One In Six Hospitals Offers Private Services To Boost Income, Finds BMJ Investigation, UK

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Article Date: 17 Jul 2013 - 16:00 PDT Current ratings for:
One In Six Hospitals Offers Private Services To Boost Income, Finds BMJ Investigation, UK

One in six hospitals in England have introduced new private treatment options this year, as cost pressures tighten restrictions on some NHS services, reveals a BMJ investigation today.

This includes a growing number of hospitals offering patients the choice of "self funding" for treatments and services that are subject to restrictions or to long waiting times on the NHS, such as IVF, cataract surgery and hernia repair.

In these cases, treatments are offered at cheaper rates than in the private sector.

The BMJ obtained data from 134 acute hospital trusts in England through freedom of information requests and found that:

119 trusts (89%) now offer traditional private care or "self funded" services21 (16%) added new self funding or private treatment options for 2013-14, and17 (13%) now allow patients to pay for one or more services at notional NHS rates, under the self funding scheme

Providers told the BMJ that the schemes make care more accessible. But critics say that the growth of self funding has muddied the waters between private care and the NHS by creating a two tier system - particularly in combination with government rule changes that allow hospitals to raise up to 49% of funds through non-NHS work.

Hospitals to have introduced new options for patients in the past year include Warrington and Halton Hospitals NHS Foundation Trust for varicose vein surgery, Epsom and St Helier University Hospitals NHS Trust for liver scans, and age related macular degeneration, and Princess Alexandra Hospital NHS Trust in Essex for imaging services and chemotherapy.

Mid Cheshire Hospitals NHS Foundation Trust has also recently begun offering "self funded" cycles of IVF treatment for patients who have used up their NHS funded cycles.

Many trusts that the BMJ contacted said they did not differentiate between "self funded" and "private" care. But John Appleby, chief economist at the healthcare think tank the King's Fund, said that, regardless of price, care was still being funded from patients' own pockets and was driven by cost restrictions.

Critics argue that self funding not only blurs the lines between NHS and private care but could also disadvantage NHS patients because, unlike more traditional private patients, self funding patients are often treated in the same premises as NHS patients.

The lines are arguably being blurred even further by a new scheme from the private provider Care UK, which recently introduced a new self pay option at four of its 11 NHS funded treatment centres across England.

A spokesman for Care UK said self-pay patients "will not be prioritised over NHS patients." But Nicholas Hopkinson, a consultant chest physician in London, said he opposed self funding as it could lead to an "inferior service" for those not paying.

John Appleby believes that, as self pay schemes expand, they should be strictly governed and separated from NHS care to ensure that NHS patients are not being adversely affected.

The Foundation Trust Network, which represents NHS foundation hospital trusts in England, said that most trusts had systems in place to stop paying patients "queue jumping" ahead of NHS patients when being treated in the same facility, and that it expected more treatments to be available to self funding in the future.

But David Hunter, Professor of health policy and management at Durham University, warns that not only could self funding schemes pave the way for "a two-tier or multi-tier system which is both complicated and inequitable," they could also lead to commissioners and providers focusing their energies on more lucrative procedures to raise additional funds.

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Lose Weight While You Sleep? Yes, Sleep is That Powerful

Late-night munchies can wreck havoc on your diet plans so the next time they strike, hit the sack instead. The more sleep you get, the less likely you are to succumb to delicious temptation, and the faster you’ll lose weight.

More studies are showing a link between sleep deprivation and weight gain, says Meredith Barbour, MD, a family medicine physician at Duke Primary Care Brier Creek. “Lack of sleep triggers the release of hormones that stimulate hunger and appetite, especially for those high-calorie, carbohydrate-dense foods like cookies, chips and ice cream,” she says. Going to sleep is the best way to satisfy that craving.

Sleep deprivation occurs more regularly in people who routinely get less than seven hours of shut-eye at night. “Generally speaking, adults should aim for seven to eight hours of sleep per night,” Barbour recommends.

Weight gain isn’t the only health problem associated with lack of sleep. Sleep deprivation can impair your daytime performance and decrease your levels of alertness. That can put you at increased risk for all kinds of accidents. Sleep deprivation can also put you in a bad mood, make you irritable; cause you to suffer from low energy and increased tension.

There are serious ramifications too. Lack of sleep can lead to high blood pressure and heart disease. “It can also have a negative effect on the body’s immune system, which makes it more difficult to fight off infections, such as respiratory viruses and the common cold,” said Barbour.

If you’re having trouble falling or staying asleep, heed this advice:

Maintain a regular sleep scheduleAvoid caffeine after lunchAvoid alcohol near bedtimeAvoid screen stimuli from televisions, computers, tablets and your smart phone for at least one hour prior to bedtimeExercise regularlyRelaxation techniques also help. When you are ready to fall asleep, relax every muscle in your body, starting with your facial muscles, and moving down to your toes, one at a time, until you’re fully relaxed.

“If these methods don’t work, talk to your doctor who may be able to suggest alternative treatment options,” said Barbour. It is also important to consult with your doctor before trying any over the counter sleep aids or herbal remedies.

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Spring 2013 Duke Med Magazine

From: DukeMed Magazine
Published: May 10, 2013
Updated: May 10, 2013

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Let’s Get Stronger Together

Art, Jazz, Food and Health Screenings at Health Fair May 3 and 4

My name is Kathy Kastan. I survived a bypass when I was 42.  I know the unique challenges faced by women living with heart disease, and I’ve made advocating for women’s health my passion. As the director of the Duke Women's Health Initiative, I share my passion with women across the region and beyond.

Women have unique health concerns, and need to work together to demand accurate diagnosis, proper treatment and exceptional care. That is why I encourage you to join me May 3 and 4 for an unprecedented series of events.

Stronger Together: Fighting Disparities and the Leading Causes of Death in Women will redefine what a health fair should be. It harnesses the power of creative energy to reach all your senses. We believe the combination of music, food, art, education and health screenings will be a powerful motivator for change. You won’t just leave with the results of your screening. You’ll leave with a plan. Healthcare professionals will let you know what next steps you should take.

On Friday, May 3, the Stronger Together: A Community Benefit Concert will feature:

Prominent leaders discussing healthcare reform and its potential impact on women's health. Sandra Dubose-Gibson, the first bald beauty queen, who will share her story of empowermentNnenna Freelon, a six-time GRAMMY-nominated international jazz artist performing with the Duke Medicine Orchestra and Choir.

The concert will take place at the Durham Convention Center from 6 to 10 p.m. Individual tickets are $125. Dinner and drinks are included.

On Saturday, May 4, Stronger Together: A Women’s Health Education Community Outreach Event will include:

Joe and Terry Graedon of NPR’s The People's Pharmacy, who will discuss Making Positive Lifestyle Changes. Duke’s Edna Ballard, MSW on Caregiving: Challenges and Opportunities for WomenAlice Cooper, RNC/OGNP on Caring for Women's Health: A Holistic Approach and Being Your Own Best Healthcare Advocate. Wellness screenings, performed by Duke providers, including blood pressure, Body Mass Index (BMI), HIV testing, depression, thyroid abnormalities and lipid profiles – a test that normally costs $100. (A lipid profile tells you your “good” and “bad” cholesterol levels.)30 vendors will conduct demonstrations ranging from healthy cooking to yoga and Pilates. Artwork from 12 regional artists will be for saleNnenna Freelon will sing a cappella during lunch, and Sandra Dubose-Gibson (Mrs. Black North Carolina) will be our keynote speaker. Anita Woodley, AKA “Mama Juggs,” will share how her family has coped with breast cancer, and transform how all of us view survivorship. An exciting raffle will end the day.

