We have been inundated with so much information about the 2009 H1N1 that it’s hard to keep it all straight. Here’s my top ten list of what’s most important to know, much of it coming from the website of the Centers for Disease Control and Prevention, which has done a spectacular job of providing timely and useful information:
1) What is the 2009 H1N1 Flu (Swine Flu)?
Different from the typical seasonal influenza virus, this is a new type of flu virus that appeared in Mexico in April, 2009 and soon spread to the United States and around the world. It contains a combination of genetic material found in influenza viruses that infect humans, birds, and pigs.
2) Why are people concerned about the 2009 H1N1 pandemic?
Over the past century, three major pandemics have swept through the world and caused severe illness and death. The most devastating by far was the influenza pandemic of 1918, which killed 40-100 million people worldwide and 500-750,000 Americans at a time when the U.S. population was only about 100 million. The 1957 “Asian flu” caused about 70,000 deaths when the U.S. population was about 170 million. The last pandemic, in 1968, killed about 34,000 out of 200 million Americans.
3) How does the 2009 H1N1 influenza compare to the typical seasonal flu?
Because the 2009 H1N1 virus is new, most people – especially children and young adults – have little or no immunity against it. It is spreading more quickly than the usual seasonal flu but seems to be somewhat milder – though still capable of causing severe illness and death. The typical seasonal flu affects 15-60 million Americans, leading to more than 200,000 hospitalizations. Annual deaths range from 17,000 to 52,000 annually, averaging about 36,000.
The elderly are especially at high risk of seasonal flu, with over 90% of deaths occurring in patients over 65. In contrast, 2009 H1N1 has preferentially affected young adults and children while older patients appear to have some immunity. Only 18% of deaths from H1N1 have been in patients over 65.
For both the regular flu and the 2009 H1N1, certain groups are at increased risk for complications once infected – children under 5, pregnant women, and patients with underlying medical conditions such as suppressed immune systems, asthma, diabetes, neurological disorders, kidney problems, and heart disease as well as adults over age 65.
4) What Can We Expect This Fall?
Flu virus tends to die down over the summer because it survives better when the weather is cold and dry than warm and humid. That’s why during our summer the H1N1 virus spreads to the Southern Hemisphere, where it’s winter. But the virus never really went away in America and is now surging much earlier than with the regular seasonal flu.
In August, a panel of experts prepared an extensive report for President Obama about the virus. While warning that the exact impact of H1N1 was impossible to predict, the panel outlines a “plausible scenario” that included 60-120 million infected Americans, as many as 1.8 million hospital admissions, and 30-90,000 deaths. Others, including the CDC, have suggested that these estimates are a “worst case scenario.”
Unfortunately, the influenza virus is famously unpredictable and the above “plausible scenario” could be way off in either direction. Although the virus is relatively mild now, it can quickly change on its own through mutation and become more deadly. Another way of changing is if two different viruses happen to infect the same cell at the same time. The two different strains could then trade genetic material. Hypothetically, the 2009 H1N1 that is currently sensitive to the antiviral medication Tamiflu could become resistant to Tamiflu if it combines with last year’s seasonal flu strain which was 99 percent resistant to the drug. Fortunately, until now the virus has been stable genetically and it remains sensitive to Tamiflu and Relenza.
5)What are the symptoms of the 2009 H1N1?
The symptoms are very similar to those seen with the regular seasonal flu: fever, headache, fatigue, cough, sore throat, runny nose, and aches and pains. In addition, there may be gastrointestinal symptoms such as nausea, vomiting, and diarrhea.
6) How can you catch H1N1?
Just as with the regular seasonal flu, the virus enters your body through your nose, mouth, or eyes. People infected with H1N1 shed virus starting a day before symptoms begin and lasting up to a week or longer in some patients. An uncovered cough or sneeze in a patient with influenza can send infectious virus-filled droplets into the air. If you touch a surface that’s infected with flu virus and then touch your mouth, nose, or eyes, the virus can enter your body and cause infection.
7) How do you prevent the seasonal flu and 2009 H1N1?
