Thursday, June 11, 2009

HPV vaccine: Part 3

Finally the cost of HPV vaccine

Medicine is foremost a business and nothing is free. A single dose of Gardasil costs $120-$140. Each individual requires three doses over a 6-month period. Further, many physicians are also charging for a consultation fee, cost of syringe and office time. Thus, the average cost for the entire series of HPV vaccine amounts to about $500-$600 plus.

Not all health insurance plans cover Gardasil. Moreover, some insurance plans only cover the vaccine for females in-between the ages of 9-26, the age where the vaccine has been FDA approved. At present, there is no legislation mandating that insurance plans cover the cost of the vaccine.

The pharmaceutical giant, Merck now has released data that the vaccine is also useful in women up to the age of 45. If there is FDA approval for the vaccine for this older group of individuals, perhaps some insurance companies may cover the cost.

At the moment, Gardasil is covered under a federal program for those who have no insurance and to Medicaid eligible children under the age of 18. For those individuals who lack medical insurance, one can check with the physician or the local health clinic to determine if there is program to get the vaccine free.

HPV vaccine: Part 2

The one reason why Gardasil is not recommended for women over the age of 25 is that by this time it appears many women have already been exposed to HPV. However, there are studies that have documented safety of this vaccine in the older age group. At present, Gardasil is believed to be effective for at least 5 years after injection. Current research is trying to determine if a booster shot at the end of 5 years will extent protection from the vaccine.

All consumers should understand that getting the HPV vaccine does not eliminate the need for future doctor visits. Pap smears are highly recommended in all females when they become sexually active.

As far as side effects are concerned, both vaccines have proven to be quite safe. From the recent clinical trials, the most common side effects observed were redness and pain at the injection site. These transient side effects last for a few days.

Neither Gardasil nor Cervarix is recommended for pregnant women. Once injected with the HPV vaccine, more than 95-98 percent of women are protected from developing cervical cancer

What is all the fuss about the human papillomavirus (HPV) vaccine?

Cervical cancer is quite common all over the world. The tragedy of cervical cancer is that it affects young females. Current estimates indicate that in America, approximately 11,000 women develop cervical cancer and there are about 3,000 deaths each year. Over the years, a strong link between the human papilloma virus (HPV) and cervical cancer has been established. Furthermore, HPV has also been linked to cancers of the mouth, vulva, anus, and penis. With more people engaging in sexual activities at an earlier age, a vaccine would be a great way to prevent these cancers associated with HPV.

At present two vaccines have been developed to prevent infection from HPV. Both vaccines are administered by an injection in three divided doses. The current injection guidelines recommend that the first injection be followed by the 2nd and 3rd dose, two and six months, apart.

So far, only one vaccine is currently available in North America. Gardasil is currently available and recommended for all girls and young women between the ages of 9 and 26. In different countries, the age of vaccination is slightly variable. For example in Australia, cervarix is recommended for all females between the ages of 10-45 and for boys in-between the ages of 9-15. Cervarix is currently in the clinical trials stage in North America but data indicate that it is just as effective and safe as Gardasil.

The most important factor with both vaccines is that one gets vaccinated prior to becoming sexually active. Current data indicate that if the vaccine is injected in sexually active individuals, it does not get rid of HPV infection and thus protection against cervical cancer is not a guarantee.

Monday, June 8, 2009

Blood in urine: Part 4

Treatment

When hematuria occurs, the doctor has to treat the underling cause.

Urinary tract infections are treated with antibiotics and within a few days both the symptoms and hematuria will disappear. In rare cases, one may need long-term treatment with antibiotics

Kidney stones generally pass spontaneously through the ureter when one drinks a lot of water and remains active. If this method fails, then there are several other options to reveal kidney stones. One is non-invasive use of ultrasonic shock waves to break up the stone. Other more invasive methods include Cystoscopy or surgery.

Enlarged prostate does require treatment when the patient has symptoms. There is no ideal treatment for enlarged prostate. Every treatment has some negatives. In general, one is treated with medications and these do work well, but they also have side effects. When medications fail, the other options are use of heat, laser, or ultrasonic waves to shrink the prostate.

Immunological kidney disease does require treatment. The treatment depends on the type of kidney disease.

