2 Gazette Health | Summer 2012
A GAZETTE PUBLICATION
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Gazette Health is produced by The Gazette’s Special Sections, Advertising and Creative Services departments. It does not involve The Gazette’s newsrooms nor editorial departments. Send comments to email@example.com. Content is for informational purposes only and should not be construed as medical advice, nor as a substitute for seeing your own medical professional(s). COVER PHOTO: ISTOCKPHOTO/SANSARA
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Summer 2012 | Gazette Health 3
Because they have the wrong ratio of protein, fat and carbohydrates, cow’s milk, soy milk, rice milk and homemade formulas should not be given to babies younger than 1.
Percent of adults who have trouble sleeping who report difficulty remembering things
Percent of U.S. youth who are obese, triple the rate of the last generation
Beware of waterborne illnesses
Recreational bodies of water, including swimming pools, lakes and even oceans, can get contaminated with bacteria and viruses, especially from stormwater runoff. The most common illnesses caused by contaminated water include stomach and intestinal upsets, usually accompanied by vomiting or diarrhea. Because chlorine doesn’t kill germs imme-
diately, you can pick up these bugs even at properly treated swimming pools. To help protect yourself and others this summer: • Shower before and after going into a pool. • To help protect others from infectious germs, stay out of the water if you’ve had diarrhea in the last two weeks.
• Try not to swallow recreational water—or even seawater. • Avoid swimming or playing near places where stormwater is released on the beach. • Don’t go in the water for at least 24 hours after a storm. • Always remember to wash your hands before you eat or drink. -Excerpted from NIH News in Health
Danger in shifting summer temperatures? Summer temperatures that spike up and down may increase the risk of death in older people who suffer from chronic illnesses, including diabetes and heart failure. A new study by the Harvard School of Public Health found the association between summer temperature changes and mortality was especially strong in those 75 or older and in cities in warmer regions of the country.
4 Gazette Health | Summer 2012
A GAZETTE PUBLICATION
Signs of heat stroke, which is life threatening, include: • Fainting, which is possibly the first symptom • Body temperature over 104F • A change in behavior—confusion, acting strangely, staggering • Dry, flushed skin and a strong, rapid pulse or, conversely, a slow, weak pulse • Not sweating, even if it is hot -NIH
Percent of U.S. adults who are obese
90 to 98
Percent of sinus infections believed to be caused by viruses; antibiotics are ineffective in treating these
most common reason antibiotics are prescribed: sinus infection
-SOURCES: CDC and University of British Columbia and Vancouver General Hospital
ISTOCKPHOTO: SINUS INFECTION, LUGO; OBESITY, JANGELTUN; YAWN, BY_NICHOLAS; SWIMMING, STUDIO1ONE; FAN, GMNICHOLAS; BABY, YSAL
Percent who say they have trouble getting work done due to lack of sleep
Women take longer to give birth today than they did 50 years ago, probably due to different practices in the delivery room, according to a recent National Institutes of Health study.
Can coffee help you live longer?
WAYS TO TEMPT YOUR PICKY EATER Picky eating is usually temporary in young children. If you don’t make a big deal out of it, it will usually end before school age.
OFFER CHOICES. Rather than asking, “Do you want broccoli for dinner?” ask, “Which would you like for dinner: broccoli or cauliflower?”
SERVE THE SAME FOODS FOR THE ENTIRE FAMILY.
ISTOCKPHTO: PICKY EATER, NICOLESY; COFFEE, OKEA; LABOR, DIGITALSKILLET
Don’t be a short-order cook, making a different meal for your preschooler. Your child will be OK even if she doesn’t eat a meal now and then. NAME A FOOD THAT YOUR CHILD HELPS CREATE.
Make a big deal of serving “Dawn’s Salad” or “Peter’s Sweet Potatoes” for dinner. CUT FOOD into fun shapes with cookie cutters.
ENCOURAGE YOUR CHILD TO INVENT and to help you prepare new snacks or sandwiches. Have him help you make your own trail mixes from dry cereal and dried fruit.
HAVE YOUR CHILD MAKE TOWERS out of wholegrain crackers, spell words with pretzel sticks or make funny faces on a plate using various types of fruit.
JAZZ UP THE TASTE of vegetables with low-fat dressings or dips. Try hummus or bean spread as a dip for veggies.
CHOOSE FUN SNACKS AND MEALS:
SNAKE: Split mini bagels in two. Cut each piece into half circles. Spread the halves with toppings like tuna salad, egg salad or peanut butter. Decorate with sliced cherry tomatoes or banana slices. Arrange the half circles to form the body of a snake. Use olives or raisins for the eyes.
•ENGLISH MUFFIN PIZZA: Top half
of an English muffin with tomato sauce, chopped veggies and low-fat mozzarella cheese. Heat it until the cheese is melted.
SANDWICHES: Top a slice of bread with peanut butter and use an apple slice for a smile and raisins for eyes.
•FROZEN BANANAS: Insert
a wooden stick into a peeled banana. Cut large bananas in half first. Wrap in plastic wrap and freeze. Once frozen, peel off the plastic and enjoy.
•POTATO PAL: Top half a small baked potato with
eyes, ears and a smile. Try peas for eyes, a halved cherry tomato for a nose and a low-fat cheese wedge as a smile.
GRAHAM CRACKER SANDWICHES: Mix mashed bananas and peanut butter, spread between graham crackers and freeze.