The event takes place at the Durham Convention Center from 8 a.m. to 2 p.m. The $25 registration fee includes breakfast, lunch and an art show. Ten percent of proceeds will benefit Duke Medicine Women’s Health Initiative Community Outreach

To learn more or to purchase tickets, visit http://docme.mc.duke.edu/womenhealth/home.html

Kathy Kastan, LCSW/MA Ed, is director of Duke Medicine's Women's Health & Advocacy Initiative and is past president, emeritus of the board of directors of WomenHeart: The National Coalition for Women with Heart Disease. She is past chairman of the board of the Greater Southeast Affiliate of the American Heart Association. She recently accepted a board membership on the Mid-Atlantic Affiliate of the American Heart Association. She has been a national spokesperson for the National Heart, Lung and Blood Institute’s The Heart Truth®/Red Dress campaign since 2003. Kastan is the author of From the Heart: A Woman’s Guide to Living Well with Heart Disease and is frequently invited to blog at http://www.huffingtonpost.com/kathy-kastan.                                    

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Good Posture Is Important But It Won’t Prevent Scoliosis

Remember when your parents told you to sit up straight? Slouching among adolescents hasn’t gone out of style and neither has the popular refrain. Sitting and standing tall remains important because it lengthens the spine, and strengthens the back, neck and shoulder muscles.

But can good posture prevent the curving of the spine known as scoliosis? Unfortunately, it won’t, says Robert Lark, MD, a pediatric orthopedic surgeon with Duke Orthopaedics.

“Scoliosis is not preventable,” he says, “but once we diagnose it, there are things we can do to prevent progression of the curve.”

Scoliosis is an abnormal, left-to-right curvature of the spine that often resembles the letter S. In most cases, the cause is unknown, but research suggests genetics play a role.

Parents may suspect scoliosis in their child if one shoulder is higher than the other, or if the trunk of their body appears to shift from left to right. “It’s common to spot scoliosis during the summer time, when a thinly clothed child bends down to pick something off the floor,” says Lark. “You may be able to see the ribs along the spine appear more prominent on one side than the other.” Lark says the muscular imbalance can cause pain in some children.

If you suspect your child may have scoliosis, a visit to a pediatric orthopedist is warranted. The severity of the curve is diagnosed on x ray, and it’s important to make that diagnosis early, when children are young and still growing. Sometimes treatment is as simple as taking a wait-and-see approach. “If the patient is a 14-year-old girl with a small curve, we’ll just keep an eye on it as they keep growing,” Lark says. Core and flexibility exercises are beneficial to strengthen the muscles, but they won’t make the curve go away.

If the curve is more significant, bracing may be recommended to minimize curve progression.  It is important to note that bracing will not make the curve go away. 

About one-quarter of children with scoliosis may benefit from bracing. The site of the curve dictates the bracing regimen. Children with curves higher in their spine may need to wear a brace when upright for 16-18 hours daily. Lower curves may be corrected with a nighttime brace.  Braces are typically worn for one year past skeletal maturity. “For girls, that’s three years past the time of their first menstruation,” Lark explains. For boys, it is one year after the close of their pelvic growth plate.

Surgery may be required if x-rays suggest a severe curve that may progress into adulthood. While the surgery is significant – requiring a three to five-day hospital stay and up to six weeks recovery - “today’s modern instrumentation allows us to correct a lot of the deformity a child may have,” Lark explains.

If scoliosis surgery is recommended for your child, choose a surgeon with a wealth of training and experience, and a medical center with a pediatric intensive care unit, Lark says.

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How Doctors Stay Healthy Year-Round and How You Can Too

Nobody likes being around people coughing and sneezing from colds and flu yet that’s what doctors do. Every day they are on the front lines, listening compassionately to complaints ranging from aches and pain to fever and persistent coughs. Yet they rarely get sick. How do they do it?

Here, Matt Hayes, DO, at Duke Primary Care Waverly Place, reviews the top 10 ways he and his colleagues stay healthy throughout the year, and how you can too:

Wash hands frequently. “It’s the most effective preventive measure,” says Hayes. Use hand sanitizer or soap and water frequently during the day.Don’t touch your eyes, nose or mouth. They are gateways that allow bacteria and viruses access to your body.Sanitize surfaces. Disinfectant is used continually at Duke Primary Care Waverly Place to wipe down everything from exam surfaces to computer keyboards. He suggests patients do the same with high traffic areas in their homes or offices. “Wipe down your desk, your phone, any common areas, and where you eat at least once a day.”Exercise regularly. Hayes, a triathlete, works out six days per week. Brisk walking will also do the trick if you can’t get to the gym. Research shows regular exercise – 30-45 minutes per day, 4–5 days per week, boosts the immune system and helps maintain good health.Drink water. Clear liquids are best, says Hayes, who drinks water regularly. Aim for 64 ounces, or 8, 8oz. glasses per day. “It keeps your energy level up and ensures your body stays hydrated,” he says.Get enough sleep. Seven to eight hours per night is key to maintaining a healthy body. “If you do get sick, resting helps your body heal faster,” Hayes says.Eat seasonal fresh fruits and vegetables. They’re packed with vitamins and nutrients that are essential for overall good health.Beware of party food. That double dipper may be leaving his germs in the party dip. Stay away.Laugh a lot. It minimizes stress, which can weaken immune systems.Don’t smoke. Need another reason to quit? Research shows smokers have poorer health than non-smokers and take more sick days.

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What You Need to Know About Your Colon

No one likes to discuss colon health. But it’s serious business, and learning about it—and what you can do to take care of your colon—can help ensure you and your loved ones lead healthier lives.

Here, Benjamin Hopkins, MD, a Duke Medicine colon and rectal surgeon, touches every condition you don’t want to talk about – from hemorrhoids, and fecal incontinence to anal pain and diverticulitis.

Q. What’s the most important thing to do for colorectal health?

A. The best approach to good colorectal health is to maintain a high-fiber diet and drink plenty of water. Eight glasses of water a day helps prevent constipation. A high-fiber diet will help prevent complications of hemorrhoids and anal tears and will help to prevent diverticulitis.

Q. Most people know that surgery is used to treat colorectal cancer, but what other conditions do you treat with surgery?

A. Surgery is necessary to treat recurrent or complicated bouts of diverticulitis and inflammatory bowel diseases that don’t respond to other treatment. It is also used to treat benign problems of the anus and rectum when conservative management fails.

Q. Can surgery really cure these conditions?

A. Yes! That’s why I love my job so much.

Q Does surgery leave an ugly scar?

A. We specialize in minimally invasive surgery, including robotic, laparoscopic, and single-site surgeries, which leave patients with smaller scars, less pain, and a faster recovery. There is no scar from transanal endoscopic microsurgery since all work is done through the anus.

Q. What are hemorrhoids, exactly, and how do you know if you have them?

A. Everyone has hemorrhoids—they are part of our anatomy. It’s just a question of whether they’re bothering you. Hemorrhoids can become aggravated with changes in bowel habits, such as diarrhea and constipation. Over the years, they can pull away from the underlying muscle, prolapse, and bleed. Prolapse means something is hanging out “down there.” Typically, hemorrhoids cause people to experience itching, bleeding, and prolapse. Pregnancy can also cause hemorrhoids to become engorged because of the increased pelvic pressure.