Cancers of kidney and bladder are generally treated with surgery. These tumors generally do not respond well to radiation or chemotherapy. In most cases, surgery is combined with an assorted variety of chemotherapeutic drugs.

Inherited disorders of the kidney which cause hematuria, do not always require treatment. Some disorders may cause extensive kidney damage and dialysis may be the only alternative.

Prevention of blood in urine

Unfortunately, one cannot not prevent hematuria. Even then, one should lead a healthy life style. Drinking adequate water and urinating right after intercourse does help prevent some urinary tract infections

To decrease the risk of kidney stones drink lots of water, limit salt, excess protein, and foods such as spinach.

To decrease risk of cancer, stop smoking, avoid exposure to heavy metals or chemicals and get regular exams from a physician.

Blood in urine: Part 3

What are risk factors?

Anyone can develop blood in the urine.

Age: Many men in the 5th decade of life develop and enlarged prostate and have blood in urine

Females generally tend to have hematuria in urine from a UTI

Family history may predispose one to kidney stones which may lead to blood in urine.

Medications like aspirin and penicillin can cause blood in the urine.

Athletes who are long distance runners or joggers often develop hematuria.

Diagnosis

After a complete history and physical examination, hematuria work up depends on the suspected cause.

Urine analysis can determine if there is blood, infection, or a stone. Urine analyses is not specific for diagnosis and some type of radiological study is usually required.

Imaging with CT scan, MRI, or ultrasound can help look at the urinary tract.
Sometimes a long flexible camera (cystoscope) is passed from the penis or vagina into the urethra and up the ureter. The camera can help visualize structures and biopsy can be obtained.

In a few cases the diagnosis of hematuria may not be evident. This may occur if one has had a prior exposure to a drug or an environmental toxin.

In elderly individuals, the cause of hematuria is almost always investigated to rule out a cancer.

Blood in urine: Part 2

Causes of hematuria

There are a number of structures that make up the urinary tract. Starting with kidney, there are the ureters, bladder and urethra. The kidneys remove waste products and make urine. The urine is then carried by the ureter to the bladder where it is stored. When the bladder is full, the urethra opens and one urinates. blood can originate from any one of these structures.

Urinary tract infections (UTI) are common in women then men. Often some women develop microscopic hematuria during a UTI. This usually clears up once the UTI is treated with an antibiotic. No investigations are needed.

Infections of the kidney is known as pyleonephritis and can also result as microscopic hematuria. The condition is associated with significant flank pain, fever, and difficulty passing urine. The condition is typically treated with antibiotics.

Stones are a common cause of blood in urine. Urinary stones are excruciatingly painful and often cause both gross and microscopic hematuria. Identification of stones is easy with a dye study. When the stone has passed, hematuria usually clears up.

Enlarged prostate is a leading cause of hematuria in man over the age of 50. The prostate is located at the base of the bladder. As men age, the prostate gets bigger and compresses the urethra; often this leads to difficulty in urination. Often the condition is associated with both gross and microscopic hematuria. The condition is easily diagnosed with a rectal exam or an ultrasound.

Kidney disorders; There are many kidney disorders that can cause microscopic hematuria. Most of these disorders are either infections or immune mediated. These disorders also have other organ involvement and need to be worked up. Most of these immunological kidney disorders present much early in life.

Cancer: Gross hematuria is often the first sign of cancer of bladder, kidney or prostate. Unfortunately, when gross hematuria occurs the cancer is generally more advanced.

Trauma is a common cause of hematuria. Individuals into contact sports may see blood in urine after trauma.

Medications like aspirin and blood thinners can also cause blood in urine.

Strenuous exercise can cause gross hematuria. This is most probably related to dehydration, trauma to the bladder or breakdown of red cells. The condition usually improves within a few days.

Why do I have blood in my urine?

Having blood in urine is not normal. Seeing blood in urine can be a frightening experience for most people. When blood occurs in the urine, the condition is medically known as hematuria. In most cases, having blood in urine is not a cause for alarm. Sometimes participating in strenuous sports can cause blood to appear in urine. Some footballers often see traces of blood in urine after being knocked down on the sports field. Other common causes of blood in urine include kidney stones and drugs. However, in the elderly individual blood in urine may signal the appearance of a cancer.

