To mammogram, or not to mammogram

I’m not surprised there’s so much confusion about the new mammogram recommendations from the U.S. Preventive  Services Task Force.  The findings are counter-intuitive.  And the message is coming from data people, who can’t communicate it in a way that makes sense.

What’s more: There are a lot of people with a vested interest in the current mammogram regime.  I don’t mean to impugn their motives.  They have the best of intentions.  But, if your medical career, or your clinic, is built on the premise that all testing is good and early diagnosis is the Holy Grail, then it’s hard to be objective.  And, if you are affiliated with a non-profit advocacy group, trying to raise awareness and money to battle breast cancer, then it’s going to be hard to swallow the idea that not everyone needs to be tested.

A young woman lines up for her mammogram (at Baylor Medical Center)

This is intuitive:  Cancer starts small, and if you test for it, you might find it before it spreads and becomes lethal. If everyone gets tested, we’ll catch most cancers before they can kill.  Period.

This is not intuitive:  If we test people, and get a lot of false-positives, that causes anxiety and unnecessary biopsies.  So, it’s better to do less testing and risk a few deaths.

I’m not a specialist, and I won’t make any claims to know what all women should do.  But, the panel making the new recommendation deserves to be respected.  And their conclusion is not unprecedented.  Other researchers have been arguing for years that we do too much breast and prostate cancer screening.  European countries with the most advanced health systems do not recommend annual mammograms under the age of 50.

And as I talk to middle-aged women, I hear a lot of stories of false positives, or hard-to-read mammograms, and unhappiness with what feels like a treadmill of testing and worry. (Not to mention the mammogram procedure itself ….)

Back in the 1990’s, as CT scanning machines became more common (and less expensive),  “full body scans” became the rage.  Remember the ads?  They promised to find the diseases lurking in your body that hadn’t yet shown up in symptoms.  The medical profession roundly condemned these scans.  Why?  Because they lead to a lot of false positives, further useless testing, and possibly procedures that are unnecessary.  In the end, for most people, they do more harm then good.

If the government or medical profession is recommending that everyone should get a certain test or vaccine, then they need good evidence that the benefit outweighs the risks.

One fact we don’t like to think about:  We are all carrying around parasites and growths and abnormalities all the time.  Most of these are kept in check by natural systems.  If we tried to intervene on all of them, we’d create chaos in our bodies.

I imagine as this story evolves, we’ll see two sets of recommendations emerge–one for women with a family history of cancer (or other higher-risk status), and one for everyone else.

Keeping up with all the flu news

A lot of people are wondering, Just how dangerous is the swine flu virus? (More formally known as, 2009 H1N1.)

The word from epidemiologists is: Not very dangerous, for most of us.

However ….  It’s quite dangerous to people falling in certain categories.  Watch out if you are: a pregnant women, a baby, elderly, immune-compromised, morbidly obese.  Or, if you have: any lung disease or disorder, an underlying chronic health problem.  (More details on this at the federal flu website.)

H1N1 virus particles invading body tissue. (CDC)

The easiest way to think about swine flu is that it’s remarkably similar to regular flu, except it spreads more rapidly.  Most people get only mildly sick and are better in three days or so.  I was surprised to hear epidemiologist Jeff Duchin of Public Health Seattle & King County go so far even as to urge most of us not to call the doctor.  There’s too much over-crowding as it is.

But there is some research that indicates this virus might be a little more dangerous than seasonal flu—especially for those in the “vulnerable” list I mentioned above.  For example, one team of researchers (at Imperial College in London) found the novel H1N1 flu virus lodges deeper in the lungs than regular flu virus.  That enables it to cause more severe lung infections and may account for some of the fatalities.  But it also is less aggressive in the nose and throat – making most infections less severe.

The message from this is, if you notice complications, such as breathing problems, don’t delay seeking medical help.  The best way I’ve found to sort all the usual questions is via Children’s Hospital of Atlanta, on their website.

Other tidbits:

• The vaccine tests are full of good news. It appears to be highly effective and can be given in a single dose.
• The first vaccine shipments may arrive on time, or even in early October.

Other recent posts and stories:

• “Schools ready for swine flu?” on this blog
• “Have Swine Flu, Should I Call a Doctor? Maybe Not” on KPLU
• “Swine Flu Vaccine Could Be Major Help, If It Were Ready” on KPLU

Schools ready for swine flu?