Q. How are hemorrhoids treated when they become aggravated?

A. Initial management includes increasing the amount of fiber and water in the diet. Most of my patients find that’s all that is needed. Be sure to increase fiber slowly: I tell people to increase daily intake by 5 grams for a week, then another 5 grams for another week, until they reach 20 to 25 grams per day. That way they avoid bloating and gassiness. If adding fiber to your diet doesn’t work, there are simple and painless office procedures to treat hemorrhoids. If these fail, surgery may be the next step. One of the procedures my colleague, Linda Farkas, MD, and I perform is a transanal hemorrhoidal de-arterialization (THD). It is a less-painful way to treat hemorrhoids than a standard hemorrhoidectomy. Not all hemorrhoids can be treated with a THD; treatment depends on the severity of the hemorrhoids.

Ben Hopkins, MD, is part of the team at Duke Colon and Rectal Surgery of Raleigh. To make an appointment, call 888-ASK-DUKE (275-3853).

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Exercise Isn’t Optional; It’s Mandatory for Good Health

Some people speak of a “runner’s high”—an intoxicating feeling derived from going the distance and pushing your limits. And then there are those for whom exercise is a chore, an item to be checked off a to-do list.

Matthew Hayes, DO, of Duke Primary Care Waverly Place believes everyone can—and must—exercise, and that there’s some kind of exercise out there for everybody and every body. He takes exercise so seriously that he gives each of his patients a prescription for it.

“I prescribe specific ways to exercise— running, lifting, tennis, and more— based on what my patients like to do,” he says. “I make recommendations on frequency and duration of exercise based on the patient’s current fitness level. I then discuss intensity using target heart rate or how much exertion you feel. It can get fairly scientific in a high-level someone just starting out.”

Hayes tells his patients that exercise is essential to good health and that making time for exercise has to be among the things you consider non-negotiable. You have to buy groceries. You have to pay bills. You also have to exercise—even if you have to trick yourself into doing it.

Sneaking exercise into the day is something anyone can do, Hayes says. “Take the stairs, park farther away than you need to, walk to lunch. Try 10 minutes of core exercise and pushups to start the day or a 15-minute walk over your lunch break. It adds up.”

If you have kids, get them into the game, too. “Encourage kids to play outside, like we did growing up,” Hayes says. “Limit their screen time to less than two hours a day, and set a good example by being active yourself.”

Hayes recommends you start somewhere. A little exercise is, after all, better than none. But he says the current recommendation from the medical community is to exercise four to five days each week for 30 to 45 minutes at a time.

The obvious exercise for the most committed couch potato is walking. “If you are not disabled, then you can walk for exercise,” Hayes says. Beginners could start with a 20-minute walk three days a week. The goal of each walk should be to break a sweat.

And just to drive the point home a little more, Hayes includes a quote from former U.S. Surgeon General C. Everett Koop on his prescriptions: “Exercise is the most effective medicine known to man.” 

Get it any way you can.

• Do stretching exercises while you’re waiting for lunch to heat in the microwave.

• Lunge a little as you wheel your grocery cart down the aisle.

• Get up from your desk and walk a lap around the office, the building, or the block.

Walk to any destination  that’s less than a quarter-mile away. It will take longer to drive and park, anyway.Walk your dog 30 minutes a day or more. All dogs need structured exercise. (Humans do, too.)Take the stairs if you’re going up one or two floors. Do you really want to be that person who takes the elevator up one floor?Start your day with 10 minutes of core training or calisthenics, such as pushups or crunches. Or do a few minutes of a yoga DVD. You will have done more exercise before breakfast than most Americans do all day!Join a gym that has child care. The kids can have fun while you work out.To schedule time with Dr. Hayes or any Duke Primary Care provider near you, call 888-ASK-DUKE (275-3853)

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Podcast: Terry Kim, MD, on Eye Health Screenings

In this podcast, Terry Kim, MD, the Duke Men's Basketball team physician, discusses the vision and eye health screenings he performs for the team and how it helps their performance on the court.

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Radio Announcer:  We’ve got a lot to cover on today’s show. We’re going to begin with a special guest who’s joining us up here in our “Crow’s Nest” position overlooking Coach K Court.  He’s Dr. Terry Kim who’s a professor of ophthalmology at the Duke Eye Center here on campus.

Dr. Kim, I know you’re the team eye doctor for the Duke Men’s Basketball program so we thought we’d get you tell us a little about some of the things you do for the team as far as how you screen them and how it helps their performance in basketball.

Dr. Kim: Well, thanks for having me today, Jon. Well, with the full support and endorsement from Coach K, I started the annual eye screenings for the basketball team back in 1999. We’ve been doing it every year since then.

 You know, my staff and I actually bring our eye testing equipment over here to Cameron where we check the player’s vision, the eye pressure; we examine the front and back parts of the eye, and even do visual fields. You know, over the years we’ve been surprised to find some players that have some near sightedness, farsightedness, and astigmatism. We’ve also caught some important eye diseases early like glaucoma before they advanced. But by correcting the player’s vision with contacts or procedures like LASIK, we’ve been basically able to provide these players better vision and also just as importantly help them maintain healthy eyes.

Announcer: Obviously over at the Duke Eye Center, you also deal with a lot of other patients that aren’t on the Duke Basketball team, in fact, most of your patients aren’t.  And for the average person who wants to avoid wearing contacts or glasses when they play sports, what are some of their options?

Dr. Kim: Well, you know, we’ve spoken about this before; here at Duke we do strongly advocate the importance of protective eyewear for sports, especially the sports that have a higher risk for eye injury, like lacrosse or field hockey. But for the leisurely athlete that plays golf or tennis, we have a very active and well-respected refractive surgery program here at Duke where we perform a very comprehensive eye exam and determine if that patient is a good candidate for LASIK, PRK, or even procedures like ICL, or the implantable contact lens. And patients can get these evaluations at any one of our multiple locations. We have Durham, Raleigh, Cary, Research Triangle Park, and Winston-Salem.

Announcer: Dr. Terry Kim from the Duke Eye Center is our guest here on the Duke Basketball Tipoff Show. You know, I’ve heard cataracts are being diagnosed a lot earlier now than in previous generations. What are some of the advancements you’ve made for cataract patients over at the Duke Eye Center?

Dr. Kim: Well, you know at Duke we do use the latest techniques and technologies to provide the best options for our cataract patients. This translates to small incision, no-stitch, topical anesthesia cataract surgery. We also offer our patients what are called advanced technology, or premium lenses, that help address astigmatism and even reduce the need for distance and reading glasses after cataract surgery. On top of that, we have a very knowledgeable, experienced, and award-winning faculty that offer these cataract evaluations at all of our multiple locations.

Announcer: Well, Dr. Kim, before we let you go I know we’d like to ask you just one thing about the new facility you’re opening in 2015. I know you’ve broken ground on a new clinical area, tell us what that’ll mean for your patients.

Dr. Kim: Well, we’re really excited about this. You know in the twenty-five years I’ve been here at Duke as an undergraduate, medical student, and of course, on faculty, I’ve seen the Eye Center grow tremendously into an entity that now sees close to 150,000 patients a year and performs over 10,000 surgical procedures annually. Of course, it also produces groundbreaking eye research and it’s a premier center for training our next generation of eye specialists and researchers. You know, so with all this growth, there’s no question that our patients will benefit from the new facility in terms of better customer service, improved technology, and state-of-the-art equipment, but also our providers, our researchers, our trainees and staff will also benefit by taking advantage of the increased space and resources we have to improve not only the eye care, but also the eye health of our patients.