The most effective way is through vaccination – assuming you are in a group for which immunization is appropriate. The CDC recommends vaccination with both the regular seasonal flu vaccine, which is already being given, and the 2009 H1N1 vaccine once it becomes available around mid-October. So far, the 2009 H1N1 vaccine has been shown to be safe in adults; the CDC told me this week that studies in children and pregnant women should be done within about 2-3 weeks. Health officials want to vaccinate at least 159 million Americans. Experts predict there will eventually be enough vaccine for all Americans who want it. But only about 45 million doses are expected to be available with the first batch in mid-October.
Those on the priority list to get the 2009 H1N1 vaccine include pregnant women, people in close contact with infants 6 months and younger, health care workers, those ages 6 months to 24 years, and people ages 25 to 64 with serious conditions that put them at high risk for complications from flu.
Experts stress the importance of covering your mouth with a tissue when you cough or sneeze. Wash your hands often with soap and water or an alcohol-based hand cleaner. Remember: you don’t get flu from virus that’s only on your hands; you get it when you touch your face and give the virus a way to enter your body. Avoid close contact with sick people. And if you are sick with the flu, the current CDC recommendation is to stay home for at least 24 hours after your fever is gone without the use of fever-reducing medication. In some situations, the use of a face mask may be indicated, especially to try to prevent flu in patients at increased risk for complications; click here for the CDC’s recommendations.
8.) Who should receive treatment with anti-viral medication such as Tamiflu and Relenza?
Last week the CDC said that most people who come down with the 2009 H1N1 flu should just ride it out and not take antiviral medications such as Tamiflu and Relenza. Dr. Anne Schuchat of the CDC said the majority of adolescents, adults and children “can be cared for with mom’s chicken soup at home, rest, and lots of fluids.” But she stressed the importance of early treatment with antiviral medications – within 48 hours if possible – for certain patients at increased risk of complications, especially those hospitalized, under age 5, over age 65, or with chronic medical conditions.
A key change in advice from the CDC involves patients at high risk who may have been exposed to the H1N1 virus. Before last week, doctors were advised to give them medication to prevent infection; now doctors are being given the option of “watchful waiting” – observing the patient closely and only starting antiviral treatment if evidence of flu develops.
9) What warning signs should prompt immediate medical evaluation and treatment?
In adults, warning signs include: trouble breathing, pain or discomfort in the chest or abdomen, dizziness, confusion, severe or persistent vomiting, and symptoms that improve but then return with fever and worse cough. In children, warning signs include: trouble breathing, bluish or gray skin color, inability to drink enough fluids, severe or persistent vomiting, change in mental status (e.g., not waking up, not interacting, or being unusually irritable), and symptoms that improve but then return with fever and worse cough.
10) Should I get the 2009 H1N1 vaccine if I think I’ve already had the H1N1 flu?
The CDC told me “yes” – because the vast majority of patients diagnosed with 2009 H1N1 were not specifically tested for the virus. It may have been some other virus that made you ill. And even patients who had positive “quick tests” in the office for influenza A cannot be absolutely certain they had the 2009 H1N1 virus because the kits are sometimes wrong and because there’s a small chance that the strain of influenza A detected was NOT the 2009 H1N1. So the CDC recommends playing it safe and getting the both the regular seasonal vaccine and the 2009 H1N1 vaccine if you are in a group for which immunization is suggested.
For this week’s CBS Doc Dot Com, I discuss very practical advice – especially for parents – about H1N1 with Dr. Thomas Farley, who was appointed New York City Health Commissioner in May 2009 and immediately found himself smack in the middle of the 2009 H1N1 outbreak.
Click
here to watch the interview.
Last night, President Obama made a pitch for preventive care in his address to a joint session of Congress on health care:
“And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies – because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.”
As a doctor who has held the hands of patients dying from totally preventable illnesses, I couldn’t agree more. The largest number of deaths in the United States are caused by two preventable causes – tobacco smoking and high blood pressure – killing an estimated 467,000 and 395,000 people respectively in 2005. The list goes on and on, including obesity, physical inactivity, and poor diet.
