said.

And a hasty "I'm sorry" from a physician may not always be adequate, Delbanco added.

"Apology only means something when you show what you are going to do for that person -- and for the next person," he said. "Otherwise, they are just words."

More information
There's more on preventing medical errors at the U.S. Agency for Healthcare Research and Quality.

Periodic Health Checkups Boost Cancer Screening Rates

(HealthDay News) -- For people age 50 and older, getting a checkup every year or two may improve the likelihood they'll get the cancer screenings experts recommend, a U.S. study finds.

"Because people go to the doctor anyway when they feel sick or have a medical problem, some authorities have questioned whether preventive, or general, health examinations are worth the extra time and effort," study lead author Joshua Fenton, assistant professor of family and community medicine at the University of California, Davis, said in a prepared statement.

"Our study suggests they are. If people over 50 have checkups every year or two, they're more likely to go ahead and get the cancer screenings they need," Fenton said.

The two-year study, published in the March 26 issue of the journal Archives of Internal Medicine, included over 64,000 patients, ages 52 to 78, who were eligible for breast, colon or prostate cancer screenings. Patients who had a regular checkup during that time were more than three times as likely to get a colon or prostate cancer screening than those who didn't have a checkup. Women who had a checkup were also more likely to be screened for breast cancer.

This difference in screening rates persisted, regardless of how many "illness" visits patients made to doctors during the study. This suggests that doctors may not have time to promote cancer screening when they're assessing a sick patient.

Fenton noted that a recent survey found that 97 percent of primary care doctors said they recommend appropriate cancer screening tests to patients during checkups, but few doctors discuss cancer screening during other types of patient visits.

"The preventive health exam may be an auspicious time to promote cancer screening. These visits may afford primary care physicians the opportunity to discuss and recommend cancer screening when indicated, and physicians' recommendations have been consistently associated with timely cancer screening," Fenton said.

More information
The U.S. National Cancer Institute has more about cancer screening.

Sleeping Pill Wakes Woman After 2 Years in Coma

(HealthDay News) -- A dose of the prescription sleep aid Ambien had the opposite effect on one French woman, awakening her from a two-year coma.

The 48-year-old woman suffered from akinetic mutism -- a sort of persistent coma in which the patient is alert but can neither speak nor move. She had lain in this state after sustaining damage to the frontal lobe of her brain due to a lack of oxygen caused by an attempted suicide by hanging.

But one day she was given zolpidem (Ambien) to treat ongoing insomnia.

"Twenty minutes later, her family noticed surprising signs of enhanced arousal," the study authors wrote. "She became able to communicate to her family, to eat without (swallowing) troubles, and to move alone in her bed. These effects started 20 minutes after drug administration and lasted for two to three hours."

After treatment, the patient could walk for short periods, and to speak if prompted, though not spontaneously. "This phenomenon was so reproducible that caregivers used to give her up to three tablets each day without sleepiness as 'side effect,' " the researchers wrote.

Using positron emission tomography (PET) scans, the researchers found that the drug treatment caused the woman's frontal lobes to become "way more active," noted Dr. James Grisolia, a neurologist at Scripps Mercy Hospital in San Diego. He was not involved in the research, which was led by Dr. Christine Brefel-Courbon, of the University Hospital in Toulouse, France.

Speaking of the case, Grisolia said that, "It is a function of drugs like this that, besides putting you to sleep, they can also increase blood flow. And that activity apparently trumped the sleepiness caused by the medication in this one patient," he explained.

The results are published in the March issue of Annals of Neurology.

"This is a clinical mini-miracle that may give more insight into how the brain works," Grisolia added. "In the long run, it might help us to help other people that are in unresponsive or semi-coma states."

According to Grisolia, other case reports have shown coma patients "awakening" through stimulant medications, but never from a medication like zolpidem. How the drug worked its magic in this case remains unknown. "It needs case reports and further study in the lab to get a handle on this," he said.

Dr. Tetsuo Ashizawa, professor and chairman of the department of neurology at the University of Texas Medical Branch, Galveston, called the report "interesting." But he cautioned against using such a single-patient study as a basis for treating other, seemingly similar cases.

"I understand the desire of the family member to give Ambien to patients" as a result of this study, he said, "but I would not tell them that they should expect improvement. As a physician, I would say this worked in this lady but it may not work in your father or mother, so they should not have unreal expectations. If it works, OK, but if it doesn't, don't be disappointed."
Still, Grisolia said he expects more reports on the effect of zolpidem in akinetic mutism will be published as a result of this study.

"I'm sure that anyone that has a relative who is in a long-term coma is going to be interested in having the doctor try Ambien and see if it makes a difference. So we may get more case reports very quickly," he said.

A spokeswoman for Sanofi-Aventis, the pharmaceutical company that manufactures Ambien, declined to comment on the study.

More information
For more information on zolpidem, visit the U.S. National Library of Medicine.

Researching Alternatives: A Talk With Donald Abrams

By Bob Huff
June 2003
You have a reputation as being a rigorous clinical researcher and tough advocate for making evidence-based treatment decisions.

Yet you've also been very open to studying a number of alternative and complementary therapies that have been used in the HIV patient community. How did all these concerns come together and what are you involved with these days?

I was training in oncology at UC San Francisco just as the first AIDS cases were reported. I helped found the AIDS program there and I've been participating in academic clinical research for over 20 years. More recently I've become an associate fellow of the Program in Integrative Medicine at the University of Arizona that was founded by Andrew Weil.

This is a two-year program, mostly online, that is increasing my training and background in integrative medicine, including things like botanical medicine, manual medicine, and spirituality. It's been a stimulating experience so far and I'm really enjoying it.

I've been interested in complementary medicine since the very beginning of my career, so one of the reasons I'm doing the fellowship is to learn more that I can integrate into my own healthcare discussions with my patients. Of course another impetus is to see what other things we might want to do clinical research on.

My intention is to continue to investigate the complementary and alternative approaches that our patients are using. We want to determine whether or not they may be beneficial, but also determine whether or not they may be harmful, particularly in how they interact with the conventional medications that patients are taking.

In the earliest days of AIDS we didn't have any treatment for this new disease; people were dying and everybody was frightened. Being here in San Francisco, we were near the Linus Pauling Research Institute in Palo Alto, so there were a number of people in the city who were proponents of high doses of Vitamin C.

One of the first responses we saw in the early '80s were storefront clinics opening up where people went to receive intravenous injections of very high doses of Vitamin C.

At that point in time we didn't even know that it was a virus causing the disease. So I used to go around on the lecture circuit with someone who would talk to audiences of concerned people who listened to him while hooked up to intravenous infusions of Vitamin C.

Then I would speak as the academician who cautioned people that we really don't know if this is beneficial and there may be some dangers to being hooked up to intravenous vitamin C, and so on. Ultimately, this led to me to write a grant proposal in collaboration with the Linus Pauling Institute.

It was right about the time we learned that HIV was the cause of AIDS so we wrote a proposal to the NIH to study the in vitro effects of Vitamin C on HIV. That grant didn't get funded.

In San Francisco at that time there were also a number of DNCB proponents. DNCB, dinitroclorobenzene, is actually a photographic chemical used for developing pictures, but it is also a skin sensitizer that had been used to test for delayed hypersensitivity reactions.

There were people who believed that somehow it might be useful in restoring some of the T-cell immunity that patients with this new disease were lacking. So there were people who would paint themselves weekly or so with DNCB until they developed these skin reactions, thinking that the skin reaction was some sort of improved T-cell immune response that would help combat the virus.

And again, seeing that people were using this and seeing that we really didn't have much else happening, I worked with some of the DNCB proponents, as well as some experts from the University of California -- I remember Jay Levy was involved, as was Marcus Conant and others -- and we wrote a protocol that we submitted to the FDA for funding. That also was rejected.