Announcer: Well that sounds exciting and we certainly appreciate you coming up here and sharing the story of the Duke Eye Center with us and hope you enjoy watching the game today.

Dr. Kim: I will! Go Duke! Thanks for having me.

Announcer: That’s Dr. Terry Kim a professor of ophthalmology over at the Duke Eye Center, our special guest, today. And when we come back we’ll talk more about the Duke-Miami contest, that’ll be next right here on the Duke Basketball Tipoff Show.

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Why All The Buzz About Gluten-Free

Today, gluten-free products and diets are all the rage. In fact, a recent study finds as many as 1.6 million Americans avoid gluten, even though they haven’t been diagnosed with celiac disease or gluten sensitivity.

Although there is no harm in eliminating gluten from your diet, doctors say there is no reason to avoid it—unless you’re one of the two million people who cannot tolerate the proteins.

“Gluten is bad for some people, but certainly not all,” explains Michelle Nacouzi, MD, a primary care physician at Duke Primary Care Brier Creek. “So unless you’ve been diagnosed with celiac disease or gluten sensitivity, gluten-free products aren’t necessarily going to give you a health benefit.”

What Is Celiac Disease?

Once considered a rare childhood disorder, celiac was frequently misdiagnosed and just as frequently overlooked. Today, doctors are more attuned to the seemingly vague symptoms that can signal celiac disease, and diagnose it frequently in children as well as adults.

“Celiac disease is now estimated to be four times more common than it was 50 years ago,” Nacouzi says. “And more advanced diagnostic tests may be the reason it seems to be on the rise.” But researchers also believe that the way wheat is now grown, the proliferation of processed foods, and the use of gluten in medications and vitamins, toothpaste, and lip balms, are all responsible for the increase in cases.

The main culprit in celiac disease is gluten, a protein found in wheat-, rye-, and barley-based products. Gluten triggers an immune response that makes it difficult for the body to absorb essential nutrients. In a healthy body, long, fingerlike protrusions called villi line the small intestine and aid in the absorption of nutrients into the bloodstream, explains Nancy McGreal, MD, a pediatric and adult gastroenterologist at Duke University Hospital. The gluten-triggered immune response damages the villi and inflames the intestinal wall. “Patients end up malnourished no matter how much they eat,” McGreal says. “They experience anemia, as well as deficiencies in vitamin D, vitamin B12, and folate.”

Genes play an important role in the development of celiac disease, but environmental exposures can also contribute. “Research is looking into whether being exposed to gluten as an infant predisposes you to getting celiac later in life,” McGreal says. Childhood intestinal infections may be a factor, too. People who have autoimmune disorders like type 1 diabetes and Down syndrome are at greater risk. Researchers are looking into whether breastfeeding may offer protection against the disease later in life.

Celiac? Gluten Sensitivity? Wheat Allergy?

About 6 percent of the population may have non celiac gluten sensitivity (NCGS), a condition that is less severe than celiac disease, and one for which there is no genetic basis and no tests to confirm its diagnosis. Symptoms include abdominal pain and headaches. There is some evidence to suggest that gluten-free diets may offer relief to sufferers of NCGS.

Wheat allergy—often confused with celiac disease—is something very different in that it is an immune-system response to gluten as opposed to a digestive system response. Wheat allergy is most common in children and can be outgrown (unlike celiac disease). Symptoms mimic those of other common childhood food allergies: itching, swelling, runny nose, watery eyes, upset stomach, and even difficulty breathing. As with all food allergies, the best treatment is to avoid the offensive food altogether.

Why Diagnosis Is Important

Celiac disease can cause a host of physical problems ranging from irritability, vomiting, and delayed puberty in kids to joint pain, depression, and anxiety in adults. In some people, the disease lies dormant until an event such as surgery, pregnancy, childbirth, viral infection, or severe emotional stress triggers a symptomatic attack.

Getting a definitive diagnosis is important, McGreal says, because “this is a lifelong condition. We don’t have a cure.”

Undiagnosed celiac disease can lead to serious health conditions including growth problems in kids, osteoporosis, infertility, seizures, and, in rare cases, various forms of cancer. If symptoms or a patient’s family history lead a physician to suspect celiac disease, blood tests are used to screen for antibodies, which signal its presence. A biopsy of the small intestine confirms the antibody tests.

The Gluten-Free Diet

The only treatment for celiac disease is a gluten-free diet. Learning to adopt it can be challenging for the newly diagnosed. Lesley Stanford, MS, RD, a pediatric nutritionist at Duke Children’s Hospital, helps patients navigate the challenges and educates them about what they can and can no longer eat. “This isn’t the easiest diet to follow,” she says. “You can’t just try it. You have to plan your grocery shopping and eating out. A true gluten-free diet is important for people with celiac disease and requires education. There’s more to it than just looking at labels to see if something contains gluten. Gluten proteins can be found in other additives.”

Fortunately, food manufacturers and even restaurants are answering the call. Gluten-free products by the shelf load can be found everywhere from supermarkets to big-box stores, and restaurants are adding gluten-free selections to their regular lineup and on the kids menu as well.

Classic Symptoms Of Celiac Disease

Abdominal cramping, intestinal gasDistention and bloating of the stomachChronic diarrhea or constipation (or both)Fatty stoolsAnemia—unexplained, or due to folic acid, b12, or iron (or all) deficiencyUnexplained weight loss with large appetite or weight gain infants, toddlers, and young children who have celiac disease may often exhibit growth failure, vomiting, bloated abdomen, behavioral changes, and failure to thrive.Sources: Celiac Disease Foundation, American Journal of Gastroenterology

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Kids Stash the Darndest Things

By Carol Harbers

On occasion, one of my kids will present me with a particularly challenging problem, and I know exactly what to do. So rare and so perfect are these moments that I remember them with great detail for long after. Like the time nearly two years ago when my son, then three years old, came to me with a popcorn kernel lodged too far up his nose to grab. I didn’t hesitate.

"Let’s do this,” I said to him, as I pinched closed the unaffected nostril, placed my mouth over his, and blew a sharp puff of air. I’m not sure why my son erupted into giggles a second later. It could have been that this medical maneuver tickled, or it could
have been the sight of my face covered with “collateral”—and one popcorn kernel.

I was able to be Mom of the Year at this moment because just a week prior I had seen Ben Linthicum, nurse practitioner at Duke Urgent Care Hillandale (for an unrelated problem). We got on the subject of kids leaving their things where they shouldn’t—such as up noses—and he clued me in to the blowing trick (which actually has both a cutesy name, the “kiss technique,” and a fancy medical one, “positive-pressure expulsion,” I later learned from Jennifer Swanson, MD, medical director for Duke Urgent Care). Swanson told me more tips about dealing with foreign objects in various places, some cautions, and a few eye-openers.

In truth, the kiss technique is the only trick that’s usually safe for novices to attempt at home. As for other methods and other places in the body, those are best left to the professionals. “Most people don’t know the anatomy well enough—of the ear, for example—to know how to remove foreign objects without doing damage,” Swanson says. “We not only know the anatomy, but also have the proper tools to ensure safe removal.”

Take an impossibly tiny Polly Pocket doll shoe in the ear, for instance. “Unless you can easily work it out with your finger, you really don’t want to make an attempt on your own with any kind of tool because you could rupture the eardrum,” Swanson says.

Turns out, I was pretty lucky to have had to deal only with one foreign object in one orifice. Once younger kids discover that things can fit in one place, they’re likely to try other places—just for fun. So if there’s a rock in the nose, check the ears as well.