A recent study from the National Cancer Institute involving people 50 to 71 showed that those who drank coffee—whether caffeinated or decaffeinated—had a lower risk of death overall than those who did not. Coffee drinkers were less likely to die from heart disease, respiratory disease, stroke, injuries, diabetes and infections, although no benefits were found regarding cancer. Researchers cautioned, however, that they can’t be sure whether these associations mean that drinking coffee actually makes people live longer.
•FROZEN JUICE CUPS: Pour 100 percent fruit juice
into small paper cups. Freeze. To serve, peel off the paper and eat. •ANTS ON A LOG: Spread peanut butter thinly on celery sticks. Top with a row of raisins or with other diced and dried fruit. - USDA
If you’re a baby boomer, the Centers for Disease Control and Prevention strongly suggests you get tested for hepatitis C. Last month, the CDC issued this “draft” recommendation, noting that those born between 1945 and 1965 account for more than threequarters of infected Americans, yet many “do not perceive themselves to be at risk.” Those risk factors include being born to a mother who was infected, having injected a recreational drug—even if only once and a long time ago—having received a clotting factor concentrate made before 1987, and having had a blood transfusion or organ transplant before 1992. The virus, which can take years to produce noticeable symptoms, damages the liver and can lead to death by cirrhosis or liver cancer. New treatments can cure up to 75 percent of hepatitis C infections, according to the CDC.
Summer 2012 | Gazette Health 5
AS MANY AS 1 IN 5 TEENS WILL SUFFER FROM MAJOR DEPRESSIVE DISORDER.
MORE THAN A MOOD
BAT T L I N G D E P R E S S I O N I N T E E N S BY KAREN FINUCAN CLARKSON
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A GAZETTE PUBLICATION
eens are known during the pubescent period to be anxious, a little rebellious and moody,” said Jackee Shull, staff clinical educator at Adventist Behavioral Health Rockville. Rapid developmental changes in the adolescent mind and body can result in moods that swing like a pendulum. But when melancholy becomes “pervasive and doesn’t go away and affects all aspects of life—biologically, academically, emotionally, socially and spiritually—that’s something else.” Depression is a serious medical condition that, untreated, can lead to substance abuse, criminal activity and suicide. Teens living with depression “talk about an overriding sense of inadequacy, hopelessness and helplessness in every part of their lives,” said Shull. In any given year, about 8 percent of adolescents will experience a major depressive episode, according to the National Alliance on Mental Illness (NAMI). And multiple authorities, including NAMI, say that at some point, up to 20 percent of teens will suffer from depression. While the condition does occasionally resolve spontaneously in youths, it tends to be recurrent, with one episode increasing the risk for another. Some 40 percent of teens will have a second bout of depression within two years.
There is a laundry list of warning signs but, according to Shull, the three more common ones are depressed mood, loss of interest in activities and general irritability. Irritability, which does not always present in adults, includes “frequent outbursts and increased frustration over minor issues that doesn’t subside and go away,” said the registered nurse. “Red flags are noticeable changes in thinking and behavior,” said Pedro Sarmiento Jr., M.D., a Waldorf pediatrician with privileges at Southern Maryland Hospital Center in Clinton. Teens “may lack motivation; become withdrawn, staying behind closed doors; sleep excessively; or experience a change in their eating habits. Softer, more subtle signs include apathy, body aches or pains, difficulty concentrating or making decisions, excessive guilt, forgetfulness or memory loss and anxiety.” It is a willingness to engage in risky behaviors—such as drug and alcohol use, promiscuity, shoplifting and fistfights—that differentiates teen depression from adult depression, according to NAMI. It is a preoccupation with death and dying or suicidal or homicidal thoughts that necessitates immediate intervention. SEVERAL BIOLOGICAL FACTORS ARE
known to contribute to depression in adolescents. The brain of a depressed teenager may appear
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physically different than that of his peers and may not contain the proper balance of neurotransmitters, chemicals that help communicate information, according to the Mayo Clinic. Changes in hormonal levels may have some bearing on depression as well. Environmental factors include high levels of stress, major losses, such as the death of a loved one, and early childhood trauma. Being subjected to bullying or struggling with one’s sexual identity can increase the risk of depression, according to NAMI. Socioeconomic factors also have been implicated. A brief from the National Institute for Health Care Management (NIHCM) Foundation points to studies showing that depression is nearly twice as high among adolescents whose mothers didn’t graduate from high school and 1.5 times as high for teens living with a single parent. Gender plays a role. Girls are twice as likely as boys to suffer from depression. “It’s not that girls are more emotional or dramatic,” said Shull. “It’s that boys tend to choose physical ways of acting out or avoiding problems whereas girls tend to ruminate, thinking things over and over in their minds.” Girls also are more prone to experience eating disorders, such as anorexia nervosa or bulimia, in conjunction with their depression, according to NAMI. Other coexisting conditions include ADHD, learning disabilities, and in 40 percent of cases, anxiety, according to the NIHCM report. Somewhere between 20 and 40 percent of teens with depression will, within five years of onset, show signs of bipolar disorder, an illness characterized by both manic and depressive episodes, according to the National Institute of Mental Health. A comprehensive medical
Somewhere between 20 and 40 percent of teens with depression will, within five years of onset, show signs of bipolar disorder. exam and psychological evaluation can determine if the bipolar disorder is a coexisting condition or the cause of the depression. MOST TEENS RECOGNIZE THAT
something is wrong, although they may not be able to label it or accurately articulate what they are feeling, said Sarmiento. “Half the battle is getting the teenager to open up and become aware. That requires trust.” “Hopefully you already have established effective ways of communicating,” said Shull, who suggested that parents address the issue openly and matter-of-factly. “Explain why you are concerned. Be specific. Describe the changes you’ve seen. Let them know that there is hope and help.” Listen intently. If a child’s problem is “specific to a situation—my boyfriend broke up with me or I wasn’t picked for a team—it may be something to work through and keep an eye on,” said Shull. If the mood seems more pervasive, with or without cause, help is in order. No matter what the parentchild dynamic, some teens are hesitant to share their depression with a parent. “Find somebody else who your son or daughter can relate to,” said Sarmiento—another relative, clergy member or pediatrician. The pediatrician is often the first stop on the road to treatment. “Be prepared to describe the changes you’re seeing or comments the child is making in order [continued on 16]
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Summer 2012 | Gazette Health 7
THE FIRST SYMPTOM OF SHINGLES IS USUALLY ONE-SIDED PAIN, BURNING OR TINGLING BEFORE ANY RASH APPEARS.