When I was working in the emergency room as a medical resident, it was heartbreaking to see a patient with poor routine medical care roll into the emergency room with a devastating stroke that could have easily been averted with regular office visits and blood pressure medication – both relatively inexpensive compared to the cost of caring for the stricken patient.
We’re not preventing enough deaths by the types of cancer screening tests mentioned by President Obama. One reason is the technology is still not good enough. We need to develop better screening tests that pick up problems early but don’t lead to an unacceptable number of unnecessary biopsies, procedures, and further tests. And not enough patients are screened. Only about about 60 percent of women get mammograms and about 50 percent of men and women get routine colonoscopies.
Lack of insurance coverage is certainly a big reason why some patients don’t undergo screening. Another reason is patient fear and misunderstanding. In order to educate the public about the risks of colon cancer and the benefits of screening exams, Katie Couric underwent a colonoscopy on national television in March, 2000. Three years later, researchers at the University of Michigan found that colonoscopy rates jumped by 20 percent across the country following Katie’s procedure, calling the rise the
“Katie Couric Effect.”
It’s almost 10 years later and we’re still not screening enough patients. Although the death rate from colon cancer has dropped in recent years – likely mostly because of screening efforts – colorectal cancer still strikes almost 150,000 Americans every year and kills about 50,000.
As a gastroenterologist, I have seen patients’ lives saved by the removal of polyps and early cancers found by colonoscopy. I have also taken care of patients whose colon cancers were found too late to save them. Over the years, I must have heard every excuse for ducking a colonoscopy. The top four (and my answers):
I have no symptoms (most colon cancers start small and have no symptoms until they grow larger.)
I have no family history of colon cancer (that’s true in about 70 percent of patients with colon cancer.)
I’m afraid it will hurt (that’s why we use sedation and, if needed, anesthesia.)
I can’t do the prep (we’ll figure out a way to clean out your colon that you can tolerate.
And even if you have a tough night, it sure beats chemotherapy.)For this week’s CBS Doc Dot Com, I follow Katie’s lead and undergo a colonoscopy with cameras rolling in an attempt to remind people that a screening colonoscopy can save your life. I had the benefit of a house call the night before by my office nurse, Debbie Fitzpatrick, who held the video camera and offered advice and encouragement as I had a taste of my own medicine: the colon cleanout solution. The colonoscopy was performed expertly by Dr. Mark B. Pochapin, director of The Jay Monahan Center for Gastrointestinal Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
For more information about the Jay Monahan Center,click here.
For more information about screening for colon cancer, click here.To watch my colonoscopy, click below:
At a time when two thirds of Americans are either overweight or obese, health officials are correctly warning that most of us need to lose weight. But we may be setting ourselves up for a surge in eating disorders.
The two main types of eating disorders are food restricting (commonly referred to as “anorexia”) and binge eating and purging (commonly referred to as “bulimia”). The disorders typically begin in adolescence and affect women much more commonly than men.
Statistics are tough to come by – partly because of under-diagnosis and incomplete reporting – but a recent review estimated that 500,000 women in the U.S. have anorexia and 1-2 million women have bulimia.
A key feature of an eating disorder is the disparity between perception and reality. Over the past thirty years, obesity (BMI >= 95th percentile) in teenagers increased from 5.0 percent to 17.6 percent. While that rate has skyrocketed, it’s still much lower than the perceived rate of obesity among students.
Among children in grades nine through 12, 10 percent of females were obese and 15.5 percent were “at risk” for becoming obese (BMI >=85 percentile but <95th percentile). Yet 38.1 percent of students described themselves as overweight and 61.7 percent were trying to lose weight.
Put another way, more than half the women trying to lose weight were not overweight.
Why do people who are not overweight think they need to lose weight? There’s no simple explanation. Experts believe that genetic, environmental, psychological, and social factors can all play a role in eating disorders. Studies suggest that movies, magazines, and television contribute to eating disorders by idealizing overly thin women and exacerbating body dissatisfaction, especially in people with low self-esteem. Fashion magazines often feature models with obvious signs of anorexia. The theme is clear: less is more.