Some kids are just too young to be able to confess what they’ve done. Recurrent, icky, purulent nasal discharge or nasal infection could be a sign that something is lodged in the nose and has been there for a while.

And children don’t necessarily outgrow the tendency. Swanson and colleagues have seen
tweens and teens with objects in noses and ears, but they won’t admit it. Instead, they might visit the urgent care office complaining of ear pain.

Then there’s the issue of kids swallowing objects, which can lead parents to a different kind of detective work a day or two later. But it’s important to know that any swallowed object calls for immediate medical care. Any nonfood item that goes in the mouth and doesn’t come back out can potentially be lodged in the airway or esophagus, so it’s best to find out where it landed right away.

Two ingestible items that are deceitfully dangerous are small batteries and strong magnets, says Scott Elston, MD, of Duke Urgent Care Morrisville. “Small batteries, like the ones in hearing aids and small toys, are not only easy to swallow, but can quickly begin to corrode the intestinal wall. Multiple magnets that are ingested can link together and cause an obstruction or even an interruption of circulation to the bowel.”

If the swallowed object does turn out to be harmless and goes into the stomach, once it gets to the small intestine, you’re pretty much home free. Just keep an eye out for a day or two to make sure the “rite of passage” completes.

After my heroic success with the kiss technique, I e-mailed Linthicum to thank him for the advice. He replied, “I’m glad it worked. Not that you want to encourage it, but what kind of distance did you get on the kernel?”

He brings up a good point. Can you discourage kids from sticking stuff in weird places to begin with? The simple rule that parents already know seems to be the best advice: “Just be careful what is left in reach of children and toddlers, not only from this standpoint, but also as a choking standpoint,” Elston says. “Items lodged in the nose can ultimately  Become a choking hazard, be aspirated into the lung, and cause other complications.”

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Why Does My Nose Run - And Other Common Allergy Questions

Allergies got you down? Wondering how to get relief? Namrata Shidhaye, MD, a family physician at Duke Primary Care Waverly Place, helps sort out the causes and cures for your annoying runny nose.

The older I get, the more my nose runs. Can you develop seasonal allergies as an adult that you didn’t have as a child??
Yes, adults can develop environmental allergies at any age. Asthma can develop during adulthood as well. A runny nose isn’t always a sign of allergies, though. Older individuals may experience runny nose due to age-related physical changes—some people, as they age, develop overactive tear ducts and nasal secretions (it’s called cholinergic hyperactivity). Also, some medications taken for other conditions such as high blood pressure, prostate enlargement, or erectile dysfunction can cause a runny nose as a side effect.

How do I know when it’s just a cold?
When should I consider seeing an allergy specialist??A common cold is usually associated with a variety of symptoms in addition to a runny nose: cough, body aches, fatigue, and occasional yellow nasal discharge. All of these symptoms usually resolve in one to two weeks. Allergies occur immediately after contact with the allergens that provoke them. They’re associated with clear discharge from the nose, nasal congestion, and itchy eyes, and the symptoms persist as long as contact with the allergens continues. Body aches are unlikely, but fatigue may occasionally occur with allergies. Your primary care physician can usually help treat your allergies, but if specific testing is required to identify the cause for your allergies—or if symptoms are not adequately controlled with medicines prescribed by your doctor—then a consultation with an allergist is probably needed.

Is it safe to take an over-the-counter allergy medication every day??
I strongly recommend consulting with your physician. There are several types of over-the-counter allergy medications. Some of them, such as Benadryl (diphenhydramine) and Zyrtec (cetirizine), can cause sedation and performance impairment, so I don’t recommend them for everyday use. Claritin (loratadine) and Allegra (fexofenadine) usually don’t have that side effect. Over-the-counter decongestants such as pseudoephedrine (found in Sudafed) and phenylephrine should be used very carefully—they can cause elevated blood pressure, heart palpitations, difficulty falling asleep, and irritability. I don’t recommend them for patients who have heart conditions, high blood pressure, or hyperthyroidism.

Can certain foods give me a runny nose??
Food allergies are not likely to cause a runny nose. They usually cause scratchy, itchy mouth and throat; or you may develop hives, a skin rash, nausea, vomiting, diarrhea, or stomach cramps, or have difficulty breathing. Some older individuals experience a runny nose when they eat spicy, hot foods. That’s called gustatory rhinitis, and the quickest cure is to finish eating—or order something else.

Sometimes I wheeze a little. How much wheezing is OK??
Always consult your doctor when you experience wheezing. Wheezing can be due to allergies or asthma, but sometimes it’s a sign of a heart problem. It’s better to be safe and check in with your physician.

What about natural remedies, like eating local honey or pollen??
There is no scientific evidence to support the theory that eating local honey or pollen will cure allergies. Practically speaking, most people’s seasonal allergies are caused by airborne pollen from grass and ragweed, and those aren’t the plants that honeybees are visiting. So it’s unlikely that the pollen you’re allergic to is the pollen you’ll find in honey. What’s more, some people can have allergic reactions to impurities in some honey. It’s fine to eat honey if that’s part of your diet, but adding honey as an allergy treatment doesn’t have any scientific rationale behind it.

I’m afraid that I’m allergic to my beloved dog. I love him too much to give him up. Is there anything I can do besides investing in Visine and Kleenex stock??
Avoidance is the best defense against allergies. But if you can’t get away from your allergen—or, more specifically, if you can’t bear to give up your dog, or cat, or  gerbil—and your symptoms can’t be helped by over-the-counter medications, see an allergist. For some patients (ask your doctor) a custom-made allergy shot can be designed to desensitize you to your four-legged allergen friends.

To make an appointment with Dr. Shidhaye or another Duke Primary Care provider at an office near you, call 1-888-ASK-DUKE.

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The Dos and Don'ts of Summer Fun

The school year may be almost over, but that doesn’t mean you should adopt a school’s-out attitude when it comes to your health. Regardless of your plans, heed these simple dos and don’ts to ensure you get a passing grade.

At the Park

DO outsmart the bugs. Wear light-colored, breathable clothing—you’ll be less attractive to bees, which like bright colors. Light colors also make it easier to spot ticks. If you’re planning to be outside for an extended time, spray your clothes, not your skin, with a bug repellent that contains DEET. If you are stung or plagued with insect bites, ice the swollen area, says Meredith Barbour, MD, a family physician at Duke Primary Care Brier Creek. An over-the-counter antihistamine will help reduce the swelling and the itching.

DON’T ignore your body’s warning signs. If a sting or a bite is serious, your body will let you know fairly quickly. Hives, facial swelling, or trouble breathing may signal a severe allergic reaction and require immediate medical care. If you know you’re prone to a severe allergic reaction, carry an epinephrine autoinjector (EpiPen). If you develop a rash or a fever after a tick bite, see your health care practitioner, as it may be a sign of Rocky Mountain spotted fever or lyme disease.

At the Backyard BBQ

DO eat seasonal produce. Visit your local farmers market or grow your own. “Fresh fruits and vegetables add color to meals, taste better, and are loaded with vitamins and nutrients,” says Brinkley Sugg, RN, FNP, a family nurse practitioner at Duke Primary Care Morrisville. Meet the daily-recommended five servings of fruits and vegetables by adding berries to salads, grilling pineapple and summer squash, and snacking on watermelon.

DON’T grill meats over high heat. Studies suggest it breaks down muscle proteins in meat and creates a cancer-causing substance, which can jump-start the cancer development process, Barbour says. Shorten grill time by microwaving food first.