shingles The vaccine older adults might not know they need BY MARY WADE BURNSIDE
8 Gazette Health | Summer 2012
A GAZETTE PUBLICATION
ISTOCKPHOTO/VACCINE, ALEXRATHS; SHINGLES, ROSICASABOTANOVA
Shingles, a painful rash that usually presents only on one side of the body, is caused by the same virus that causes chickenpox. The risk of getting it increases as we age and our immune systems weaken. The vaccine for shingles is generally recommended for those 60 and older.
ara Vazer, M.D., once had a patient in his 40s who presented with shingles, a painful rash that creates blisters usually only on one side of the body. In this case, it was on the man’s chest. “He couldn’t put his shirt on,” said Vazer, a primary care physician at Adventist Medical Group in Gaithersburg. “Clothes, bed sheets, anything that touched his skin was hurting…” The patient put off going to the doctor, who put him on antiviral antibiotics when he finally did see her. The rash went away, but the pain continued for a year, Vazer recalled. That patient’s ordeal was not uncommon with shingles, which is why Vazer recommends the shingles vaccine, Zostavax, available to older adults. Shingles is caused by the varicella-zoster virus, the same virus that causes chickenpox. After a person has had chickenpox, the virus becomes dormant in certain nerves, and can reactivate years later to produce shingles.
The risk of getting shingles increases as a person ages because immunity weakens, which is why the Centers for Disease Control and Prevention (CDC) recommends the vaccine for those 60 or older. “Anyone who has had varicella may develop herpes zoster [i.e., shingles], including children,” said Tara Saggar, M.D., medical director of the Medical & Surgical Clinics of Southern Maryland, an affiliate of Southern Maryland Hospital Center in Clinton. “However, herpes zoster most commonly occurs in older people, with the risk increasing sharply after 50 years of age. It is also more common in people who are immunocompromised or who are taking medications that suppress the immune system.” In May 2006, Zostavax was approved by the U.S. Food and Drug Administration (FDA) for shingles prevention in those 60 and older, and five months later, the CDC issued the same recommendation. Last year, the FDA approved it for those 50 to 59, noting that shingles affects
and primary chickenpox infection in adults tends to be more severe, with a higher risk of varicella pneumonia, a nasty pneumonia that can land you in the hospital,” she said. According to Posorske, the shingles vaccine might not be a good fit for anyone who has any immune deficiency, including HIV, has lymphoma/leukemia, or takes highdose steroids. The CDC advises cancer patients undergoing radiation or chemotherapy to avoid the shingles vaccine.
The vaccine, a one-time injection covered by most insurance, was most effective for people between 60 and 69. Although shingles can sometimes be difficult to treat with complete effectiveness, it is usually easy to diagnose, Posorske said. “The shingles rash is one that we can often diagnose from across the room. It’s the only rash that stops, dead center, at the midline of the body.” Posorske said interest in the vaccine among her patients is “moderate,” but like many doctors and government health agencies, she believes it is important. “Both of my now-deceased parents, and both my in-laws, now in their late 80s, have had shingles, so I’ve had more than enough opportunity to observe that this can be painful and sometimes produce long-lasting consequences, so I feel strongly about it.”
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200,000 otherwise healthy people in that age group each year. The CDC declined to mirror that recommendation, saying in part that data is limited on the long-term effectiveness of the vaccine. According to the CDC, in a clinical trial conducted with 1,000 people 60 and older, Zostavax reduced the risk of shingles by 51 percent and the instance of postherpetic neuralgia—the lingering pain after the rash disappears—by 67 percent. The vaccine, a one-time injection covered by most health insurance, according to both doctors, was most effective for people between 60 and 69, but still provided protection for elder individuals, the CDC reported. Zostavax, Saggar said, differs from Varivax, which is the vaccine for chickenpox, in that the shingles vaccine consists of attenuated varicella virus at a concentration 14 times that of the chickenpox vaccine. The shingles vaccine, not for use in children, cannot be used in place of the chickenpox vaccine, and vice versa, she said. Risks associated with the shingles vaccine include “redness, soreness, swelling or itching at the shot side and headache,” as well as a chickenpox-like rash near the injection site, she said. Older adults who have not had chickenpox and wonder which vaccine to get should have a blood test, said Lynette H. Posorske, M.D., a partner at Montgomery Infectious Disease Associates in Silver Spring who practices at Holy Cross Hospital. “If varicella antibodies are positive for past infection, then I recommend the shingles vaccine. If they are negative, then the chickenpox vaccine. It’s a higher dose
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Summer 2012 | Gazette Health 9