My intuition tells me we’re at a tricky point in the national discussion of weight. Since research suggests that the wrong public message can be especially dangerous for patients at risk of an eating disorder, we need to be very careful as we develop strategies against obesity. As they create their plans, agencies such as the Centers for Disease Control (CDC) should include experts in eating disorders.
For this week’s CBS Doc Dot Com, I talk to Leslie Lipton and her father, Roger, about how Leslie has successfully battled anorexia. Click below to watch the video:
I also interviewed Dr. B. Timothy Walsh, a renowned expert on eating disorders and Professor of Psychiatry at Columbia University Medical Center and author of the book, “If Your Adolescent Has an Eating Disorder.” Click below to watch the video:
For years my friends and patients have told me how surprisingly shocking the death of an elderly parent can be. We know it’s inevitable yet the finality is jarring. But knowing and KNOWING are two different things. So her son the doctor reacted just like so many others when my mother died unexpectedly last March at 86 after falling and striking her head. I found it hard to get my arms around the idea that my mother was no longer alive.
I received an outpouring of beautiful condolence letters and contributions but have only written a handful of thank you notes. My undoubtedly over-simplistic armchair psychiatrist explanation is that if I don’t write the notes then maybe she didn’t die. And I’m not alone in my behavior. My 90-year-old father, married to my mother for over 66 years, asked me a few months after her death if it was ok that he was pretending she was still alive. “Absolutely,” I replied. “That’s why God invented denial.”
My mother lived totally in the moment. She’d start to peel an orange and would say “at this moment this orange hasn’t seen the light of day.” Every morning she would look out the window at our breakfast table and say, “Good morning, dogwood tree.” More often than not, whatever she was experiencing was “the best ever.” The best ever sunset was the one she was watching. The best ever salad was the one she ordered at our last lunch alone together a few weeks before she died. Her best ever meal was the one she had just finished. She did not want to waste a single second, as was reflected in a hilarious essay she submitted to the New York Times upon turning 75. It was rejected; so here is the world premiere {link to NYT submission below}.
My wife had the idea to plant a dogwood tree on the top of the beautiful Vermont hill where we had sprinkled my mother’s ashes. Yesterday my family gathered under cloudy skies for the ceremony. One of my two sons sang a beautiful song he had composed using the lyrics of a poem called “Growing” that my mom had written when my three sisters and I were little.
Growing
Goodnight sweet baby and goodbye
I’ll see you as you are no more.
For dusk has settled in the sky
And you have wondrous dreams in store.
As you sleep, a magic hand will touch you
And you’ll grow more wise.
Tomorrow morning you’ll awaken
New and different in my eyes.
This morning my father admitted that he still finds it hard to accept she’s gone and sometimes imagines that “she’s just out shopping.” But we’re both starting to accept that we’ll see her as she was no more. This afternoon I’m going to start writing thank you notes in earnest. Well, maybe tomorrow.
***
Dear Editor:
I just celebrated my 75th birthday, and do you know what? I’m better than ever! Well, I guess you could say I’m stronger than ever. No, not in my muscles, which can be developed and maintained during regular workouts in the gym, but in my mind, which gets a daily ongoing on site workout. I now have the strength of my convictions, something I never had when I was young because in those days I always aimed to please, so that everyone would like me. I have now become much more assertive, more determined, more stubborn, and more aware of the passage of time, and as I calculate how much of it I have left, I have made a firm decision not to waste one moment of it.
With that thought in mind, here are some resolutions I’ve made to myself for the New Year:
1. I will not open unsolicited advertisements in the mail. This includes 10 million dollar lotteries and free trips to the Caribbean. Into the garbage they go!