Around the time that AZT first became available in 1986, I went to a conference in Japan where I was introduced to some investigators from the Ueno Fine Chemicals company who told me that they had the cure for this disease. They said it was something that was very commonly used in Japan but they couldn't tell me about it until I signed a confidentiality agreement.

That turned out to be dextran sulfate. Not long after I was going through the process of filing the paperwork to get approval from the FDA to do a phase I study of dextran sulfate in the United States when evidently some people heard about it.

They realized that it was a product that was widely available in Japan -- I believe it was used for lowering cholesterol -- so they started an importation scheme similar to what had happened in earlier days with isoprinosine and ribavirin, which were brought across the Mexican border.

But people had now become more sophisticated in their methods and began to import dextran sulfate from Japan to sell in the underground AIDS therapy market.

I remember that activists stormed the offices of a Japanese drug distributor in New York for refusing to make dextran sulfate more widely available. Ultimately it became such a political issue that, even though my clinical trial here in San Francisco didn't show much benefit, Congress got involved and the AIDS Clinical Trial Group (ACTG) was asked to do a study of dextran sulfate through the NIH-funded mechanism. It turned out the drug was not even absorbed into the blood.

Another Japanese product I worked with was lentinin, which was an intravenously administered extract of shiitake mushroom. In Japan it was felt to be an immune booster for patients with cancer. Although it was being used by mainstream doctors in Japan, it was an alternative therapy here because it was not something that we had ever learned about or used in hospitals in the U.S. That's David Eisenberg's description of what an alternative therapy is -- that it's not taught about in medical schools or widely available in U.S. hospitals -- and certainly shiitake mushroom extracts qualified. Again, that's another study we did that had negative findings;

there was no benefit to the intravenous infusions of lentinin. Since I've learned more about botanicals, it would seem to me that if there were immune enhancing benefits to shiitake mushrooms then they are more likely to be obtained by eating them rather than by injecting an extract intravenously.

During that time I was also involved with studies of conventional therapies. Even in the days of early AZT monotherapy, which I was not a big supporter of, I was involved in trying to put some evidence behind the claims of the proponents for these various agents. And since that time, I've had a constant history of investigating conventional therapies through the federally-funded CPCRA (Community Programs for Clinical Research on AIDS), and more recently through the ESPRIT study of interleukin 2, as well as in other, sometimes pharmaceutical industry-sponsored trials. But always ongoing with those studies, I've been involved with clinical trials of complementary and alternative interventions.

When we first became aware of immune thrombocytopenic purpora (ITP) in AIDS, I worked with a nurse who was very interested in therapeutic touch and we studied men with low platelet counts to see if therapeutic touch could decrease their stress and increase their platelet counts. That was another study that turned out to be fairly negative.

I then became interested in traditional Chinese medicine (TCM) and, in fact, one of the colleges of TCM here in San Francisco sent me to China in 1989 just to learn about Qigong (Chi Kung) -- that exercise that's felt to improve the immune system -- to see if it was something that I wanted to study here. Although I never studied Qigong I collaborated with Misha Cohen from the Quan Yin Healing Arts Center here in San Francisco. We did three studies of traditional Chinese herbal interventions for, first, symptomatic HIV, then for patients with diarrhea without a pathogenic source, and then another study for patients with anemia.

The last two were hindered by the fact of being initiated about the time that HAART became available, so patients with diarrhea as well as anemia became scarce. There were also a lot of pills that needed to be taken in these Chinese herbal investigations and patients at that time were taking huge amounts of pills with their antiretroviral regimens, so the studies weren't very attractive. None of these studies had spectacular results and the anemia study was terminated for poor enrollment.

Have "soft endpoints" such as life satisfaction created a problem for designing and conducting credible studies?

The TCM herbal study that we published in 1996 investigated herbs versus placebo in symptomatic HIV infection. At the time of the study in 1993, we had patients with about 14 symptoms on average and we found that there was a significant decrease of symptoms in the herb-treated group -- they decreased from 14 to 12 -- whereas the other group still had 14 symptoms. We also found that they had improved "life satisfaction" which improved by a factor of +0.86 or thereabouts.

Yet, if you look at the rest of the results, the Chinese herbal patients actually lost weight over 12 weeks compared to the placebo group, and their CD4 counts also dropped -- not statistically significant, but it was a trend. So that was an example of where their symptoms improved and their life satisfaction increased, but the parameters that we would normally look at to see if a patient is doing well (i.e., weight and CD4 count) went in the wrong direction. So, although I was also first author on a study that showed that epoetin alfa improves quality of life in HIV patients who are anemic, I'd have to say that a study whose main endpoint is quality of life is something I would find difficult to interpret.

The CPCRA actually did a large study of acupuncture for patients with HIV-related peripheral neuropathy that was published in JAMA. That was a landmark, having the NIH support an acupuncture study, although, again, it turned out to have negative results; acupuncture didn't appear to be effective in treating peripheral neuropathy.

About this time I began trying to study another botanical, which has consumed my efforts for the past decade, and that would be cannabis, or marijuana. Starting in 1992 I began proposing and developing clinical trials to investigate first the effectiveness -- but then I realized that that wasn't going to happen -- so subsequently, the safety of smoked marijuana in patients with HIV.

We finally completed a study in the year 2000, that we hope will soon be published, that looked at the safety of marijuana in patients taking protease inhibitor regimens. And since that time we have obtained funding from the State of California that allows us now to conduct clinical trials to look at the potential effectiveness of smoked marijuana in patients with various syndromes. We have also just completed a pilot study in patients with HIV peripheral neuropathy, which allowed us to ascertain that there was some effectiveness of marijuana. But an open-label pilot study is not going to prove that, so we're now in the process of continuing on with a randomized, placebo controlled, double-blind trial in patients with HIV-related peripheral neuropathy. We're also doing marijuana studies in patients with cancer who have pain who are on opioid analgesics, and another study to look at the effect of smoked marijuana in patients who have delayed nausea and vomiting from breast cancer chemotherapy.

It was working with marijuana and all the problems that are inherent in studying a plant as a therapy that has led me to a broader interest in botanicals and the use of substances that come from nature as medicinal agents. Certainly, for thousands of years, people have depended primarily on these things. Whether or not they worked is unclear, but as an oncologist I know that many of my most potent chemotherapeutic agents were derived from plants. So right now we are waiting to hear if a protocol we submitted to the National Center for Complementary and Alternative Medicine (NCCAM) to investigate the lipid lowering effects of oyster mushrooms in patients on Kaletra is being funded. There's good evidence that mushrooms, including oyster mushrooms in particular, have some activity for lowering blood lipids and cholesterol.

We're also just finishing a three-year NCCAM grant studying the effects of DHEA, dehydroepiandrosterone, which is an over-the-counter adrenal steroid that people are taking for many reasons. We received a grant to investigate it as an antiviral and to see what impact it has on the immune system. Hopefully that data will be available by the end of the year and we will know if DHEA had any impact, positively or negatively, in our patients.

The goal, ultimately, would be to submit a center grant to the NCCAM, to allow us to establish a center here for the study of botanicals in HIV because there are still a number of herbal preparations and mushroom extracts that warrant further investigation for their potential benefit -- and to make sure that they're not harmful in our patients.

Safety keeps coming up again and again as one of the inarguable justifications for doing this research.

There's not a huge amount that we know about some of these botanical products and how they're metabolized, but there's probably more than people think. There are a number of textbooks available that talk about herb-drug interactions. That was the question in our marijuana study: is there an interaction between cannabinoids and protease inhibitors, which are both metabolized by cytochrome P450 enzymes in the liver, that may alter the activity of the protease inhibitors such that patients lose their viral suppression when they mix cannabis with their treatments?