Soon after kids return to school, in the coming few weeks, we may see  the H1N1 swine flu come back with sudden swiftness.  That’s based on what’s happened during past pandemics, such as in 1957, and on the virus’ behavior in the southern hemisphere.  Are the schools ready?

It’s hard to tell.  They basically are continuing where they left off when the first wave of sickness passed through last spring.

My colleague, Jennifer Wing, reports on discussions between Public Health Seattle & King County and school districts.  They don’t plan to close schools this time, and sick kids won’t have to stay home for as long (it was a full week last spring).  But, from what we’ve heard so far, it doesn’t seem like anyone’s making contingency plans for absentee rates that might range in the 30-50% range.

The Virus: H1N1

Epidemiologists are concerned with getting timely updates on the numbers of absent students.  This is essential for monitoring when and where outbreaks are happening, and last spring some schools were better than others about reporting.

Don’t be surprised if outbreaks begin as early as September.  The evidence keeps mounting that wherever kids congregate in large numbers, that’s where you’ll see rapid transmission of flu virus.  In 1957, it took just 3-6 weeks after school started before  many cities saw a surge of illness.

What about a vaccine, to prevent illness?  The first doses may not be available until after the first wave of sickness.  But, there may be additional outbreaks long into winter, and the vaccine will protect against those.

On the other hand, swine flu infections still appears to be mild, unless you have an underlying sickness or medical condition.

The Magic Sweetener?

Dental researchers have known something most of us don’t know – that the natural sweetener xylitol can prevent cavities.  It may be about as good as fluoride.   Dr. Peter Milgrom, who teaches, researches and practices dentistry at the University of Washington, has become a big fan of xylitol.   Earlier this week, I reported on his latest study, showing a benefit to babies.

Here are some additional xylitol facts from Dr. Milgrom that I couldn’t shoe-horn into the story:

• The shortcomings of xylitol:   It has “cool” taste, similar to mint, so works best in cold foods or mint flavors. And it’s a little more expensive than other sweeteners.
• Most studies so far have shown you need to get at least two, often three, doses of xylitol per day to get a benefit.  And if it’s in a gum or toothpaste, for example, it needs to be the number one ingredient, not diluted with other sweeteners.
• But, if you get too much xylitol (admittedly rare), you might get stomach upset and diarrhea.
• There were some suggestive studies from Finland, using very small samples, saying xylitol also might prevent ear infections.   Weird, and not verified.   Milgrom has applied for funding to investigate that.

Birch trees in Finland (Flickr photo by Slider5)

Finland, by the way, is like the World Capitol for xylitol.  The Finns have been building up a xylitol industry, presumably because they can grow big crops of birch trees, which are the main source of the substance.

Milgrom’s research is mostly government funded, but he does get free xylitol for his experiments from a Danish company called Danisco.   If you’re intrigued, he says Danisco runs a credible website for basic facts about xylitol.

(What does xylitol do?  Basically, it blocks the bacteria that form dental plaques, interfering with their ability to feed and to stick to teeth.)

More about that “slow earthquake”

I wrote about “deep tremors” (also nicknamed “slow earthquakes”) last January, both in this blog and for KPLU.  You didn’t feel it, no matter where you live, but the quake happened under western Washington during April and May.  That was a couple months earlier than scientists expected.  So, they didn’t get their instruments in the ground in time to record it.  No matter — the deep tremors come back approximately every 15 months.

There’s a nice write-up by Sandy Doughton in The Seattle Times today.  She went on the scene, in Sequim, as the researchers lay down their seismometers in the Olympic forest (great photos, too), and she gives a lengthier explanation of the science behind (or beneath) these episodic tremors.

Findings I like, this month

These bits of research failed to make headlines, but you might enjoy them, as I did (disclaimer: I didn’t look into the quality of any of these studies):