Blood in the urine is classified as gross or microscopic. When the urine is only slightly red and red blood cells are only seen under a microscope, this is known as microscopic hematuria. When there is frank blood in urine, this is known as gross hematuria.

When gross hematuria occurs, one must always rule out a cancer. When there is microscopic hematuria, the cause may be an infection or a stone.

Hematuria that is caused with exercise or sports trauma usually disappears within a few days and does not require any extensive work up

Symptoms

In many individuals, microscopic hematuria may present as red or pink colored urine. It takes only a few red blood cells to make the urine look red. In most cases, there is no pain associated with blood in urine.

Sunday, June 7, 2009

Blood clots:Part 6

How can I prevent blood clots?

The best methods of preventing blood clots include:

- Being active, walking on a daily basis
- If flying or driving a long distance, walk around
every few hours
- Wear compression stockings
- Lose weight
- Avoid prolonged standing
- If possible, avoid the birth control pill

Are there any home treatments to treat blood clots in the legs?

Yes, once you have been started on a blood thinner, you can do a number of things at home to relieve symptoms:

- Frequently elevate the leg, this will decrease
swelling and pain
- Avoid standing for long periods
- Wear compression stockings
- If it feels warm at the back of the leg where the
blood clot has been identified, apply a warm compress

Final advice

All individuals who are being treated with blood thinning medications should wear a medical bracelet to alert health care workers of their medical problem.

Blood clots: part 5

Is there a risk from taking these medications?

Yes, all blood thinning medication can cause bleeding. Thus one should avoid activities that can lead to trauma to the body, otherwise severe bleeding can occur.

Can blood clots be dissolved instantly?

Yes, there are medications (thrombolytics) which can rapidly dissolve blood clots. However, there are specific indications for use of these medications and they all carry a higher risk of complications. Their use is only limited to hospital patients.

Is surgery ever used to treat blood clots from the legs?

Yes, in very rare cases surgery (thrombectomy/embolectomy) is sometimes used in the treatment of blood clots. However, this is done for life or limb threatening cases only. There is no role for surgery in the routine treatment of blood clots in the legs. The surgery is hazardous and fraught with complications. However, it is life saving.

What happens if I am unable to tolerate a blood thinning medication?

Today, there are several devices (filters) which can be placed in the vein to prevent blood clots from migrating to lungs. The filter has to be placed before the blood clot has broken off. The filter acts like an umbrella and is quite effective in preventing the blood clot from moving to lung. These devices have an umbrella like appearance and do not dissolve the clot but prevent it from going to lungs. Filters are more commonly used in individuals who can not take blood thinners. There are both permanent and temporary filters available today but they do cost a fortune. Some of the temporary filters cost more than $15, 000.

Blood clots:Part 4

What is treatment of a blood clot?

If a blood clot is found in the deep veins, you will require admission to hospital for at least 4-7 days. Following some blood work, you will be started on heparin.

What is heparin?

Heparin is a blood thinner that is given intravenously. It does not dissolve the clot but helps to stabilize the clot so that it does not move. After a few days, you will be started on an oral medication called warfarin and then discharged home. Anyone who receives warfarin needs his or her blood assessed on a weekly to monthly basis to ensure that blood thinning is adequate.

How long do I need to take a blood thinner?

For a first time blood clot, you will need to take warfarin for at least 6-9 months. Those with recurrent blood clots will require warfarin for an indefinite time.

Are there any other medications one can take for blood clots?

Yes, the newer medications are called low molecular weight heparins (LMWH). These medications do not require monitoring and can be taken at home. Unfortunately they need to be injected daily and are more expensive.

Blood Clots: part 3

What causes blood clots in the veins?

There are many reasons why blood clots can form in veins. These include

- Prolonged immobility (after surgery)
- Long airplane ride
- Taking the birth control pill
- Trauma or fractures of leg(s)
- Injury to veins
- Cancer
- Stroke- which has caused one to become bed ridden
- After any surgery- especially hip and knee
- Obesity
- Congestive heart failure
- Pregnancy or just after delivery
- Inherited blood disorders
- Prior blood clot –there is increased chance of a
second clot if one has had a previous blood clot

Are blood clots dangerous?