And in fact, in our article that was already published in AIDS, we saw no such effect. We've all heard about garlic and St. John's Wort and their interactions, and I think there are many other agents that we would like to study to make sure that they are not having significant interactions with protease inhibitors. We don't want people to either lose control of their viremia (through underdosing) or experience toxicity (through overdosing) because of antiretroviral concentrations that have been affected by herb-drug interactions.

You had to be enormously persistent to accomplish your marijuana study. In the current political climate, is it going to be more difficult to do marijuana studies?

I think we're blessed to live in the State of California, which is somewhat of a freestanding republic in and of itself. In 1996, the people of California voted to allow physicians to talk to their patients about the medicinal use of cannabis. Then, through the work of Senator John Vasconcellos, one of our state senators, appropriations were made to the University of California that established the Center for Medicinal Cannabis Research (http://www.cmcr.ucsd.edu/). And that Center has had funds for the past three years that allows it to support clinical trials to investigate the use of marijuana for medicinal purposes.

Whereas the NIH and NIDA, via their congressional mandate, could only give marijuana to clinical trials that show that it was harmful (they are the National Institute on Drug Abuse, not for Drug Abuse, as NIDA's director Alan Leshner always reminded me), they were not really able to provide us with marijuana to study the benefits. But now, they have modified their system so they can provide marijuana for peer reviewed clinical trials that will look at its effectiveness as a therapeutic agent -- as long as they are not funding it. So they have now created this ability for us to obtain government marijuana.

Is there a need to increase provider knowledge about these issues?

I think a part of the problem is a lack of communication from both sides. Patients don't really perceive that these substances are something that they need to tell their doctor about -- in fact many studies show they don't want to tell their doctor because they're afraid they're going to be reprimanded or told that they're wasting their money. And many physicians never even think about asking about these things as potential confounders or as things that are causing clinical symptoms.

There also may be a variable of where in the country you are. I know many surveys show that we in the West have the highest percentage of people in the population who are using complementary and alternative interventions. So many of my colleagues here might be more familiar with how to ask the question and what to be looking for.

I remember once seeing a patient at our drop-in clinic who clearly had a drug rash. I looked through his chart -- this was when we had paper charts -- and he had a high CD4 count and a low viral load but he wasn't taking any medications.

So I said to the guy, "You're not taking any medications, huh?" And he said, "No."
"Are you taking any vitamins?" And he said, "Yeah."

So I asked him what he took and he listed about four or five vitamin preparations. Then I asked, "Do you take any herbs?" And he said, "Sure."

And so I listed the three or four herbal substances th
at he took.
"Do you take any minerals?" And he said, "Yeah."
By the time I finished I had a list of 12 different things he was taking.
So I asked, "Well, how come everybody else wrote down that you don't take anything?" And he said, "Well, nobody ever asked me before."


more info at:
http://www.dreddyclinic.com/integrated_med/integrated_med.htm

Poorer, Less Educated Women Get Less Chemo for Breast Cancer

(HealthDay News) -- Poorer women with breast cancer are more likely to receive reduced doses of chemotherapy from their doctor, a new study suggests.

And less-educated women, as well as obese women, are also more likely to get reduced chemotherapy doses. Severely obese women in the study were four times more likely than lean women to receive less chemotherapy, and those with less than a high school education were three times more likely to get a reduced dose, the researchers said.

The study, by researchers at the University of Michigan Comprehensive Cancer Center, is published in the Jan. 20 issue of the Journal of Clinical Oncology.

"Many of these decisions are actually subconscious," Dr. Jennifer Griggs, lead author of the study, said of the findings. "I don't believe doctors set out to give anything but the best of care."
Griggs, an associate professor of internal medicine at the University of Michigan Medical School, suggested that the decisions to give lower doses of chemotherapy are based on benevolence.

"Doctors are concerned that patients who have less social support and fewer resources [including financial ones] are going to be less likely to continue therapy if they get the full dose" and perhaps more side effects, she said.

As for giving obese women reduced doses, Griggs said she suspects the concern is safety. Chemotherapy doses are based on body surface area, with heavier women having more surface area. Some doctors may fear that a dose based on body surface area would be too much if a woman is very heavy, she said.

But Griggs added that her interpretations of the study results were based on speculation, because the research did not include interviews with doctors.

For the study, Griggs and her colleagues evaluated 764 women who were in a cancer registry and were being treated for early breast cancer with chemotherapy, among other regimens. Study participants were enrolled at 115 hospitals and doctors' offices across the country. The researchers looked at data on household income, education, and body mass, and then evaluated correlations with doses of chemotherapy.

It has long been known that breast cancer survival rates are lower among poorer women, even though the incidence of breast cancer is lower among these women. Griggs said her findings may help explain this apparent paradox.

Chemotherapy dose matters most for the type of breast cancer known as estrogen receptor-negative, or ER negative, Griggs said,. "Up to a third to a half of breast cancers are ER-negative, depending on age," she said.

Griggs and her colleagues published a small study in 2003 with similar findings, she said, adding that the new study was larger and confirms the earlier results.

Another expert, Dr. Christy Russell, a medical oncologist and associate professor of medicine at the University of Southern California's Keck School of Medicine in Los Angeles, called the study interesting.

Russell said similar findings have been discussed at medical meetings, and efforts are already in place to educate doctors about dosing issues and patient compliance. "Many patients say, 'The side effects are too bad, can you lower the dose?' " she said.

As for the finding of reduced doses for obese women, Russell said that might be due to a doctor's training. "Some of us were trained to cap off the chemo," she said. Very heavy women would get the same dose as someone who was simply heavy. These approaches are changing, however, with most now not recommending a cap, she said.

Dosing of chemotherapy is traditionally not a decision shared by physicians and patients, Griggs said. "But women should be aware of this pattern," she said. "They should feel free to ask their doctor how the dosing decision has been made."

Russell agreed. "Women need to be aware and have the discussion with their physician that they anticipate they will be given the full dose of chemotherapy," she said.

More information
To learn more about breast cancer and treatment, visit the U.S. National Cancer Institute.

Taping Doctors' Conversations Helps Parents of Newborns in Intensive Care

(HealthDay News) -- Parents of infants hospitalized in intensive-care units are often upset and stressed and don't always fully understand what the doctors are telling them.

But by taping the doctors' conversations, parents can review the talks later and understand exactly what they were being told and the advice being offered, according to a report by Australian researchers.

"Patients, especially when stressed or in a state of shock, find it difficult to recall information given by senior doctors," said lead researcher Dr. Tieh Hee Koh, a neonatologist and clinical director at the Women's and Children's Health Institute of James Cook University Medical School, in Douglas, Queensland. "Even if we doctors discuss at length with the patients about their conditions, they may still not recall anything," he added.

For the study, the researchers recruited 200 mothers with babies in neonatal intensive care. The women were put into two groups: One group had their consultations with doctors recorded and were given a copy of the recording. The second group did not receive a recording.

After 10 days, and then again at four months, the mothers were asked to recall the diagnosis, tests, treatment and outcome of their babies, as explained by their neonatologist.

Koh's team found that women who received a tape recalled significantly more about diagnosis, treatment and outcome, than mothers in the control group. "Six of the 100 mothers not given the tapes did not recall any of the conversations," he said.

The study is published in the Dec. 2 edition of the British Medical Journal.
Although the tapes did not affect the mothers' levels of anxiety or depression, 96 percent listened to the tapes and found them helpful. Moreover, among babies with poor outcomes, the mothers who got tapes were significantly more satisfied with the conversations with the doctors than those who didn't get tapes, the researchers found.

The study authors believe that this method of improving communication between doctors and family members and patients can be extended to other areas of medical care.
Koh, who has been using this method for 12 years, advises "buying a tape recorder for anybody going into hospital or for any doctor friends."