4 OUT OF 5 WHO SUFFER FROM INCONTINENCE ARE WOMEN.
SUFFERING IN SILENCE the latest treatments for urinary incontinence BY ARCHANA PYATI
10 Gazette Health | Summer 2012
A GAZETTE PUBLICATION
n a gorgeous day in May, Terri Merryman and her husband celebrated their 25th wedding anniversary by heading to Chesapeake Beach. The couple hopped in the car for a relaxing hour-long drive, lingered over a seafood lunch at the Rod ‘N’ Reel Restaurant and took a leisurely stroll along the water before returning home. For Merryman, a 51-year-old nurse who lives in Silver Spring, the occasion wasn’t just a watershed moment in her marriage, but also a personal milestone: “I did the whole drive without having to go to the bathroom,” she said. Before her pelvic reconstructive surgery in 2011, the trip would’ve been impossible. For years, she suffered from urinary incontinence, a problem she had postponed treating out of fear and uncertainty. Outings with her family had become a thing of the past as her need to be near a bathroom took priority. “My husband and I never went very far,” she recalled. “It was upsetting to him, and upsetting to me because I was holding everyone back.” Urinary incontinence itself is not a disease, but rather a serious symptom of underlying damage to the muscles, nerves and tissues surrounding the bladder. In Merryman’s case, her pelvic organs—her bladder, uterus and rectum—had fallen out of place, a problem known as prolapse. The cause is a common one among
“The more they void without their bladder being full, the more the bladder feels like it has to void without being full.” -Lynne Schill, physical therapist
women who have experienced vaginal childbirth. Both of Merryman’s children had been 10 pounds at birth, causing her pelvic floor muscles to stretch and lose their supportive function. While both sexes suffer from incontinence, it is more common in women. The National Association For Continence estimates that of the
25 million adult Americans who experience incontinence, as many as 80 percent are women. And while incontinence has long been associated with the elderly, doctors say they are seeing greater numbers of younger women—in their 30s and 40s—coming to their offices complaining of involuntary loss of urine. “They want to come in, they’re doing their research, they’re leaking, and they’re asking their gynecologists about it,” said Anita Pillai-Allen, M.D., the pelvic surgeon and urogynecologist who performed Merryman’s surgery at Holy Cross Hospital in Silver Spring. STRESS AND URGE INCONTINENCE
are two distinct conditions, although occasionally, a woman will have both. Stress incontinence happens when the urethra, the tube that carries urine from the bladder out of the body, loses support from the pelvic floor muscles and becomes “hypermobile.” A woman with stress incontinence will leak urine when she exerts herself through coughing, laughing, sneezing, vigorous exercise or heavy lifting. Pelvic floor muscles deteriorate for a variety of reasons, said Pillai-Allen. Vaginal births and surgical procedures that assist vaginal births, such as an episiotomy, traumatize the muscles and nerves of the pelvic floor. Genetic factors also come into play, with some women inheriting weaker connective tissue around the pelvis.
Hormonal changes may also prevent women from tightly contracting pelvic floor muscles, said Cynthia Moorman, M.D., a staff urologist with Frederick Memorial Hospital. “As we get older, estrogen levels decrease, which decreases strength and tightness in those muscles,” she said. That may be why some women, like Merryman, don’t experience loss of urethral support until years after giving birth. “Our bodies are better at recovering when we’re younger.” The most common treatment of stress incontinence is the surgical placement of a sling around the urethra. The sling, crafted from a narrow strip of a synthetic material called polypropylene, is inserted through the vagina and held in place by tissue surrounding the urethra and bladder, according to interviews with doctors and marketing materials from American Medical Systems Inc., a manufacturer of a brand of the sling. While the sling procedure is widely practiced and considered safe, after receiving complaints of pain and injury among women who had undergone the surgery, the U.S. Food and Drug Administration released a statement last year urging doctors and patients to proceed with caution. Slings have a less than 1 percent chance of eroding and breaking through the vaginal wall, a result more commonly seen with larger meshes used to treat prolapse, where all the pelvic organs need to be lifted back into place, said Moorman. “People are hesitant to use meshes. The bigger the mesh, the more problems you could have with them.” URGE INCONTINENCE IS CAUSED
by a miscommunication among bladder nerves, the central nervous system and the brain, causing an overwhelming urge to urinate, said
Moorman. Much less is understood about its origins and the best way to treat it. Women with neurological damage caused by strokes, Parkinson’s disease, multiple sclerosis, spinal cord injuries—even diabetes, as high blood sugar levels can impair nerves—may struggle with urge incontinence. “The bladder is saying to the brain, ‘you’ve got to go,’” even if the bladder isn’t full, said PillaiAllen. Two-thirds of women who incessantly feel the need to urinate, also known as overactive bladder or urgency frequency syndrome, don’t actually wet themselves, she said. Yet they may be running to the bathroom dozens of times a day. “We have to teach them to overcome the urge and to enable their bladder to fully expand,” said Lynne Schill, a physical therapist at FMH Crestwood in Frederick who treats women with incontinence. “The more they void without their bladder being full, the more the bladder feels like it has to void without being full.” Medications can temporarily calm the bladder’s hyperactivity but have significant side effects, such as dry mouth and constipation, said Moorman. In those cases, doctors may recommend InterStim Therapy. InterStim Therapy stimulates nerves that control the bladder by sending electrical pulses through a thin wire inserted near the tailbone. During a trial period, the pulses are generated through a device a woman wears externally, according to Medtronic, which manufactures the device. If the therapy proves successful, as a long-term solution, a neurostimulator can be surgically implanted under the skin of the upper buttock. While InterStim has proven life changing for many patients, doctors [continued on 17]
Summer 2012 | Gazette Health 11
BEGINNING IN THEIR 30s, MEN START TO EXPERIENCE ABOUT A 1% PER YEAR DROP IN TESTOSTERONE LEVELS.