Most definitely. Any time you have one of the above symptoms; one should go and see a doctor. Blood clots in veins have a high tendency to break off and migrate to the lungs where they can cause serious problem’s including death.

How can blood clots in veins be detected?

Your physician will first examine you and order the most appropriate tests. The first test to detect blood clots in all cases is an ultrasound.

Doppler ultrasound is a painless test that takes a few minutes and can easily detect the presence of blood clots in arm and leg veins. However, if blood clots are located in the chest, abdomen or pelvis, Ultrasound is not good enough.

MRI: This non invasive test is also excellent for evaluating presence of blood clots. The test does not use radiation but is slightly more expensive. It is useful for detection of blood clots almost anywhere in the body, but is not the first test of choice.

Venogram: In the old days Venogram was used to look for blood clots. However this test is rarely used to day because of availability of US and MRI. Venogram requires use of a dye and radiation.

CT scan: The newer CT scans can easily identify presence of clots in the lungs. However, CT scans are not routinely used to detect blood clots as the initial test. CT scan requires exposure to radiation and use of an iodinated dye.

Friday, June 5, 2009

blood clots: part 2

What are veins?

Veins are thin walled vessels which play a role in removing all deoxygenated blood from the tissues and take it back to the lungs for oxygenation. They are numerous veins all over the body; the largest vein is called the inferior vena cava.

Can blood clots occur in veins?

Most definitely, blood clots are far more common in veins than arteries. When clots occur in veins they have a tendency to break off and move to the lungs where they can compromise breathing. Clots can occur in both the arm and leg veins.

Which veins are more prone to blood clots?

The majority of blood clots occur in veins of the leg but they can occur in any vein in the body.

Which blood clots are of importance?

Blood clots can occur in both superficial and deep veins. Only blood clots in deep veins are of concern. Blood clots in superficial veins do not need any treatment except for an aspirin.

What happens when blood clots migrate to lungs?

The lungs are important for gas exchange. When blood clots move into the lungs, they can block blood vessels and impair oxygen transport. If the clots are large, one can have severe difficulty breathing and death is not uncommon.

Are blood clots in veins common?

In the United States, about 2 million people per year develop blood clots. Most of them are aged 40 years or older. Statistics reveal that at least 200,000 patients die each year from blood clots in their lung.

How do I know if I have blood clots?

It depends where the blood clot has formed. In most cases blood clots form in the legs, especially the calf area. You may have some of the following symptoms:

a. heaviness of leg
b. tenderness in calf area
c. swelling in calf area
d. warmth near the calf
e. at least 30% will not have any symptoms

Blood clots 101

In a healthy human there is a delicate balance between factors that cause blood clots to form and factors that dissolve blood clots. Blood clots form all the time in blood vessels, but the body immediately responds by breaking them up. However, sometimes, the body’s defense mechanisms fail and blood clots form. Blood clots when they initially form look like red jelly. Blood clots are useful because they can help stop bleeding. However, in some cases, blood clots continue to form and can break off can create problems

Where do blood clots generally occur?

Blood clots can occur in arteries and veins of any size. Veins usually take blood back to the heart. Thus, when a blood clot occurs in a vein blood starts to pool and collect in the vessel. The most obvious sign of a blood clot in the leg vein is swelling, pain, and discoloration. Blood clots in small veins like in the feet or hands are not important. However, when blood clots occur in large veins, they are important. These blood clots can break off, go to the lung, and make breathing difficult.

What are arteries?

Arteries are muscular blood vessels which take blood from the heart and supply oxygen to the body. When a blood clot forms in an artery, the body part does not get oxygen. Hence the leg goes blue, feels cold and is painful. Blood clots commonly block off arteries in the leg vessels near the groin.

Can clots occur in arteries?

Yes, blood clots can and do occur in arteries. Since arteries supply oxygen to the body, blood clots formation is usually more serious. Blood clots can deprive the hand or leg of oxygenated blood. This is what happens in a stroke or a heart attack. Blood clots generally tend to occur in arteries that supply the brain, heart, legs, or kidneys. Blood clots formed in leg arteries generally require urgent surgery