One expert thinks the taping method isn't necessarily the best way for patients and family members to get the medical information they need.

"Patients never hear what doctors tell them," said Dr. Charles Safran, an associate clinical professor of medicine at Harvard Medical School and an expert in patient-doctor communication. "It's not surprising in neonates, where parents need a Ph.D. in intensive care to even remotely understand what's happening to their kid, [that they] don't remember what their doctors tell them."

Safran thinks there's a need for better communication, and the answer may rest with the Internet. Using Web-based, interactive communication allows people to access the information they need as they need it and helps improves communication between doctors and patients and patients' families.

"Web-based intervention, where there is persistence of information, where information, rather than just being given in one large taped session, is made available where and when a parent needs it, has a huge value," Safran said. "When you do that, you can improve parent satisfaction dramatically."

More information
For more on doctor-patient communication, visit the American Academy of Family Physicians.

Can Prayer Heal What Ails You?

(HealthDay News) -- Whenever a loved one suffers a health crisis, well-wishers often pass on the heartfelt promise that they'll "pray for you."
In fact, so many people believe in the power of prayer that it's now caught the attention of scientific researchers.
"Praying for your health is one of the most common complementary treatments people do on their own," said Dr. Harold G. Koenig, co-director of the Center for Spirituality, Theology and Health at Duke University Medical Center. "About 90 percent of Americans pray at some point in their lives, and when they're under stress, such as when they're sick, they're even more likely to pray."
More than one-third of people surveyed in a recent study published in the Archives of Internal Medicine said they often turned to prayer when faced with health concerns. In the poll involving more than 2,000 Americans, 75 percent of those who prayed said they prayed for wellness, while 22 percent said they prayed for specific medical conditions.
Numerous randomized trials have been done to assess the effect of intercessory prayer on heart patients' health.
In one such study, neither patients nor the health-care providers had any idea who was being prayed for. The coronary-care unit patients didn't even know there was a study being conducted. And, those praying for the patients had never even met them.
The result: While those in the prayer group had about the same length of hospital stay, their overall health was slightly better than the group that didn't receive special prayers.
"Prayer may be an effective adjunct to standard medical care," wrote the authors of this 1999 study, also published in the Archives of Internal Medicine.
However, a more recent trial from the April 2006 issue of the American Heart Journal seemed to contradict these findings, suggesting that it's even possible for some harm to come from prayer.
In this study, which included 1,800 people scheduled for heart surgery, the group who knew they were receiving prayers developed more complications from the procedure, compared to those who had not been a focus of prayer. Additionally, this study found no benefit in the group that received prayers, but didn't know it.
But Koenig said there's a simple explanation why people might fare worse if they knew they were being prayed for in a study.
"These people got the news just before they went into surgery. They were given pieces of paper that said they'd be getting prayer, which may have made them think, 'Oh my God, what's wrong with me?' " Koenig explained. "That's a totally artificial situation. Normally, you have loved ones and friends praying for you and there's nothing negative in that situation."
This new study also points out the difficulty of trying to quantify the effects of prayer, said Koenig.
"Studies cannot prove that prayer does not work. We don't know any more about the efficacy of prayer after reading these studies and they shouldn't affect anyone's belief in prayer," he said.
With scant evidence to support prayer for healing, should doctors encourage the practice?
Clearly, many patients are reluctant to bring up the subject with their physicians. In one study, only 11 percent of people surveyed have mentioned prayer to their physicians. But, physicians may be more open to the subject than patients realize, particularly in serious medical situations.
In a study of doctors' attitudes toward prayer and spiritual behavior, almost 85 percent of physicians thought they should be aware of their patients' spiritual beliefs. Most doctors said they wouldn't pray with their patients even if they were dying, unless the patient specifically asked the doctor to pray with them. In that case, 77 percent of physicians were willing to pray for their patient.
The bottom line on prayer and health: If it's something you want to do and you feel it might be helpful, there's no reason you shouldn't do it.
"I think many people are convinced that prayer helps, otherwise I don't think they would do it. Some people are 'foxhole religious' types and prayer's almost a reaction or cry to the universe for help. But, many people do it because they've experienced benefit from it in the past," Koenig explained.
"So, if you have any inclination that prayer might work, do it," he said.

More information
For more research on spirituality and health, head to the U.S. National Center for Complementary and Alternative Medicine.

Ovary Removal Raises Young Women's Death Risk

(HealthDay News) -- Younger women who have had their ovaries removed should consider estrogen therapy if they are under the age of 45, a new study suggests.

Mayo Clinic researchers found that those who said no to hormone therapy faced a higher death risk than those who said yes.

Many women with high-risk family histories have their ovaries removed, a procedure known as an oophorectomy, to help them avoid cancer or other diseases. However, experts said this new data should give them pause when deciding whether to use hormone replacement therapy afterwards.

According to one specialist, the study suggests that estrogen may have different risks and benefits, depending on a woman's age: protecting health at a younger age, seemingly neutral at menopause, but harmful at an older age.

"The study tells us that estrogen for women under 45 is very important to maintain health. Estrogen is a complex hormone in its interactions in the body, and has importance far beyond the reproductive tract," said Dr. Bobbie Gostout, a Mayo Clinic gynecologic surgeon who was not involved in the research.

The findings are published in the Oct. 1 issue of Lancet Oncology.

In their study, the researchers developed a statistical model of death due to ovarian cancer, breast cancer, coronary heart disease, hip fracture and stroke. Risks for all of these illnesses have been tied to estrogen levels.

"We aimed to investigate survival patterns in a population-based sample of women who had received an oophorectomy, and compare these with women who had not received an oophorectomy," the researchers wrote.

Women who had oophorectomies for reasons other than cancer before menopause were compared with age-matched women in the same population who did not have oophorectomies.

There were nearly 1,300 women with unilateral oophorectomy (one ovary removed), nearly 1,100 with bilateral oophorectomy (both ovaries removed), and close to 2,400 controls in the study.

The team found that certain younger women who have prophylactic bilateral oophorectomy -- surgical removal of both ovaries -- were at an increased risk of death from all causes.

Overall, mortality was not increased in women who had both ovaries removed, but that changed when the researchers broke down the findings by age.

For example, mortality was significantly higher in women who had both ovaries removed before the age of 45 years than women with intact ovaries. Furthermore, this increased mortality was seen mainly in women who had not received estrogen supplementation to the age of 45 years.

Although having both ovaries removed before age 45 years is associated with increased death risk, it is uncertain whether it helps cause death, or is merely a marker of some other underlying risk, the authors wrote.

No increased mortality was recorded in women who had just one ovary removed, regardless of their age, the study found.

In the United States, prophylactic oophorectomy prevents about 1,000 cases of ovarian cancer each year. Over the last three decades doctors have been gradually increasing their recommendations that women have ovaries removed at time of hysterectomy to avoid the risk of cancer, "but that wonderful prevention has been at the cost of removing ovaries in 300,000 women per year," Gostout said.

"This 25-year study showed a decreased incidence in ovarian cancer, however that was countered by adverse health impact in other areas," said Gostout. The increased death risk did not show up for at least a decade, and was 1.7 times greater than normal, the study found.

The work is exciting because it fills in part of the information deficit for women in this age bracket, she added.

Before this study, people were applying lessons from Women's Health Initiative -- a study that focused on women 60 years and older -- to much younger women, recommending that estrogen not be used any longer than five years.

"This study shows that could be an error -- that women under the age of 50 face a different risk/benefit scenario than older women," Gostout said.

But whether all women who've had bilateral oophorectomy should receive estrogen therapy isn't yet proven, another expert said.

The researchers looked at associations in this study, "but don't prove cause and effect," noted Dr. Andrew Berchuck, director of gynecologic oncology at Duke University, and president-elect of the Society of Gynecologic Oncologists. Estrogen replacement after menopause is a "patient-by-patient decision, and physicians and patients must look at individual risk factors and symptoms," he said.