2. I will not make dinner dates with boring people. This includes people who didn’t used to be boring but are now.
3. I will not put off doing things that I want to do.
4. I will not attend meetings out of a feeling of obligation.
5. I will not play singles rather than doubles in tennis or play an extra hour because I’m afraid to say no.
6. I will not ride when I can walk or walk when I can ride, depending on how I feel at the time.
7. I will not take part in long phone conversations with talkative people who are boring.
8. I will not dress up to go out if I feel like wearing a shirt, sneakers and jeans.
9. I will not shop ’til I drop. I never did and I certainly won’t start now.
10. I will not agree with someone unless I really do. I won’t be afraid to express my opinion.
11. I will hang up instantly on phone solicitors with no apology whatsoever.
12. I will remove the tag from each and every mattress that I own with absolutely no fear of penalty of the law, and when I make the bed I won’t always do hospital corners. Sorry, Mom!
13. I won’t be afraid to break a date if something better comes along.
14. I plan to make a lot of money selling something on Internet. Don’t know what yet.
15. I will not be intimidated by a surly maitre d’ or waiter. I won’t be afraid to send something back if it’s not to my liking, and if the rolls aren’t hot, back they’ll go.
16. I’ll squeeze the toothpaste from the top of the tube–so there!
17. I’ll watch every Seinfeld rerun, all Frasier episodes and all Woody Allen movies.
18. I will wear white before Memorial Day and after Labor Day if I want to.
19. I will always remember that health takes priority over everything, and I will guard it carefully.
20. I will keep smelling the roses and seeing, tasting, touching and hearing the world about me for a long, long time.
Senator Ted Kennedy’s death from brain cancer underscores the urgent need for more funding of basic cancer research. Despite the best efforts of a team of top doctors, Kennedy died 15 months after the diagnosis of a malignant brain tumor called glioblastoma. Over the past ten years, some progress has been made against this deadly illness and the silhouettes of some promising new approaches are becoming visible. But our treatment options remain woefully inadequate.
With over 560,000 cancer deaths each year, that comes to less than $10,000 in research spent for every cancer death. That simply is not enough money spent on a problem that strikes almost 1.5 million Americans each year and causes nearly one of four deaths.
Research for certain cancers is especially under funded. Earlier this year, I helplessly watched a dear friend and patient die from esophageal cancer, both of us knowing that only 22 million dollars each year – about $1,500 per death – was being spent by the NCI on the disease annually. One reason is that patients with esophageal cancer don’t have a strong advocacy group to push for their fair share of the funding pie. Lung cancer, which tops the list of cancer killers in America, only gets about $1,500 per death. At the top of the list based on research spending per death are cervical cancer (about $19,000), breast cancer (about $14,000) and brain cancer (about $12,000).
Click here for a chart that I compiled with the help of statisticians at the NCI that breaks down government spending on the top cancers.
Of course, there shouldn’t have to be a competition among cancer advocacy groups. There should be adequate funding of basic medical research to help discover the underlying cellular mechanisms that many cancers share and that hold the key to prevention, early diagnosis and effective treatment. But there’s not enough money for our young researchers. In 1980, almost 25 percent of first independent government grants went to scientists under age 35; that figure has plummeted to only 4 percent as the first-grant age rose from 34 to 42.
Faced with increasing competition for shrinking dollars, many of our best and brightest are considering other careers.
My cancer patients desperately need a bailout. The best way to increase our spending on cancer research responsibly is through health care reform. The Institute of Medicine has estimated that about 20 percent of the annual $2.5 trillion in health care costs is unnecessary. That’s $500 billion annually or 100 times the current budget of the National Cancer Institute. There could be no better tribute to Senator Kennedy or wiser investment in our own futures than to fix a broken system that threatens to bankrupt us while inadequately addressing one of our most devastating health problems.
For this week’s CBS Doc Dot Com, I take you behind the scenes to an edit bay at the CBS Broadcast Center in New York. I talk to Dr. Henry Friedman, an expert on brain cancer. He is co-deputy director of the Preston Robert Tisch Brain Tumor Center at Duke University Medical Center. In addition to hearing about the latest treatments for the disease, you’ll see the secret behind how we do long-distance interviews for the CBS Evening News with Katie Couric.
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