BY KAREN FINUCAN CLARKSON
12 Gazette Health | Summer 2012
A GAZETTE PUBLICATION
exam can uncover causes other than aging, for which treatments may return testosterone levels to normal. There is a range of normal. A lab test measures the amount of testosterone in the blood. Results typically would fall between 300 and 1,200 ng/dl (nanograms per deciliter). If a man is experiencing symptoms associated with low testosterone—such as low libido, erectile dysfunction, reduced muscle mass or irritability— “but is told he has ‘normal testosterone,’ he should press the doctor and find out if he is in the lower third, middle third or upper third. If he has a level of 350 and we can get it to 600 or so, he may see significant improvement,” said Litvak. Low testosterone affects men differently, said Eric Emanuel, M.D., a urologist with MidAtlantic Urology Associates who has privileges at Doctors Community Hospital in Lanham. “There are men with low testosterone who are completely unaware of it; they have no outward indications,” he said. Treating low testosterone has become easier and more convenient over the past decade. Because oral testosterone is toxic to the liver,
hile it’s not realistic to look at testosterone replacement as a fountain of youth, the increasingly popular therapy holds great promise for men whose quality of life has deteriorated over the decades due to a drop in hormone levels. “The benefits of therapy include increased sexual desire and function, improved muscle mass, enhanced mood and even perhaps improved cognitive function,” said Jared Berkowitz, M.D., a urologist with Frederick Urology Specialists and privileges at Frederick Memorial Hospital. More than 13 million men in the U.S. suffer from low testosterone, according to the American Diabetes Association, but less than 10 percent of them receive treatment. Still, that’s significantly higher than treatment rates around the globe. The average across European countries is under 1 percent and in Australia it’s just over 1.6 percent, according to a March 2009 report on the National Center for Biotechnology Information’s website.
Produced primarily in the testes, testosterone is a hormone “that during fetal development and puberty leads to the growth of the male sexual system,” said Berkowitz. During puberty, it puts hair on the chest and deepens the voice. “It also has an important role in the general physiology of the male, our overall homeostasis,” said Juan Litvak, M.D., a urologist with Urological Consultants, who has privileges at Suburban Hospital in Bethesda. “It influences energy, bone and muscle health, and metabolism—the way we process and store fat.” A dip in testosterone levels is normal as men age. “Men in their 30s start to see a slow decrease, about 1 percent a year,” said Berkowitz. “But it’s generally not until their 50s that they start to notice changes.” There are other reasons, apart from aging, why testosterone levels may be low. Kidney or liver disease, diabetes, obesity, injury to the gonads or testes, or a disorder of the pituitary gland in the brain that controls the release of many hormones may be the culprit, according to Berkowitz. “Rarely, some medications may lead to low testosterone,” he said. A medical
the delivery mechanism of choice was, for many years, injection. “That would require office visits every three weeks,” said Emanuel. Patches came next, but caused skin irritation in some men. “Then there was a whole run of topical gels and, more recently, Axiron, which you rub into your armpit much like you do with an antiperspirant. The newest option is implantable pellets.” Known as Testopel, these cylindrical pellets are about an eighth of an inch wide and three-eighths of an inch long. “I numb a 2-by-2centimeter area on one buttock and make a 3-millimeter incision,” said Emanuel. “Then I use an insertion device to implant the pellet in the subcutaneous tissue.”
“Anyone who is potentially interested in fathering a child should understand the risk.” The therapy does not cause prostate cancer, “but it can accelerate pre-existing prostate cancer,” said Kurnot, who uses a prostatespecific antigen (PSA) test to help detect cancer. “Hormone-dependent cancers, such as prostate cancer, are easy to detect.” While men with prostate cancer are not candidates for testosterone replacement, it’s less clear as to whether former cancer patients should undergo the therapy. “Some newer studies say those who were adequately treated and whose cancer has not recurred may be eligible,” said Berkowitz. “It’s an area of ongoing investigation.”
The newest treatment option is pellets, known as Testopel, implanted in the buttock. Testopel is the most effective treatment currently available. “A topical [gel] might bring levels up 20 to 30 percent. With continuous dosing, a patient might go from 300 to 400,” said Emanuel. “With Testopel, a patient could go from the mid 300s to 700 or 800, even to the higher end of normal.” Testopel requires that patients see their doctor every three to six months, according to Richard A. Kurnot, M.D., a urologist with Chesapeake Urology Associates who has privileges at MedStar Montgomery Medical Center in Olney. “I bring them back in the first couple of months to check their blood cell count and liver enzymes,” he said. Testosterone replacement can cause polycythaemia, “a condition where the blood gets too thick. It can also be toxic to the liver.” Replacing testosterone can have “a detrimental effect on sperm production,” said Emanuel.
