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What Is Secondary Prevention?

A November letter to the editor in American Family Physician chastises that publication for misusing the term “secondary prevention,” even using it in the title of an article that was actually about tertiary prevention.

I am guilty of the same sin. I had been influenced by simplistic explanations that distinguished only two kinds of prevention: Primary and secondary. I thought primary prevention was for those who didn’t yet have a disease, and secondary prevention was for those who already had the disease, to prevent recurrence or exacerbation. For example, vaccinations would be primary prevention and treatment of risk factors to prevent a second myocardial infarct would be secondary prevention.

No, there are three kinds of prevention: Primary, secondary and tertiary. Primary prevention aims to prevent disease from developing in the first place. Secondary prevention aims to detect and treat disease that has not yet become symptomatic. Tertiary prevention is directed at those who already have symptomatic disease, in an attempt to prevent further deterioration, recurrent symptoms and subsequent events.

Some have suggested a fourth kind, quaternary prevention, to describe “… the set of health activities that mitigate or avoid the consequences of unnecessary or excessive interventions in the health system.” Another version is “Action taken to identify patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable.” But this is not a generally accepted category. Read more »

*This blog post was originally published at Science-Based Medicine*

Ovarian Cancer Screening Is Still Subpar

Cancer of the ovary is a particularly nasty disease. It often remains asymptomatic until it has reached an advanced, incurable stage, and scientists have been unable to develop an effective screening test for the disease like the ones in widespread use for cancers of the breast and cervix.

The dismal status of ovarian cancer screening was underscored a year ago when an NIH-sponsored study showed that over 70 percent of cancers detected by transvaginal ultrasound and CA 125 biomarker testing — the two best ovarian screening tests we’ve got — had reached stage III or IV at the time the patients screened positive. That’s about what happens when women aren’t screened at all.

That wasn’t the worst of it, however. In just the first year of that screening program, positive test results obligated 566 surgical procedures which uncovered only 18 cancers. That’s an awful lot of unnecessary surgery and associated morbidity right there. Things were no better on the false-negative side of things. Overall, 89 cases of ovarian cancer were diagnosed during the NIH study, and a third of them had been missed by both screening modalities.

What’s new?

The NIH study didn’t evaluate the impact of screening on ovarian cancer mortality, but a recent study by Laura Havrilesky and colleagues at Duke did indeed address the point. Sadly, the results were abysmal. Read more »

*This blog post was originally published at Pizaazz*

Mental Illness And The Tucson Shooting

When reports arrived that accused gunman Jared Lee Loughner had opened fire in Tucson, Arizona on January 7, journalistic first responders linked the incident to the fierceness of political rhetoric in the United States. Upon reflection, some of the discussion has turned to questions about mental illness, guns, and violence.

And plenty of reflection is required, because the connections are not at all simple. To get a sense of just how complicated they are, we invite you to read the lead article in this month’s Harvard Mental Health Letter entitled, “Mental Illness and Violence.” Strangely (for us) it was prepared for publication a month before the tragedy in Tucson. In light of the shooting, we are making the article available to non-subscribers.

I am not surprised at the outrage expressed in the news or at the impulse to blame. A quick scan of the news, however, shows there is not much agreement about whom to blame. In addition to the alleged perpetrator, one can find explicit and implicit criticisms of politicians for playing to our baser instincts; of media figures, various men and women of zeal, for their disingenuous or manipulative partisanship; of the various community bystanders (police, teachers, doctors, family members, neighbors, friends), whom we imagine could have intervened to prevent tragedy.

The political debate flowing from this incident will continue, as will the endless cycle of blame and defensiveness. But I caution all of us — and especially mental health professionals — not to make clinical judgments about Mr. Loughner. Very few people will or should have access to the kind of information that would allow such judgments. From a public health perspective, however, we should make careful judgments about policies that could reduce risk. Read more »

*This blog post was originally published at Harvard Health Blog*

Skin Cancer Risk, Indoor Tanning, And Maternal Influence

teen tanning bedNot all maternal influence on daughter behavior is good. Take for example the influence of the unhealthy use of indoor tanning beds as presented in a recent Archives of Dermatology article (full reference below) which “investigated whether indoor tanning with one’s mother the first time would influence frequency of tanning later in life and whether it was associated with age of initiation.”

Joel Hillhouse, Ph.D., of East Tennessee State University-Johnson City and colleagues published a study the May 2010 issue of the Archives of Dermatology which looked at which health-based intervention worked best in reducing skin cancer risks. They found that “emphasizing the appearance-damaging effects of UV light, both indoor and outdoor, to young patients who are tanning is important no matter what their pathological tanning behavior status.”

For this study, Hillhouse and colleagues randomly selected a total of 800 female students who were then sent a screening questionnaire on their indoor tanning history. Those who reported ever indoor tanning (n = 252) were invited to participate in the study and offered an incentive ($5). A total of 227 (mean age, 21.33 years; age range, 18-30 years) agreed, signed informed consent documents, and completed assessments.

One of the questions asked who accompanied the participant the first time they indoor tanned (i.e. tanned alone, with friend, with mother, or other). Read more »

*This blog post was originally published at Suture for a Living*

When Cancer Hits A Doctor’s Home

This year has been a weird one for me and cancer. In the ER, we see cancer patients pretty infrequently. The occasional chemotherapy with fever, but that’s about it. I think the oncologists try hard to keep the patients out of the ER — to everybody’s benefit.

But this year, I’ve had a weird rash of cases where I’ve made primary diagnoses of cancer in the ER — several times over and over and over again. In ten years I don’t think I’ve made as many cancer diagnoses as I have this year alone. Just very strange.

Unfortunately, it came home to roost. My wife was diagnosed with breast cancer last week. Read more »

*This blog post was originally published at Movin' Meat*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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