• “Parents Influence on Children’s Eating Habits is Small.” Really?  How could that be?  Apparently, the community, peers, television viewing, and the “food environment” are more important.   I don’t think they were able to separate out young children from teenagers, for this study from Johns Hopkins University.  It claims to be the first-ever study to look at parental influence on eating habits.  (The news release is here.)
• Autism Medication is Ineffective for Repetitive Behaviors. This is from Seattle Children’s Hospital.  They compared a common anti-depressant (citalopram) that is used to control repetitive behavior in children with autism against a placebo, and found no benefit.  The children wring their hands, or rock back and forth.  The drug was prescribed because some clinician thought that there was a common problem with the brain chemical serotonin.  (The news release is here. )
• A New Material to Use Inside the Body — Blending Crustaceans and Polyester. Some University of Washington researchers are bio-engineering a substance that can blend two important qualities, stickiness and sturdiness.  You want a severed nerve to be able to grow back in the right direction, so you need some scaffolding that it can grab onto, like a wisteria in your garden.  And you need something that won’t dissolve too easily inside the body. This is an interesting blend, of shells and polyester.  They claim it has prospects for muscle and tendon repairs, too. (The news release is here.)

Chitosan and polyester fibers, at the nano scale. (UW)

• A Faustian Bargain, for Our Brains? This theory — and it’s more like a hunch — says our evolutionary history is a two-sided coin.  In exchange for evolving bigger, intelligent brains, we may have also been cursed with cancer.  Apparently, humans are more cancer-prone than other primates, and it may be related to a gene that kills off potentially bad cells.  By being more lax, our bodies are able to grow bigger brains.   (The news release is here.)

A concussion is a brain injury

Concussions are scary, the more you learn about them.  I like the way Brian Adler summarizes the underlying message:  “All concussions are brain injuries, and all brain injuries are serious.”  (Adler is an attorney who represents accident victims, not a doctor, but he seemed to get a lot of nodding heads at a  sports medicine conference in Seattle.)

The biggest danger is getting a second injury.

There’s been a lot of discussion among scientists and neurologists about concussions and athletics.  The most common system for many years makes a distinction between people who lose consciousness and people who don’t.  But, the latest guidelines, published this month as the “Zurich concussion statement,” says you don’t have to lose consciousness to have a serious concussion.  (I can’t find a free accessible version online.)

The new guidelines say youth athletes should never return to action on the same day as the injury (and adults should only take that risk after a medical evaluation).

Washington’s new youth concussion law (reported on KPLU) is perhaps the most advanced in the world, because one of its architects also served on the Zurich panel.  That’s Dr. Stan Herring of the UW/Harborview.  One big change is simply recognizing that each individual and each injury is different.  You can’t simplify by saying, it’s only minor because he never lost consciousness.  Instead, someone trained to evaluate head injuries needs to run the  victim through a series of tests, similar to a neurological exam.  If there are any problems with balance or coordination, for example, then the brain needs time to heal.

Technically, a concussion is less severe than a “mild traumatic brain injury.” But it can be hard to tell where one stops and the other starts.  A head injury can lead to internal bleeding, which damages brain cells by creating pressure inside the skull.  And a lot of damage happens when the “wiring” of the brain, the long axons that connect one brain cell to another, get severed.  There are bundles of axons, and a jolt to the head can rip them in clusters.  Such damage may not show up in x-rays.

Helmets?  Surprisingly, the international panel can’t agree on whether they’re a good thing in many sports, since they may encourage athletes to take bigger risks and hit things with their heads.  Helmets are definitely recommended for bicycling, skiing and snowboarding.

Oh yeah, one bit of good news.  Most concussions heal within a week and leave no lasting damage.

Flash-forward, the flu of December 09

Here are four interesting items I learned yesterday from King County’s chief epidemiologist, Jeff Duchin, MD.

1. Lesson learned:  Closing individual schools is not effective for limiting flu transmission in a community.  Next time — if the virus appears to be more deadly — the health department will close all schools in the county, perhaps for 8 weeks or longer.
2. Lesson learned #2: This virus spread far more rapidly than planning scenarios had predicted.  Basically, flu virus can be widespread before we know what’s hit us.
3. Who’s first in line for a vaccine, if there’s a limited supply? Heavy-duty planning is underway for how to distribute an A-H1N1 (swine flu) vaccine next winter, assuming it’ll be available.  This will be in addition to the normal, annual flu shots.   First-responders, and most medical workers, are clearly at the top of the list.  Pregnant women, and people with compromised immune systems.  After that, it might be all children under 18, given signs that they’re being hardest hit so far.  (Normally, the elderly are considered most at risk, but not in this case.)
4. If the virus remains less severe?  Expect simply a lot of people to be out sick, especially in schools, as everyone who didn’t get sick this spring, gets it on the second pass.   But, it wouldn’t be much different from what we’ve seen this past month.