The effects of testosterone replacement therapy are felt in short order, according to Kurnot. “Patients can feel good within weeks—a whole lot better. It differs from patient to patient, but the sky’s the limit.” Men who begin testosterone replacement therapy may need to continue with it over the long term as it “actually shuts off the body’s own production of testosterone,” said Kurnot. “The higher levels of testosterone in the blood signal the brain that the body doesn’t need to create any more, and so it shuts down.” While testosterone replacement therapy may come across as the ultimate anti-aging formula, physicians claim that’s not so. “We are not using super-therapeutic amounts but, rather, bringing testosterone levels back to where they should be,” said Litvak. It is about “restoring health and a general sense of well-being.”
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Summer 2012 | Gazette Health 13
1 IN 50 AMERICANS SUFFERS FROM OCD, WHICH IS CLASSIFIED AS AN ANXIETY DISORDER.
BY KAREN FINUCAN CLARKSON
can be,” said Eyre. “They will turn themselves into pretzels to do it.” And they cannot stop even if the practice becomes physically painful or damaging, he said. “Patients generally know there’s a problem, that their thoughts are irrational,” said Eduardo Espiridion, M.D., chief of psychiatry for Frederick Memorial Hospital. That does not mean they readily get help. “By the time most seek treatment, they’ve been suffering for years.” The average age of onset is 19, according to the National Institute of Mental Health. “We usually see it in early adulthood,” Espiridion said. “There’s no predilection for gender; men are equally as affected as women.” Gender may not matter, but intelligence does. “There’s a positive correlation between higher intellect and this disorder,” said Eyre. Many gifted and talented individuals have suffered from OCD.
or some, relief comes only after washing their hands, perhaps a dozen times or more, until the parched skin cracks and bleeds. Others must check, sometimes several times an hour, that the door is locked, the stove is off, the hair dryer is unplugged. Still others become extreme pack rats, cluttering their homes with useless items. These rituals are a few of the more common ways in which people with obsessive-compulsive disorder (OCD) seek to alleviate the stress associated with their illness. Classified as an anxiety disorder, OCD afflicts roughly one in 50 Americans, according to Stan Eyre, administrative director/educator of psychiatry at Southern Maryland Hospital Center in Clinton. THE DISORDER IS CHARACTERIZED BY
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OCD SHOULD NOT BE CONFUSED
Recognizing and living with obsessive-compulsive disorder washing, showering, cleaning and repeatedly checking things—are routinely associated with OCD, compulsions can take other forms, such as avoidance or hoarding. Hamilton noted that someone with obsessive thoughts about injuring a child might avoid holding a baby or visiting playgrounds or schools. Compulsive hoarding is experienced by 25 to 40 percent of those with OCD, according to the Obsessive-Compulsive Disorders Clinic at the University of California, San Diego. Not all hoarding is compulsive, however, and may be
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caused by other psychiatric disorders, or no psychiatric disorders at all. Studies to identify root causes are ongoing, according to the clinic. THERE IS NO ENJOYMENT, ONLY A
temporary sense of relief, associated with the rituals and behaviors of OCD suffers. In many cases, the compulsion, like the obsession, does not mesh with an individual’s selfimage, according to Eyre. And as the need to perform the ritual or behavior eventually grows, so too does the shame associated with it. “It’s amazing how secretive this class of patient
with a condition known as obsessive-compulsive personality disorder (OCPD), said Hamilton. Those with OCPD tend to be preoccupied with orderliness, perfectionism and control in every part of their lives. “Imagine a type ‘A’ personality on steroids—meticulous, rigid. That person does not, however, have obsessions and compulsions,” she said. “Another key difference between the two disorders is that those with OCPD find their personality consistent with their self-concept and those with OCD do not.” Obsessive-compulsive disorder tends to run in families. Recent research found that low levels of a neurotransmitter known as serotonin could be responsible for the disease. This serotonin imbalance also may be genetic, Eyre said. The prevailing theory is that stress does not cause OCD, but that it serves as a trigger. “Many researchers believe it [OCD] has
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unwanted, irrational thoughts and compulsive behaviors, which a person adopts to hold the thoughts at bay. “These are intrusive thoughts or images that an individual can’t shut off,” said Lynnae A. Hamilton, program director for adult services at Adventist Behavioral Health Rockville. “The thoughts are not usually associated with real-life concerns, such as being late to the babysitter or forgetting to pay a bill. They can be violent or sexual in nature and repulsive to the person—not at all consistent with the person’s self-concept.” The inability to control the thoughts and their objectionable content drives OCD sufferers to embrace ritualistic behaviors to try to ward off the thoughts. “There’s nothing exact or prescriptive about the rituals,” said Hamilton, noting that the obsession and compulsion “are not always tied together.” While rituals—such as hand
WHAT IT’S LIKE “I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good-luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ‘bad’ number. I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I got treatment.”
been at the sublevel all along and a trauma brings it to the surface,” said Eyre. “I’m convinced that something happens chemically due to a life-changing event,” thereby causing OCD. Despite the possible biological component, there is no lab test to diagnose OCD. A mental health practitioner bases a diagnosis on an assessment of the patient’s symptoms—including how much time a person spends on rituals or compulsive behaviors—based on interviews with the individual and, when possible, family members or a significant other. Many clinicians rely on the YaleBrown Obsessive Compulsive Scale, which is designed to rate the severity and nature of OCD symptoms. “The scale is an important tool, but the patient history is how you really hone the diagnosis,” said Eyre. “There is no cure for obsessivecompulsive disorder, but there are treatments,” said Espiridion. The most effective combines medication with cognitive behavioral therapy (CBT).” The idea behind CBT “is to cut the relationship between the obsession and compulsion and to give the patient back control,” said Espiridion. “We try to disconnect the two so that even if you have the thought, you don’t have the action.”