There's a long-running debate about what age to remove ovaries, "but there's very little science because these studies require long-term follow-up, and that's hard to do," Berchuck said. "This study adds some ammunition to the argument that says 'leave the ovaries in closer to the natural age of menopause' -- about 50 years -- but it's by no means conclusive," he said.

Gostout agreed these decisions are tough, and best left to an individual woman and her doctor.

"If a woman is considering hysterectomy, she will probably be invited to make a decision about her ovaries. That decision should be highly individualized," Gostout cautioned. "No woman should be told that because she's having a hysterectomy her ovaries must removed as well."

Rather, the decision is based on age and family risk for breast and ovarian cancer, she said.
If a woman needs her ovaries removed because of disease or elects to have them removed, estrogen replacement is recommended until the average age of menopause, age 50, Gostout said.

"Don't be scared away from estrogen-replacement therapy in the premenopausal age because there are some concerns in the postmenopausal age," Berchuck added.

In the meantime, women who have had their ovaries removed in the past should not be "alarmed or frightened," Gostout said, since "the increased risk [of illness] for any single woman is very tiny." She said it might also be reasonable for these women to ask their physicians about "estrogen-replacement therapy if they're not already taking it and they're less than 50 years of age."

More information
Find out more about hormone-replacement therapy at the U.S. National Heart, Lung, and Blood Institute.

Children's Health

Children's Health
In this section many common questions related to children’s health are explored.

Contrary to popular belief, children are not "little adults," and the approaches to their health conditions are often markedly different than those used for grown-ups.

The rapid changes that occur during growth and development require special consideration in choosing both treatments and medications.

In some cases, specific treatments have not been well studied in children, but the majority of childhood health concerns are those that parents have been asking about for many generations, and the solutions are tried and true. Information on other childhood conditions can be found in the QA archives.

• Acupuncture
• Attention Deficit Disorder
• Asthma from Exercise
• Bedwetting
• Broken Bones
• Carsickness
• Colicky Babies
• Constipation
• Ear Infections
• Early Puberty
• Fluoride
• Food Coloring
• Head Lice
• Overweight Kids
• Sore Throat
• Teething
• Toy Safety
• Vitamins

Acupuncture
In the United States, acupuncture hasn’t often been used to treat children, mainly because youngsters tend to be afraid of needles.

But several recent studies have suggested that this fear can be overcome and that children can benefit from acupuncture treatment for certain conditions.

The latest study on this subject was conducted at the Harvard-affiliated Children’s Hospital in Boston by Yuan-Chi Lin, MD, an anesthesiologist who specializes in pain management in children. Dr. Lin’s study included 243 youngsters ranging in age from six months to 18 years who were being treated for headaches, stomachaches, back pain and other chronic complaints that often caused them to miss school.

When the study began, the young patients rated their pain as an "8" on a scale of 1 to 10. (One of Dr. Lin’s methods of demonstrating to the kids that the needles won’t hurt is by inserting them first in the children’s parents.)

When the year-long study was over, the average pain rating among the youngsters was a "3." The kids also reported missing less school, sleeping better, and being more able to participate in extracurricular activities as a result of treatment.

In an earlier study at the same hospital, 70 percent of the 47 youngsters participating reported that acupuncture helped relieve their pain and 59 percent of their parents agreed.

The conditions for which these patients were treated included migraines, endometriosis in teenage girls, and reflex sympathetic dystrophy (a syndrome in which pain becomes chronic after an injury).

In this study, 15 children were age 12 or under while 32 were between 13 and 20 years old. Other studies have looked at acupuncture as a treatment for attention deficit hyperactivity disorder and cerebral palsy in children.

While not many acupuncturists specialize in treating children, Dr. Lin estimates that about a third of pediatric pain centers nationwide now offer acupuncture to their young patients.

Acupuncture is best used for pain reduction as part of comprehensive treatment that includes relaxation techniques, clinical hypnosis and various forms of bodywork.

Attention Deficit Disorder
Ritalin, a stimulant, remains the most common treatment for Attention Deficit Disorder (ADD), also called Attention Deficit Hyperactivity Disorder (ADHD). Paradoxically, with ADHD the drug has a calming effect, apparently because it stimulates parts of the brain that regulate activity and attention.

While it can have excellent results in some cases, it is greatly over-prescribed.
There currently is no herbal treatment for ADHD, except possibly coffee, which may work like Ritalin for some patients.

Pediatrician Sandy Newmark, M.D., of Tucson, Ariz., confirms that no herbs have been found effective for treating the main or "core" symptoms of ADHD — that is, lack of focused attention that often leads to poor school performance. And he doesn’t think coffee is a good long-term solution. However, Dr. Newmark notes that herbs can help with some of the associated symptoms. For example, valerian tea can help youngsters with sleeping problems and St. John's wort can help relieve depression. For children under 12, use half the adult dosage.

Dr. Newmark does recommend a dietary supplement, omega-3 fatty acids, for all children with ADHD because levels of omega-3s in the plasma and red blood cells of children with ADHD are lower than in normal children. He also recommends that youngsters with ADHD take a quality multivitamin as well as a good probiotic, a product that contains "friendly" bacteria that can stabilize the digestive tract. You can find milk-free brands in health-food stores.

Make certain that the underlying cause of your child’s disruptive behavior really is ADHD, and that he or she isn’t acting out difficulties at home or expressing frustration with a learning disability. Be sure to rule out hearing or vision problems, allergies, depression or even boredom in a gifted child.

As far as foods are concerned, while there’s no evidence that a dietary approach helps in all cases, a 1993 Cornell University study found that eliminating dairy products, wheat, corn, yeast, soy, citrus, eggs, chocolate, peanuts, artificial colors and preservatives seemed to decrease ADHD symptoms. An even earlier study showed that a low-allergen diet supplemented with calcium, magnesium, zinc and vitamins produced favorable results.

Asthma from Exercise
Exercise can trigger asthma symptoms in children and adults – even those who don't otherwise suffer from the condition - and can aggravate the problem in up to 80 percent of those who do have asthma.

The symptoms – coughing, wheezing, shortness of breath or tightness in the chest – usually come on after exercise, although they can occur soon after exercise has begun. It can be treated with medication and by taking precautions to prevent or minimize symptoms. Here’s a rundown of medication options, provided by pediatrician John Mark, MD, an assistant professor of pediatrics at the University of Arizona who treats asthma in both adults and children.

Albuterol – A short-acting bronchodilator that’s inhaled 15 to 20 minutes prior to exercise and that protects against symptoms for about four to six hours.

Salmeterol – A long-acting bronchodilator that’s inhaled twice a day which offers protection for up to 12 hours. You can also use salmeterol as a preventive before you work out.

Montelukast (Singulair) – A drug that blocks the action of leukotrienes in the lungs, resulting in less constriction of bronchial tissue and less inflammation. Leukotrienes are one of several classes of chemical messengers produced in the body that can trigger bronchial constriction and inflammation. Montelukast is available in pill form and is taken the night before you exercise.

Cromolyn (Intal) – An anti-inflammatory drug inhaled 15 to 20 minutes before exercising that prevents the release of histamines and leukotrienes. It’s most useful in asthma when an allergic component is present.

In addition to medication, the following approaches can help prevent or minimize symptoms:
A very slow warmup. Even to the point that your child reports the beginning feelings of the "tightness" associated with exercise-induced asthma.

Then your child should stop and stretch, or slow down if exercising vigorously. By taking this break, the development of asthmatic symptoms can often be blocked and a normal pace can be resumed. This may take some getting used to, but can sometimes eliminate the need for medication.