On the Court

DO know the air-quality index. Air pollutants are measured via a color-coded, daily air-quality index. “High levels can cause breathing problems for people with asthma, lung disease, or heart problems,” Sugg says. When the air-quality index causes concern, individuals at risk should spend more time indoors and limit strenuous activity.

DON’T think you can beat the heat. Whether you’re exercising outdoors or enjoying time with family and friends, staying hydrated is important. Heat exhaustion occurs when the body loses excessive amounts of water and salt through sweat. If you feel overheated or experience headache, dizziness, nausea, or cramps, Barbour says stop what you are doing. “Move into the shade or cool off in an air-conditioned building or car,” she recommends. Drink cool nonalcoholic beverages, take a cool shower or spray yourself with cool water. Apply a cold compress to your neck or armpits.

At the Beach

DO protect your eyes from the sun. The sun’s harmful ultraviolet (UV) rays can cause cataracts, macular degeneration, and abnormal growths. “Once the damage starts, there’s no way to stop it,” Sugg says. Never look directly into the sun, and protect your eyes by wearing a hat and sunglasses whenever you are outdoors. Opt for eyewear that blocks 98 to 99 percent of UVA and UVB rays.

DON’T choose the wrong sunscreen. Some contain questionable ingredients that have sparked health concerns. For example, oxybenzone may interfere with hormones. Nanoscale zinc and titanium oxides have been linked to potential reproductive and developmental effects. Pregnant women should avoid sunscreens that contain retinyl palmitate. When choosing a sunscreen, a sun protection factor (SPF) around 30 is sufficient, Sugg says. Apply frequently, according to directions.

Recently, the FDA announced it is investigating potential risks associated with spray sunscreens, including inhalation risks. For this reason, Sugg recommends against spraying sunscreen on children. Instead, spray your hands first, then rub on the sunscreen liberally.

Need to make an appointment? Call 1-888-ASK-DUKE or contact the Duke Primary Care location nearest you.

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Heart Attack Symptoms Women Need to Know

Chest pain, shortness of breath, dizziness. Those are the well-known signs of heart attack. But what about the not so obvious signs?

Many women experience heart attacks differently then men, and knowing the subtle differences may one day save your life.

According to Radha Kachhy, MD, a cardiologist with Duke Cardiology of Raleigh, women are less likely to experience the crushing chest pain that some men describe as an elephant sitting on their chest. Instead, they may feel a persistent pain in their back, neck, jaw or even in their shoulder blades.

“Where the pain is located is not as important as when it occurs,” explains Dr. Kachhy.  “If it happens during times of exertion, it should be taken seriously. One of my patients said her shoulder hurt every time she walked. She thought it was her purse, but her shoulder throbbed when she wasn’t holding her purse.”

Women are also more likely to experience fatigue, sweating and nausea, as well as indigestion they might mistake for heartburn. “What you are doing when you experience these symptoms makes a difference. If you feel what you think is heartburn while walking, chances are good it may not be indigestion.”

Symptoms of heart attack can also occur when you are resting.  It’s important to know your body’s signals. “If you feel like you just finished a triathlon but you haven’t moved, take notice,” she advises.

Because more women are likely to brush off their symptoms or delay seeking treatment, they are often their own worst enemy. “I have patients who experienced symptoms of a heart attack and said, ‘well, I decided to do the laundry. When it didn’t get better, I went to the doctor,’” Kacchy said.

“Time is muscle,” she stressed. “If someone is having a heart attack, we want him or her to be evaluated as quickly as possible.”

The best way for women to arm themselves against heart disease and heart attack is to take steps to prevent it. “Know your numbers,” says Kachhy, meaning your blood pressure, your blood glucose, your cholesterol and your body mass index or BMI.  If you know you carry some risks for heart disease, if you smoke or are overweight, make lifestyle changes with your diet and exercise to lower that risk.

Also, familiarize yourself with the signs of heart attack – both for yourself and your loved ones.

Women who believe they are having a heart attack, or anyone who experiences severe chest pain should call 911.  “If you experience mild discomfort for weeks, make an appointment to see your doctor.

“The longer you wait, the more heart muscle damage that can be done,” Kachhy said.

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Helping Your Children Grow into Healthy Teens

Toddlers become teenagers way too fast, and many parents worry about what their adorable child will become. Most teens do very well, especially when supported by parents who play an important role in helping their children mature. Research shows that teens thrive when they have strong relationships with supportive adults.

Healthy relationships develop over years and their foundation is effective communication. Here, Richard Chung, MD, an expert in adolescent medicine at Duke, explains how you can open the lines of communication, and foster that strong relationship with your child now and as they become teenagers.

•       Kids don’t talk to strangers: The more involved you are with your child’s lives, the more impact you conversations with your child will have. Being involved should start early on. Make it a habit to spend one-on-one time with your child on a regular basis. If you’re child is already a teen, find ways to spend time together. Go to the movies, play golf, or go shopping. The latter offer spontaneous ways to start conversations.

•       Teens need parents, not referees: Make it a habit early on to actively praise your child whenever it’s appropriate. It’s okay to offer constructive feedback, but balance it with a healthy dose of praise. A single positive comment can go a long way toward building their confidence and self esteem.

•       I learned it by watching you:  If you aren’t able to share information about your life with your children, they are unlikely to do so with you. Parents are role models who should lead by example. Share stories about your childhood and what’s going on in your world currently. Establish a sense of openness that invites them to respond in kind.

•       Open 24/7: As your child grows and strikes up conversation with you less and less frequently, it will become more important to drop what you’re doing when they actually want to talk, even when it’s inconvenient. It inevitably will be late at night or when you’re walking out the door, but it will be well worth it if they are truly ready to engage.

•       Sigh…“What do you want now!?!”: Make sure communication doesn’t just happen when something has gone wrong or needs to be done. If it’s always negative or stressful, teens will tune out. Touch base daily in a meaningful way. The value of sincere conversation with no motives other than to engage your teen cannot be overstated.

•       Meet them (well beyond) half way: It is undeniably challenging to get teens to converse. However, most parents know of at least a few things that reliably get their teen talking excitedly, whether it’s their new video game, their favorite celebrity, or something silly their friend did at school. If that’s their communication comfort zone is, then that’s where you should be.

To make an appointment with Dr. Chung, or another adolescent medicine specialist at Duke, call 1-888-ASK-DUKE.

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Spring into Physical Activity as a Family

If your kids are bored and you don't know what to do, it's the perfect time to get the whole family moving! Exercising as a family is a great way to spend quality time together, enjoy the warm weather, and show your children that staying fit is an important priority at every age.

“We, as parents, need to be good role models, if we want our children to view physical activity as important,” said Azra Shaikh, MD, a physician in Apex at Duke Primary Care Peak Family Medicine. “Being active benefits the entire family, and creates a special bond you simply can’t achieve by watching TV together.”

The Centers for Disease Control recommends kids engage in at least an hour of physical activity each day. The CDC recommends adults engage in at least five hours of exercise each week. Yet, longer workdays and daily commutes, plus a trend toward more sedentary lifestyles means less adults are meeting those daily recommendations. It’s equally hard for kids as more schools cut physical education programs and daily recess.

“Get your kids to participate in physical activity by focusing on play, not exercise,” said Shaikh. “If there isn’t an element of fun to it, your kids won’t be interested.”