The therapy includes something known as exposure and response prevention. “Slowly, over time, we expose them to what they fear….It can take years to achieve. We can’t just flood them with stimuli or they won’t stay in therapy. It must be done gradually.” The first medication considered when treating OCD is a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI), such as Paxil, Zoloft or Prozac, according to the National Institutes of Health. If the SSRI is ineffective, older antidepressants may be prescribed. The advantage to SSRIs is that there generally are fewer side effects. Anti-anxiety medications may also be combined with these treatments. While the majority of patients benefit from treatment, some 30 percent retain some level of impairment, according to Espiridion. But, he said, treatment is imperative. “People who have OCD are predisposed to develop depression, and when they are depressed, they are at risk for suicide.” While OCD symptoms may ebb and flow, there is virtually no such thing as a symptom-free period, according to Eyre. Throughout the suffer’s life, obsessions and compulsions will diminish and escalate. But those who “remain in behavioral therapy will get the redirection and support needed to maintain control in their lives.”
-Excerpted from an unattributed description published by the National Institute of Mental Health, 2010
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TEEN DEPRESSION, continued from 7
to help the pediatrician understand that this is not just the usual teenage stuff. Some pediatricians are comfortable treating depression. For most, it’s not their area of expertise and they will refer your child for a mental health assessment,” said Shull. A DIAGNOSIS OF MAJOR DEPRESSION
is based on professional observation and evaluation, information provided by family members, and the criteria found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders—commonly referred to as the DSM. Those criteria mandate, for example, that a depressed mood must last more than two weeks and that symptoms interfere with day-to-day activities. The assessor is likely to ask parents to provide detail about any trauma a teen has previously undergone and any challenges he is facing, according to NAMI. Of the 1.9 million teens who suffered a major depressive episode in 2010, the most recent year for which statistics are available, about 38 percent received treatment, the Substance Abuse and Mental Health Services Administration reported. Medications and psychological counseling, individually or in concert, can help most teens combat it. Psychotherapy and cognitive behavioral therapy are the two most common nonmedicinal forms of treatment for teen depression. Psychotherapy is intended to help teens find relief from emotional pain and gain insights into their struggles. When done on a regular basis, it allows the teen “to build a trusting relationship—one where they feel understood by a person whose empathy is authentic—with a supportive adult,” said Shull. “Cognitive behavioral therapy helps teens…change the way they are thinking and perceiving things. It is very empowering,” said Shull. “Instead of someone else figuring them out, they begin to figure themselves out and master skills— ways to relax and cope—that can be used for the rest of their lives.”
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“If they are diagnosed and there’s intervention in their teen years, they’ll
go on to lead productive lives.” -Jackee Shull, staff clinical educator
In some cases, family or group therapy may prove beneficial. Improving interpersonal relationships and communication and decreasing conflict is at the heart of family therapy, said Shull. Group therapy, as a supplement to individual therapy, can “help a teenager realize there are others with similar feelings and who also have experienced rejection.” SEVERAL ANTIDEPRESSANTS ARE
available to treat depression but, noted Shull, not all are approved for teens, whose brains are still developing. “Because everyone’s chemistry is different, it may take time to find the best medication that will stabilize a teenager’s mood.” Although antidepressants generally are considered safe when taken as directed, they can in some instances increase the risk of suicide. In 2004, the U.S. Food and Drug Administration required that warnings to that effect be included with antidepressants. The greatest risks associated with the use of antidepressant medications exist in the first few months of treatment, so teens should be closely monitored. Because some can cause withdrawal symptoms, teens should never abruptly stop taking their medication. While depressive episodes may recur throughout the teenage years, they generally stop by early adulthood. “Statistics show that about 20 percent who have risk factors may go on to have depression in their adulthood,” said Shull. “But if they are diagnosed and there’s intervention in their teen years, they’ll go on to lead productive lives. They’re not fated to deal with it forever.”
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say it won’t guarantee dryness 100 percent of the time. “They will still have good days and bad days,” said Moorman. “If you were using 10 pads a day, now you may only be using three.” But even that, she said, represents a significant improvement in a woman’s quality of life. BEFORE RESORTING TO SURGERY,
PHOTO BY ARCHANA PYATI
This urodynamics machine in Anita Pillai-Allen, M.D.’s office is among the diagnostic tools used to assess patients with incontinence.
and physically tense state. “I encourage positive self-talk,” she said. “They have such a negative self-perception, so I get them to tell themselves: ‘I deserve to be dry. I deserve to not have to wear mini pads during the day. I deserve to sleep through the night.’”
TERRI MERRYMAN SAID SHE STARTED
to feel depressed the longer she held herself back from participating in activities with her family. Women may isolate themselves and feel embarrassed by having to be near a bathroom at all times or by odor caused by leaks. Incontinence can also be detrimental to a woman’s sex life with her partner. Beyond sex, Moorman said, what’s most devastating to her patients—especially baby boomers and younger generations—is stopping their exercise routine or curbing their social activity. “There are [also] old ladies who stop going to church. They’re afraid they’re going to wet themselves and won’t make it to the bathroom.” More and more, these women are exploring their options instead of suffering in silence—like Merryman, whose surgery last year changed her life forever. “I was so happy I did it,” she said. “It’s such a relief to know I can go places with my husband and my kids and not have to worry about stopping every 10 minutes.”