Try breath work. The most effective approaches are pranayama techniques – breath control exercises taught in some yoga classes for adults. You can have your child do these after the initial warm-up, again, when the symptoms are almost felt. For most children, you can start with Dr. Weil’s technique for "The Relaxing Breath."

Find a form of physical activity that minimizes exercise-induced symptoms. Sports or activities that have intermittent rest periods (such as tennis, softball and golf) can allow your child to regain control of his or her breathing. Swimming may be better than running outdoors in cold weather, but no type of exercise is off-limits with proper treatment. In fact, some of the world’s top athletes have exercise-induced asthma, and they’re still able to compete successfully in Olympic-level events.

Bedwetting
Although by age 8 most youngsters have outgrown bedwetting, a sizeable minority still haven’t. As a matter of fact, 5 to 10 percent of boys still have enuresis (the medical term for bedwetting) by age 10. Enuresis tends to run in families and, when this is the case, children usually outgrow it at the same age as the parent, sibling or other relative who had the problem did.

No one knows what causes bedwetting, although it is sometimes associated with constipation. If so, simple dietary changes such as eating more fruits and vegetables and drinking more water early in the day can help resolve matters. Pediatrician Sandy Newmark, MD, of Tucson, Ariz., suggests making sure that children aren’t drinking any beverages that contain caffeine (such as some sodas) and trying to limit (within reason) the amount of fluids they drink in the evening.

Dr. Newmark explains that an "enuresis alarm" is the most simple and effective intervention for youngsters. This device is a wristwatch with a sensor that is attached to pajamas so that the alarm sounds at the first sign of wetness.

This system eventually conditions a child to wake when the bladder is full. Dr. Newmark says that the alarms work in about 70 to 80 percent of children. They are available at most drugstores and cost about $50. Be patient with this system since it can take weeks, and sometimes months, to see results.

If the alarm doesn’t help, Dr. Newmark suggests trying hypnosis as a safe and effective treatment. While some pediatricians prescribe drugs for children who wet the bed, using medication is controversial and should be viewed as a last resort. Homeopathic remedies also may be effective; consult a homeopathic practitioner if you want to try this approach.

Broken Bones
Results of a recent study at the Mayo Clinic in Rochester, Minn., suggest that the rate of wrist and forearm fractures among young girls has increased dramatically in the last 30 years. The study results, published in the Sept. 17, 2003, issue of the Journal of the American Medical Association showed that the fracture rate for young girls increased 56 percent from 1969-1971 and 1999-2001.

Boys still suffer more fractures, but the rate of increase among young boys was only 32 percent. Overall, the Mayo Clinic researchers found that the fracture rate among young people had increased 42 percent over three decades.

The researchers had no answers for why this is happening. It is unlikely that youngsters are breaking more bones because they’ve become more physically active. One possibility is that kids may not be getting enough calcium during a period when their bones are growing rapidly.

If so, their bones may never become as dense as they should, which raises the possibility that affected youngsters may be more vulnerable later in life to osteoporosis and hip and vertebral fractures.

The researchers noted that government surveys have shown a decrease in milk consumption among older girls and an increase in consumption of carbonated drinks. The phosphates in carbonated beverages interfere with calcium absorption.

The RDA for calcium is 1,300 mg for young people age 9 to 18. This translates to 4-5 servings of dairy per day, but kids don’t have to drink milk to get their calcium. Other good sources include yogurt, cheese, sea vegetables, collard and mustard greens, kale, bok choy, broccoli, canned salmon and sardines, tofu that has been coagulated with a calcium compound, calcium-fortified soy milk, fruit juice and blackstrap molasses.

Other experts have noted instances of vitamin D deficiency that could contribute to weakened bones. Our bodies make vitamin D with exposure to sunlight, and youngsters who spend too much time indoors may not produce optimal amounts of vitamin D. Spending 10 minutes in the sun without sunscreen a few days each week will do the trick, but it is not a bad idea for kids 12 and older to take a multivitamin supplement that includes 400 IU of vitamin D.

Carsickness
Carsickness, like all types of motion sickness, occurs when the brain receives conflicting signals from the inner ears, eyes, and other parts of the body that sense motion. A child sitting in the back seat of a car may sense movement – her inner ear perceives the motion – but she may not be able to see out the window to see that she is moving. At the same time, her perception is that her body isn’t moving at all. In some children, these conflicting messages can result in very distressing nausea.

One effective remedy for motion sickness comes from an old Chinese fisherman’s remedy of stimulating the acupressure points that control nausea. The updated version of this treatment is done with wristbands equipped with a plastic peg that presses on acupressure points on the inner surfaces of the wrists. The wristbands are available at most drug and health-food stores. Follow package directions carefully – proper placement of the wristbands is critical.

Motion sickness can also be prevented (and treated) with ginger. Mix a half teaspoon of ginger powder in a glass of water and give it to your child 20 minutes before you get in the car. Or give your child two capsules of powdered ginger.

This remedy has proved more effective than Dramamine – with none of the drowsiness that can occur as a side effect of the drug. Ginger snaps, ginger ale and candied ginger can all help with mild nausea, so keep some in the car should someone develop symptoms during the trip. You also could explore homeopathic remedies – and possibly hypnosis – as a long-term solution.

The American Academy of Pediatrics suggests trying to deal with carsickness in children by focusing youngsters’ attention away from their queasiness. Listen to the radio or tapes, sing or talk. Also, direct their attention at things outside the car, not at books or games. Make sure that they look out the front windows, where apparent motion of objects is less.

Colicky Babies
First, exclude other reasons for the baby’s crying. Make sure the infant isn’t running a fever, isn’t lethargic, is eating normally and isn’t having any trouble breathing. Your pediatrician will also want to exclude GERD (gastroesophageal reflux disease), which can occur among babies (although it is much more common among adults).

The good news about colic is that what you see is what you get – a fussy, crying but otherwise perfectly healthy baby. Some doctors think that this irritating phase may be part of normal development. Between 5 and 28 percent of infants develop colic between when they are two to six weeks old, and usually outgrow it by the time they’re three to four months old.

Here are Dr. Russell Greenfield’s suggestions for dealing with colic – and with the frustration it can breed among parents:

• Try massage therapy, a great way to enhance bonding between parent and child at a time when colic may be interfering with the bonding process.
• Rock your baby rhythmically.
• Turn on music or try the clothes dryer or vacuum cleaner. Sometimes the white noise they produce helps.
• Try cranial osteopathy or homeopathy; both may help and are safe forms of treatment.
• Try herbal remedies such as cooled chamomile or fennel tea. You can get tea bags at the health food store and give the baby one to two ounces at a time, no more than three to four ounces per day.
• Switch to a cow’s milk-free formula, or, if breast feeding, change the mother’s diet to affect what is entering her breast milk (in some cases, a food sensitivity may play a role).
  Swaddle your baby – it provides a nice snug feeling.
• Chill – find a way to relax; try breathing exercises or other relaxation techniques to lower your frustration level.

By the way, the latest international report on colic comes from a Canadian study that found that mothers don’t appear to sustain any lasting psychological effects as a result of dealing with a colicky infant.

Constipation
Constipation is a common problem for children and usually is temporary. Strictly speaking, a child is constipated if he or she has fewer than three bowel movements per week or if the stools are hard, dry, and unusually large or difficult to pass. Because constipation can make bowel movements painful, youngsters may try to avoid having them. (In addition, about 60 percent of constipated children experience recurrent abdominal pain, a common stress-related condition in youngsters.)

The causes of constipation in kids usually are simple and relatively easy to correct: not enough fiber in their diets, not drinking enough liquids or not getting enough exercise. Then, too, constipation can occur when youngsters ignore the urge to have a bowel movement, which they can do for reasons ranging from not wanting to take a break from playing to embarrassment at using a public bathroom or because a parent isn’t around to help when the urge occurs.