Here’s how all of you can have fun and stay active during your Spring Break, and how you can make physical activities a priority for your family on the weekends too:

Remember the classics: kids love when parents join in on Hide and Seek, Simon Says, Red Light/Green Light, or run fun races in the backyard.Take family walks and hikes. Bring a picnic to build in some rest time.Be a tourist. Visit a museum, the zoo or check out the offerings at the local farmer’s market.Don’t let bad weather stop you in your tracks. Play physically demanding interactive video games. Or, move the old fashioned way by turning up your kids’ favorite songs and showing them your dance moves.Start a family bowling tournament or try a game of mini-golf.Play kickball, softball, or shoot some hoops.Start a vegetable garden. Maintaining a garden can be a great activity, and children will be more likely to eat their vegetables if they took part in growing them.

Call 888-ASK-DUKE to make and appointment with Dr. Shaikh or another Duke Primary Care provider near you.

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Malaysia Meeting at 'Exciting Time for HIV'

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Published: Jun 27, 2013

KUALA LUMPUR -- The 2013 meeting of the International AIDS Society, here in Malaysia, comes at an "exciting time for HIV science," according to society president Francoise Barre-Sinoussi, PhD.

The meeting, held in the years between the biennial International AIDS Conferences, focuses on the science needed to combat the pandemic -- basic, clinical, prevention, and implementation research.

This year, Barre-Sinoussi told reporters in a telephone briefing, a central focus will be on early treatment of HIV with antiretroviral drugs.

That because evidence has been mounting that early treatment has a cascade of benefits: better health for patients, a lower risk of transmission, and -- intriguingly -- the possibility of a cure.

"Cure is one of the priorities of the IAS," Barre-Sinoussi said, and the conference will hear more details of two important studies that seem to show that very early treatment can lead to cure.

In the first, a baby born to an HIV-positive mother was given antiretroviral therapy within an hour of birth, after tests showed she carried the virus.

Mother and daughter fell off the radar screen and their treatment lapsed, but -- as reported earlier this year -- when physicians next saw the baby, she had no sign of HIV infection.

Investigator Deborah Persaud, MD, of Johns Hopkins University School of Medicine is to give a more detailed report in an invited lecture on July 3.

And, French researchers will expand on their report of so-called functional cures among 14 people treated in the acute phase of HIV infection who later -- for various reasons -- went off therapy but maintained control of the virus.

One of the physicians involved with the cohort, Laurent Hocqueloux, MD, of the Centre Hospitalier Régional in Orleans, France, is to report on 283 people who started antiretroviral therapy during chronic rather than acute infection. Other investigators will give more details on the initial cohort.

The Kuala Lumpur meeting will also be preceded -- as happened last year at the International AIDS Conference in Washington, D.C. -- by a 2-day symposium that will focus on strategies to develop a cure for HIV.

"Cure and early treatment, in my opinion, will be a highlight of the conference," Barre-Sinoussi told reporters. "There is a lot of energy to make progress."

The conference will also feature research on: Pre-exposure prophylaxis, or PrEP, with antiretroviral drugs in people at high risk for HIV. In particular, delegates will get details on a study showing the approach can work among injection drug users.Circumcision, which has been shown to reduce the risk of transmission between heterosexual men and women.Treatment as prevention, following up on evidence that HIV-positive people on antiretroviral drugs are less likely to transmit the virus to others.

In that vein, the World Health Organization is expected to announce new guidelines for treatment in the developing world, where scarcity of resources has often meant therapy is delayed, if it is available at all.

In contrast, guidelines in the developed world now recommend that HIV therapy begin as early as possible, because of evidence that delaying treatment leads to worse outcomes even if the virus is eventually suppressed,

A track on clinical science will feature research on new drugs and drug combinations, as well as the management of coinfections such as hepatitis C, which has special resonance for a meeting held in Southeast Asia, where the liver virus is a significant problem.

North American Correspondent for MedPage Today, is a three-time winner of the Science and Society Journalism Award of the Canadian Science Writers' Association. After working for newspapers in several parts of Canada, he was the science writer for the Toronto Star before becoming a freelancer in 1994. His byline has appeared in New Scientist, Science, the Globe and Mail, United Press International, Toronto Life, Canadian Business, the Toronto Star, Marketing Computers, and many others. He is based in Toronto, and when not transforming dense science into compelling prose he can usually be found sailing.

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Nevirapine Toxicity May Be Linked to Race (CME/CE)

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Published: Jul 2, 2013

By Ed Susman, Contributing Writer, MedPage TodayReviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse PlannerNote that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.In this retrospective analysis of patients started on nevirapine-based antiretroviral therapy, almost one-third discontinued therapy due to toxicities, and Malays had the highest incidence of toxicity compared with the other races.

KUALA LUMPUR -- A higher percentage of Malay people experienced treatment-limiting toxicity with the non-nucleoside reverse transcriptase anti-HIV drug nevirapine compared with other groups, and genetic differences may be the reason, researchers reported here.

"Malays had the highest incidence of treatment-limiting nevirapine toxicity amongst the different racial groups," said Joyce Yeap, MS, a clinical pharmacist at Sungai Buloh Hospital in Selangor, Malaysia. Malays had an incidence of treatment-limiting toxicity of 38.4%, compared with Indians, who had the lowest incidence of treatment-limiting nevirapine toxicities at 23.6% (P=0.016), she told MedPage Today.

It is difficult to understand why there should be a racial difference even after performing adjustments for age, sex, HIV transmission category, nadir CD4-positive cell counts, hepatitis B or C virus co-infection and other concomitant medication, Yeap said in her poster presentation at the International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention.

However, outcomes at 12 months were not different between the patients who developed toxicities and were switched to other regimens and those who did not have dose-limiting adverse events (P=0.456), Yeap said.

"Malays are 1.7 times more likely than Chinese or Indians or other ethnicities to develop treatment-limiting nevirapine toxicities," she noted. The researchers performed various logistic regression analyses and determined that toxicities to nevirapine were more frequent in the Malay population of Malaysia which has a polyglot of different races, including several indigenous peoples.

"We did not have resources to perform genome studies," she said, "but it could be due to some type of gene sub-types that makes the Malays more sensitive to nevirapine toxicity."

Yeap said that when treating Malays, physicians need to factor in sex and CD4 counts as well. "We might be more cautious in giving nevirapine to these individuals," she suggested.

While other treatment regimens are possible for HIV-infected individuals, Yeap noted that for a developing country with limited resources, nevirapine is one of the most cost-effective therapies available.

The average age of the 662 HIV-infected patients in her study was 37.4 years, and 75.8% of the patients were men. Their average nadir CD4 cell counts were 134.8 cells/mm3. The researchers identified 34.6% of the patients as Malay; 42.1% were Chinese; 10.9% were Indian; and 9.2% were foreigners.

Rash was the nevirapine treatment-limiting adverse event among 156 patients; flu-like illnesses were observed in 130 patients; hepatotoxicity was seen in 44 patients. She said 102 patients presented with rash, flu-like illness and liver toxicity.

A possible explanation for the treatment-limiting toxicity might have to do more with clinical observation rather than genetics, suggested Graeme Moyle, MBBS, director of research at Chelsea and Westminster Hospital, London.

"There are studies here that look at the genetic linkage between adverse events and specific drugs," Moyle told MedPage Today as he reviewed the poster presentation. "There appear to be certain alleles that are associated with nevirapine toxicity, especially the cutaneous toxicities. It may be due to allele variations across certain ethnic populations."

He said that another possibility that is often discussed is that among black patients nevirapine-associated rash appeared more severe. He said that may be caused by the fact that the rash may be more difficult to observe among darker-skinned individuals. Since the rash is non-itchy, the skin color may mask the rash until it reaches a more severe level, Moyle suggested.