And one note to the King County Board of Health:    Anyone watching (the meeting was recorded by King County TV) might be disappointed at the level of questioning by board members, as Dr. Duchin and other staff testified.  They asked thoughtful questions to clarify the facts.  But, nobody on the Board asked the simple questions, What parts of the “pandemic plan” did not work?  What surprises did the staff face? What needs to be improved before we face a severe pandemic?   (The lessons learned above came from a private interview, after the meeting.)

Flu reflections and questions

On Thursday afternoon, we’ll get the official “swine flu de-brief” from Public Health-Seattle & King County.  What will be the lessons learned?  Dr. David Fleming, the agency’s director, offered a possible preview back on May 4th, at a panel in Seattle hosted by the Washington Global Health Alliance (and televised by TVW).

It seems everyone involved with pandemic flu planning has been praising the response to this outbreak. Fleming said, “Boy, planning is really paying off.”  He was comparing the government reaction to anthrax and SARS outbreaks few years back, and noting that this time there was more “rational communication.”

But I don’t think the public perception is quite so triumphal.  People were confused and they see officials as being confused.  While the response may be much better than it would have been a decade ago, does it live up to the expectations of today?  After millions of dollars have been spent on pandemic flu planning, was this response good enough?

Here are a few points from the panel that struck me:

• At the peak of concern, supplies of Tamiflu were depleted at some health care centers in King County, and Public Health had to distribute some doses from the national strategic stockpile — and this was a mild strain of flu.
• Fleming acknowledged, “We planned for the wrong disease, a global pandemic of great severity,” or a high death rate. But it turned out to be a milder strain of flu.
• This strain of H1N1 spread much faster than anyone anticipated.  That means the information communicated to the public has been way behind what’s actually happening in the community.  On the other hand, officials are trying not to speculate in public, and offer assurances before they’re certain about what’s happening.
• Children and schools were a major source of transmission for this outbreak — which may have lessons for vaccinations next fall.  (A point made by Dr. Kathy Neuzil, of PATH and U.W.)
• Agricultural workers may be a weak-link in the global surveillance system, since flu viruses can jump more easily than many realize from poultry or swine to people.  There’s now system for tracking illness among these workers. (From Ann Marie Kimball, an epidemiologist at U.W.)

Swine flu and school closures – how much longer?

Wondering if you child’s school will be next?

The top public health officials in King County — Dr David Fleming, Director, and Dr. Jeff Duchin, Chief Epidemiologist — have been hinting that school closures may not be a tactic for much longer.

As my KPLU colleague Liam Moriarty reported this morning (Friday),  “So far, none of the folks in King County with the H-1-N-1 (swine) virus have gotten any sicker than they might from any of the old familiar flu viruses. Dr. Fleming says if that trend holds in the coming days – and this bug proves to not be particularly nasty – some of the precautions such as closing schools could be relaxed ….”

On the other hand, three students at Lakes High School, south of Tacoma, were taken to Madigan Army Hospital with severe flu-like symptoms, and as of Friday morning, two of them were in intensive care units, in serious condition.  That led to closing the school, as a precaution.

Seems sensible and prudent.   If tests show that they indeed are suffering from the swine flu H1N1, then we might see school closures  as a good tactic that should continue.

I have to say, the top officials in public health agencies and school districts have seemed remarkably indifferent to the hardship the closures cause.  In particular, for single parents and parents working jobs that offer little or no sick/vacation leave, this is a whole separate crisis.

When will a leader (the Governor? a Health Director?) stand up and say to employers, “We are in an emergency situation, and I’m asking all employers in the state to give extra sick days to anyone whose child’s school has been closed for a week?”

[UPDATE, Friday afternoon: Seattle Mayor Greg Nickels deserves a prize for being the first to address the work issue.  He told a news conference today that the city is offering extra flexibility to its employees ... and he called on other employers to do the same. ]

In case you missed it, in King County, four schools have been closed (as of noon Friday)(five schools as of Friday 4 pm)  because they each have a student who probably has swine flu.  (The reason for closures is to slow down the spread of the virus — to prevent a situation where lots of people are getting sick at once.  But, once the virus is confirmed to be widespread in the community, then there’s not much benefit from closing individual schools.)

If you’re like me, keep crossing your fingers that your child’s school doesn’t have a “probable” case during the next week, and maybe after that we’ll be beyond school closures.