Medication can also be a factor. Those that can cause constipation include aspirin and codeine, vitamins with high doses of iron, the bismuth in Pepto-Bismol, as well as some chemotherapy agents (vincristine) and some psychiatric drugs (imipramine).

Sandy Newmark, MD, a pediatrician at the University of Arizona Program in Integrative Medicine, recommends the best ways to deal with constipation in young children, listed here:
Decrease dairy products: They can be constipating. Provide your child with an alternative source of calcium such as soy milk fortified with calcium or a calcium-fortified breakfast cereal.
Increase fluids: Encourage your child to drink lots of water.

Increase fiber: Give your child lots of high-fiber fruits and vegetables as well as high-fiber cereals, whole-grain breads and beans.

Although these measures probably will do the trick, if a child’s episodes of constipation last longer than three weeks and prevent him or her from participating in normal activities, you might want to consult a pediatrician. Don’t be tempted to administer the over-the-counter laxatives designed for children. They can be dangerous to youngsters and should be given only under the direction of a pediatrician.

Ear Infections
Recurrent ear infections can be troublesome during early childhood. Here are two strategies:
Eliminate milk and milk products from your child’s diet for at least two months. This means avoiding all dairy products as well as other foods containing milk in any form. Soy, rice, and nut milks such as almond milk are all right. The protein in milk, casein, is often associated with recurrent ear infections in early life as well as with sinus conditions, eczema, chronic bronchitis, and asthma.

Try cranial osteopathy. It is another good treatment for recurrent ear infections. When performed by a skilled practitioner, this technique can often end cycles of ear infections, sometimes with a single treatment.

The late Bob Fulford, D.O., a leading practitioner of cranial osteopathy, had great success curing recurring infections in young children. He believed that fluid stagnation in the middle ear – caused by restricted breathing – was at the root of the trouble.

Gentle manual manipulation (and sometimes application of a vibrating instrument known as a percussion hammer) opens up breathing, which in turn helps fluid drain from the middle ear. To find a practitioner of cranial osteopathy, send a self-addressed stamped envelope to the Cranial Academy, 8202 Clearvista Parkway, #9D, Indianapolis IN 46256. At the University of Arizona, researchers are now concluding a study funded by the National Institutes of Health's National Center for Complementary and Alternative Medicine on the use of both cranial therapy and Echinacea to break cycles of recurrent childhood ear infections.

Early Puberty
In the United States, there's a virtual epidemic of precocious puberty these days – the onset of puberty at very young ages in both boys and girls. Among Caucasian girls today, 1 in 7 starts to develop breasts or pubic hair before she is 8 years old. Among African-American girls, the number is 1 out of 2! Unfortunately, no one knows why this is happening, although there's plenty of speculation. Precocious puberty can be triggered by tumors in the pituitary gland, hypothalamus, ovaries, or testicles, but these cases are rare. Environmental factors are more likely to blame for the upsurge in cases today. The theory with the most scientific support is that obesity is responsible. I think this may be true, since we've long known that overweight girls mature physically earlier than thin ones.

Research also has suggested that environmental pollution may play a small role. In the spring of 2000, results of a study reported in the Journal of Pediatrics showed that boys exposed to DDE (a breakdown product of DDT) were heavier than their peers, while girls exposed to PCBs were heavier than their peers and tended to reach puberty a bit sooner, even though the actual numbers involved in the study were not deemed statistically significant. (Both DDT and PCBs are chemicals that appear to interfere with the body's own hormones.) Researchers are also looking at other environmental chemicals – among them Bisphenol A (BPA), used in manufacturing plastic – but so far haven't found a definitive link.

Unfortunately, there's not a lot to offer in terms of treatment and no natural remedy that I can suggest. Since it's occurring so often these days, some physicians believe that precocious puberty in girls between the ages of 6 and 8 should be seen as normal and not treated at all. (We do know that the risk of breast cancer later in life increases with an earlier onset of puberty.) The only approved allopathic treatments are two drugs: Gonadotropin-Releasing Hormone, GnRH, and Luteinizing Hormone-Releasing Hormone, LHRH, both given by daily injections or at intervals of every three to four weeks. These drugs interfere with the hormonal changes responsible for precocious puberty, in effect putting them on "hold" until the child reaches a more appropriate age (typically between the ages of 11 and 13 in girls). The drugs may also reverse the changes that already have taken place.

The physical changes are only one aspect of what girls must contend with as a result of precocious puberty. Because they look like young women, they're often treated as if they were much older than they are by boys (or men who should know better) and may also be teased by friends and at school. If you are a parent with a child in the midst of precocious puberty, you must keep the parent-child lines of communication open. Make sure that your child understands that despite the change in her appearance, he or she is still a child.

Fluoride
The only children who need fluoride supplements of any type are those who live in communities without fluoridated water supplies or in homes with water purifiers that remove minerals. The easiest, most efficient and most cost-effective means of making sure that children have adequate fluoride to protect against tooth decay is to support fluoridation of your area's water supply.

If your community's water is not fluoridated, your child will need dietary fluoride supplements which are available only by prescription from your dentist or physician. To protect against tooth decay, children need fluoride on a daily basis from the age of 6 months to 16 years. (Pregnant women take fluoride supplements beginning in the sixth month of gestation to ensure strong tooth development in the fetus – check with your obstetrician about this.) The correct dosage for your child must be calculated on the basis of the natural fluoride concentration of your local drinking water as well as your child's age, and the extent of his or her exposure (if any) to other sources of fluoride, such as toothpaste or commercial products.

Some fluoride is present in all water sources, but according to the American Dental Association, most bottled waters don't contain enough to prevent tooth decay. Fluoridation of community water supplies involves adjusting the fluoride content to the optimal level for dental health, 0.7 to 1.2 parts fluoride per million parts water. Too much fluoride can be bad for children's teeth, just as too little is bad. An excess of fluoride can lead to mottled, chalky, white spots on the teeth. Other health risks include weight loss, brittle bones, anemia and weakness. Be aware that there are conflicting reports that continue to fuel the controversy over fluoridation. Yet at proper levels, fluoride is of immeasurable benefit to the teeth – during childhood and throughout life.

Food Coloring
We are seeing more and more strangely colored foods and snacks, but as a precaution, keep children – and adults – away from foods with artificial colorings. The danger is that the chemicals used to create color are energetic molecules, many of which are capable of interacting with and damaging DNA. Anything that damages DNA can injure the immune system, accelerate aging, and increase the risk of cancer. Indeed, many synthetic food dyes once considered safe have turned out to be carcinogenic. Some approved for use in Europe are considered unsafe in the United States, and vice versa.

Dyes are added to foods for the convenience of the manufacturer, not for the health of the consumer. Luckily, these are among the easiest types of food additives to avoid. Try to convey to your children that garishly colored snack foods are weird and unhealthy – rather than attractive – and make it a rule not to buy them. Watch out for labels that list any of the following terms: "color added," "artificial color added," "U.S.-certified color added," or "FD&C red No. 3" (or green or blue or yellow followed by any number; these are FDA-approved food drug and cosmetic dyes).

There is nothing wrong with foods dyed with natural colors obtained from plants. The most common, annatto, is from the reddish seed of a tropical tree. It is widely used in Latin American cooking to make yellow rice and breads, and is also commonly added to butter and cheese to make them yellow or orange. Other safe food colorings are a red pigment obtained from beets, a green one from chlorella (freshwater algae), caramel, and carotene from carrots.
Definitely keep your kids away from bright green ketchup, a product designed specifically to appeal to youngsters.

Head Lice
Head lice are a common nuisance of childhood. Kids pick them up from someone who already has them by wearing each other’s hats, scarves, hair ribbons and other clothes; sharing combs, brushes or towels; or lying on a bed, couch, pillow or even cuddling a stuffed animal that belongs to a child who has lice. Try to discourage this kind of sharing, particularly if you hear that there’s an infestation at school, at a day care center, or wherever your children spend time.