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doctors use a variety of diagnostic tools to understand a woman’s specific case of incontinence. Urodynamic testing determines how well the bladder and urethra are functioning. One test involves patients voiding into special equipment that measures the amount of urine and the rate at which it flows out of the body, while another requires insertion of a catheter into the urethra to examine the bladder. Burkhardt Zorn, M.D., a urologist with CHZ Urology in Clinton, suggests sticking to a schedule for going to the bathroom, a technique he calls “timed voiding,” and retraining the bladder to hold urine for longer than what might initially feel comfortable. Physical therapy for the pelvic floor is another popular nonsurgical treatment for incontinence. A woman consciously contracts and releases pelvic floor muscles, exercises named after California gynecologist Arnold Kegel. Physical therapist Schill asks patients to practice Kegels while connected via vaginal and abdominal sensors to a biofeedback machine. The machine measures how strong their muscle contractions are, and the results are displayed as peaks and valleys on a screen. “When it comes to the pelvic floor, we can’t see what’s happening on the inside, so this is a great way for us to see what’s happening without having to do an internal exam every time they come in,” she said. In addition to Kegels, patients practice lunges and squats to strengthen hip, back and abdominal muscles. Schill also recommends deep breathing from the diaphragm to help relax patients, many of whom are in an emotionally fragile
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experts’ advice National Institutes of Health
Breaking Bad Habits
you know something’s bad for you, why can’t you just stop? “Humans are much better than any other animal at changing and oriAbout 70 percent of smokers say they’d like to quit. Drug and enting our behavior toward long-term goals, or long-term benefits,” said alcohol abusers struggle to give up addictions that damage their bodies Dr. Roy Baumeister, a psychologist at Florida State University. His studand tear apart families and friendships. And many of us have unhealthy ies on decision-making and willpower have led him to conclude that excess weight that we could lose if only we would eat right and exercise “self-control is like a muscle. Once you’ve exerted some self-control, like more. So why don’t we do it? a muscle, it gets tired.” “Habits play an important role in our health,” said Dr. Nora Volkow, After successfully resisting a temptation, Baumeister’s research director of the National Institute of Health’s (NIH) National Institute on shows, willpower can be temporarily drained, which can make it hardDrug Abuse. “Understanding the biology of how we develop routines er to stand firm the next time around. In recent years, though, he’s that may be harmful to us—and how to break those routines and found evidence that regularly practicing types of self-control—such as embrace new ones—could help us change our lifestyles and adopt health- sitting up straight or keeping a food diary—can strengthen resolve. ier behaviors.” “Any regular act of self-control will gradually exercise your ‘muscle’ Habits can arise through repetition. They’re a normal—often helpful— and make you stronger,” he said. part of life. We can drive along familiar routes on mental auto-pilot withOne approach: focus on becoming more aware of unhealthy habits. out really thinking about the directions. Then, develop strategies to counteract “When behaviors become automatic, it them. For example, you could develop a gives us an advantage,” Volkow said, plan to avoid walking down the hall “because the brain does not have to use where there’s a candy machine. Resolve conscious thought to perform the activito avoid going places where you’ve usuty,” freeing it up to focus on other things. ally smoked. Stay away from friends and Habits can also develop when good or situations linked to problem drinking or enjoyable events trigger the brain’s drug use. reward centers. This can set up potentialTry to kick bad habits by replacing ly harmful routines, such as overeating, unhealthy routines with new, healthy smoking, drug or alcohol abuse, gamones. Some people find they can replace bling and even compulsive use of coma bad habit, even drug addiction, with puters and social media. another behavior, like exercising. “It Both good and bad habits are based doesn’t work for everyone,” Volkow The brain’s reward centers keep us craving the on the same types of brain mechanisms. said. “But certain groups of patients who things we’re trying so hard to resist. “But there’s one important difference,” have a history of serious addictions can said Dr. Russell Poldrack, a neurobioloengage in certain behaviors that are ritugist at the University of Texas at Austin. And this difference makes the alistic and in a way compulsive—such as marathon running—and it helps pleasure-based habits so much harder to break. Enjoyable behaviors can them stay away from drugs. These alternative behaviors can counteract prompt your brain to release a chemical called dopamine. the urges...to take a drug.” “If you do something over and over, and dopamine is there when Another thing that makes habits especially hard to break is that replacyou’re doing it, that strengthens the habit even more. When you’re not ing a first-learned habit with a new one doesn’t erase the original behavdoing those things, dopamine creates the craving to do it again,” ior. Both remain in your brain. In ongoing research, Poldrack and his colPoldrack said. “This explains why some people crave drugs even if the leagues are using brain imaging to study the differences between firstdrug no longer makes them feel particularly good once they take it.” learned and later-learned behaviors. In a sense, then, parts of our brains are working against us when we Some NIH-funded research is exploring whether certain medications try to overcome bad habits. “These routines can become hard-wired in can help to disrupt hard-wired automatic behaviors in the brain and our brains,” Volkow said. And the brain’s reward centers keep us craving make it easier to form new memories and behaviors. Other scientific the things we’re trying so hard to resist. teams are searching for genes that might allow some people to easily form The good news is humans are not simply creatures of habit. We have and others to readily suppress habits. many more brain regions to help us do what’s best for our health. -NIH News in Health
why it’s so hard to change:
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