The conventional treatment is one-percent lindane, sold as Kwell lotion. Yet lindane is a cousin of DDT and can harm the nervous system. Natural and safer alternatives include one-percent permethrin cream rinse, sold as Nix and Neem, which is derived from a tree in India. Lice can develop resistance to permethrin products, and they can aggravate asthma in some children, but both are relatively nontoxic. (Neem is sold in garden shops.)

Some California school systems are using a new product called Lice B Gone, a non-toxic, multi-enzyme shampoo made from plant sources that seems to get rid of lice in a single application. It works by softening the glue that holds the nits (lice eggs) to the hair shaft and also dissolves the exoskeletons of adult lice. Since it contains no pesticides, Lice B Gone is considered safe for pregnant women, nursing mothers, young children and people with asthma.

Overweight Kids
You'll probably be happy to hear that not all children who are heavy grow up to be overweight adults. However, we do have an epidemic of childhood obesity in the U.S., and all parents should be aware that for every year that a child remains overweight, his or her chances of growing into an overweight adult increase.

Aside from eliminating sodas or junk food at home, look to physical activity as a way to help your child lose weight. Try for at least half an hour of physical activity each day. Unfortunately, only 25 percent of school-aged children now take physical education classes. If your child doesn't get any exercise at school, it's up to you to make sure he or she does some type of physical activity at home.

Here are some approaches to add exercise to your child's life as well as foods that will help control his or her weight:
Curb screen time. Limit the time your child spends watching television, sitting at the computer or playing video games.
Set a good example. Studies have found that children are more likely to be physically active if their parents and siblings are active, and if they're encouraged to take part in physical activities. Take family walks, hikes or bike rides on a daily basis, if possible.
Emphasize nutritious foods. Don't limit the amount your child eats, but make sure the foods he does eat are low in fat and high in fiber. When making these changes, say that you're doing it for the entire family to avoid drawing attention to your child's need to lose weight.
Eat meals together. Family breakfasts and dinners give you more control over what your child eats and allow you to make sure that everyone gets at least two nutritious meals per day.
Think about drinks. Cut back on fruit juices, sodas and whole milk. Drinks can provide a surprisingly large number of calories per day.
Teach a relaxation technique. If your child eats in response to stress, you might show him how a relaxation technique such as deep breathing can help to calm him.

Sore Throat
The most important thing parents can do when children develop sore throats is to make sure that the problem isn’t strep, a bacterial infection that requires antibiotic treatment. Strep is diagnosed via a throat culture. (Or a rapid strep test, which takes only 10 minutes but is not as accurate.) While the results may not be available for a few days, a doctor often can tell on the basis of observation whether strep is the likely problem and begin immediate treatment with penicillin. The sore throat usually eases in 24 to 48 hours.
Besides a very sore throat, symptoms of strep often include fever, swollen and tender lymph glands under the jaw, and a swollen and marked redness at the back of the throat that may have white dots. Those symptoms don’t always mean strep, but they often do. (Another clue: suspect strep when there are none of the typical symptoms of a viral infection such as a cough, runny nose, hoarseness and eye irritation.)
It is very important to treat strep throat with antibiotics as soon as possible, because in rare cases it can lead to an autoimmune reaction – rheumatic fever – that can affect the joints, heart and kidneys.
To reduce your child’s susceptibility to sore throat, try to build up his or her immune system by administering a course of the Chinese herb astragalus (Astragalus membranaceous) during cold and flu season. You can get astragalus in tincture form or in capsules at the health-food store. Administer one half the adult dose. This herb is safe for regular use.
If your child can gargle, give her a mixture of half hot water and half hydrogen peroxide to use several times a day. Gargling with warm salt water (one-quarter teaspoon salt to one cup of warm water) is also soothing.

Teething
In many infants, the process of teething is painless, causing only some increased drooling and a desire to chew. However, some infants develop tender, swollen gums, may not sleep or eat well, and may run a low fever (under 100 degrees). A fever above 100 degrees or diarrhea suggests problems unrelated to teething.
Here are some recommendations to keep a teething baby comfortable:
Wipe the drool off your baby’s face with a soft cloth (to prevent rashes).
Rub the baby’s gums with a clean finger.
Let your baby chew on a wet washcloth that has been placed in the freezer for 30 minutes (wash it after each use). Alternatively, use a cool spoon or rubber teething ring (take it out of the freezer before it gets so hard that it bruises the tender gums).
Never tie a teething ring around a baby’s neck – it could get caught on something and strangle the child.
Homeopathic teething tablets are a good option. Many parents tell me they have used them successfully to relieve the minor discomforts of teething in their babies.

Toy Safety
Look over the toys you have at home to see if they are age-appropriate for your children. In general, this means making sure they aren't too advanced for the youngest child, but sufficiently sophisticated for the older ones. Homes with infants or toddlers should make sure all toys (and their removable parts) are large enough so they can't be put into a child's mouth and become a choking hazard. (An easy test: A child can choke on any object that fits inside the tube from a roll of toilet paper.)
Parents or grandparents should also be aware that over the last two years toy manufacturers have recalled teethers, rattles, and other products that contain a cancer-causing chemical called diisononyl phthalate (DINP) from the market. Phthalates are used to soften plastics, but high doses have been linked to cancer in mice and rats. The U.S. Consumer Product Safety Commission has said the amounts that might have been ingested by small children are not high enough to pose a risk, but it does make sense to toss any soft plastic rattles and teethers that you’ve had more than a year – that's when most toy manufacturers agreed to phase out use of the additive.
The following guidelines for toy safety are from the American Academy of Pediatrics and the Consumer Products Safety Commission:
Check the surface and edges of wooden toys. Sandpaper sharp corners and splinters.
Don't give hobby kits, such as chemistry sets, to children younger than 12.
Don't permit children to play with adult darts or other hobby or sporting equipment that have sharp points.
Examine all outdoor toys regularly for rust or weak parts that could become hazardous.
Discard all plastic wrappings on toys before they become deadly playthings.
New toys intended for children under age 8 should be free of glass and metal edges.
Toys with long strings or cords may be dangerous around infants and very young children. Never hang toys with long strings, cords, loops, or ribbons in cribs or playpens where children can become entangled.
Keep toys designed for older children out of the hands of little ones.

Vitamins
Yes, children should take vitamins, mostly because so many kids don’t eat enough fruits and vegetables, and because their diets are often full of processed and refined foods. However, vitamin supplements shouldn’t be substitutes for whole foods, especially fruits and vegetables.
Teach children of any age to enjoy healthy food by involving them in its preparation, even if they’re only in the kitchen to observe. In "The Healthy Kitchen," Rosie Daley and I give a number of ideas for recipes and snacks that kids will like. Also, try to discourage your children from eating too much fast food, processed food, sugar and caffeine (in cola and other soft drinks). There’s no harm in the occasional ice cream, pizza or candy bar in the context of a well-balanced diet, but try to encourage snacking on healthier foods – fresh or dried fruit; a small handful of raw, unsalted nuts such as cashews and walnuts; a piece of flavorful, natural cheese; or a piece of dark chocolate.
As far as supplements are concerned, give children a complete antioxidant formula as well as multiminerals. Be sure to keep the vitamins out of the reach of young children – some supplements for kids taste and look like candy and there is a danger of overdosing, especially when supplements contain iron.

Andrew Weil, M.D.–Author of:
Eight Weeks to Optimum Health
Spontaneous Healing
The Natural Mind
The Marriage of the Sun and Moon
Health and Healing
Natural Health, Natural Medicine
From Chocolate to Morphine (with Winifred Rosen)