"When you have darker skin you don't recognize early rash that can lead to discontinuation when the rash is mild," he said. "People continue to take therapy and the rash continues to a more severe event."

Yeap had no disclosures.

Moyle has reported commercial interests with Gilead, Ardea Biosciences, Abbott Laboratories, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Tobira Therapeutics, Panacos Pharmaceuticals, Pfizer and Tibotec.

Primary source: International AIDS Society
Source reference:
Yeap J, et al "Incidence and risk factors for treatment-limiting toxicities in patients starting nevirapine-containing antiretroviral therapy" IAS 2013; Abstract MOPE092.

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Teens with HIV Need Transition to Adult Care (CME/CE)

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Published: Jun 24, 2013

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse PlannerWith current antiretroviral therapy, most HIV-infected children now survive into adulthood. Successful transition requires several factors according to a policy statement of the American Academy of Pediatrics.The care transition should include a written policy for the transfer of HIV-infected youth to adult care and the plan should be introduced to the youth in early adolescence and modified as the youth approaches transition.

HIV-positive adolescents, who face isolation, ostracization, and confusion as they transition to adulthood, need sensitive and directed guidance to an adult healthcare provider, according to the American Academy of Pediatrics.

Clinicians should follow four steps to guide HIV-positive teens to successfully maintain their healthcare: create a formal, written transition care plan, start communications about HIV status and transition around age 12, make the transition between 18 to 25 years of age, and document and evaluate the transition upon completion, the AAP outlined in a policy statement published online in Pediatrics.

"Pediatricians and adolescent and family medicine providers have a pivotal role in facilitating seamless and effective transition at a very vulnerable and anxious time of life for both HIV-infected youth and their families," wrote Russell B. Van Dyke, MD, FAAP, and Rana Chakraborty, MD, for the AAP's Committee on Pediatric AIDS. "These essential transitional activities can improve health outcomes for HIV-infected adolescents."

HIV infection is the seventh-leading cause of death among youth and adolescents and 12,200 (25.7%) of all new HIV infections in 2010 were in youths. Nearly six out of 10 (59.5%) were unaware of their infection, a higher percentage than in any other age group, the authors wrote.

The written care plan should include supporting documents that assist the new team, according to the policy statement, including goals and a timeline. An important piece of the plan, the authors noted, is a system, such as a registry, to track youth as they make their way through the transition process so as to minimize loss to care that might accompany a move out of the family home.

Introducing the concept of transition is important, the policy stated, because children who are unaware of their status should be fully informed at age 10 to 12, depending on maturity and neurocognitive abilities. Readiness assessment tools may help identify strengths and weaknesses that can focus patient attention.

The teenager's or young adult's educational, vocational, and social service needs should be addressed, as well.

"The plan should emphasize education of all involved parties and empowerment of the HIV-infected youth to assume responsibility for his or her own healthcare," the authors wrote." It is important to encourage independence through personal ownership and management of healthcare. Particular attention should be paid to identifying and addressing behavioral, emotional, and mental health problems."

Helping the patient successfully make the actual transition depends greatly on the team handing off care, the policy stated. Creating and maintaining a portable medical summary and an emergency care plan is essential.

Transition should include direct contact between providers and a letter of transition, the portable medical summary, and electronic health records before the patient transfers to the new provider.

"Ideally, the youth would be introduced to the adult healthcare provider personally by the pediatric, adolescent, or family medicine provider, either in the referring or adult clinic," the AAP authors wrote.

"This support could consist of periodic contact by a member of the referring healthcare team, such as a nurse or social worker. A peer support group may assist youth with dealing with anxiety resulting from the transition process."

However, once adult care is established, the pediatric, adolescent, or family medicine provider should bow out to prevent confusion and reinforce the adult healthcare provider.

"Adolescence is a developmental stage characterized by immature concrete reasoning often manifested by denial of illness, a sense of invulnerability reflected by risk taking, and behaviors that are strongly influenced by peer norms," the authors wrote. "These characteristics all have a direct negative effect on the ability to adhere to complex medical regimens."

Dramatic improvements in HIV care combined with psychosocial stressors including loss of a parent, foster care, poverty, homelessness, unemployment, discrimination, and abuse have made for a generation of HIV-infected youth whose future -- and others -- depends on managing their chronic condition on their own, the policy stated.

Furthermore, among HIV-infected youth 18 and older who transitioned from National Institutes of Health clinical research protocols to adult care, 15% reported not having health insurance.

No conflict of interest statements were published with the policy statement.

Kathleen Struck joined MedPage Today after serving as Managing Editor for EverydayHealth.com, Stars and Stripes and MediaNews Group. She lived and traveled internationally for more than 15 years and has written and edited for publications including, Washington Post, Baltimore Sun, Newsday and Regulatory Affairs Professional Society. At MedPage Today, she reports and edits on general news and information.

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HIV Cure Has Long Way to Go Before the Clinic

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Published: Jul 1, 2013

KUALA LUMPUR -- The science of an HIV cure is in its infancy but scattered cases of remission -- so-called "functional" cures -- give hope that it is possible, experts said here.

But if the tempo of development is similar to that of anti-HIV drugs in the late 1980s and early 1990s, a useful strategy is still some years away, according to Steven Deeks, MD, of the University of California San Francisco.

"I think we're in 1987," Deeks told MedPage Today -- a period when no drugs were yet available and researchers were just learning such basic things as how to measure HIV in blood and what viral targets for drugs existed.

It would take another 8 or 9 years before the first triple-drug cocktails were proved to stop HIV replication and stave off AIDS.

Similar basic questions now preoccupy scientists trying to find a cure for HIV, Deeks said here on the eve of the 7th International AIDS Society meeting on HIV pathogenesis, treatment, and prevention.

But how long it will take until a safe, effective cure is available remains an open question, commented Nobel laureate Francoise Barré-Sinoussi, PhD, the AIDS society's president.

The "sporadic cases" of apparent cure and even much of the basic research being presented at the AIDS society meeting and at a separate 2-day pre-conference symposium on curative strategies are "pieces of the puzzle," she told MedPage Today.

The solution of the puzzle may not use all of the pieces being investigated today, Barre-Sinoussi said, but the "knowledge that we are accumulating now" will eventually lead to a cure or remission.

But a cure is the next important step in combating the HIV/AIDS pandemic, Deeks later said in a keynote speech to the conference's opening session, because even well-treated HIV has a series of dangerous consequences, including premature aging, dementia, and cardiovascular disease.

Given the sheer number of people with HIV in the world -- some 34 million according to the Joint United Nations Programme on HIV/AIDS (UNAIDS) -- those consequences have the potential to overwhelm healthcare systems not geared to deal with chronic disease, Deeks told delegates.

Evidence is mounting, he said, that curing HIV infection is possible. Among that evidence:

But, while those cases are encouraging, they remain anecdotal, commented Sharon Lewin, MD, of Monash University in Melbourne, Australia, who was a co-chair, with Deeks, of the cure symposium, which featured many of the same players as the AIDS society meeting.

"Anecdotes never mean much to me," she told MedPage Today, adding she prefers the hard data from clinical trials.

Nonetheless, Lewin said, what much of the evidence seems to be saying is that the reservoir of resting T cells that are infected with HIV must be depleted or destroyed for a cure to have a chance.

Those latently infected T cells, though, are difficult to find -- they are infected in the sense that they contain HIV DNA integrated into their genome, but they only rarely lead to HIV replication.

But if a patient is not on effective antiretroviral therapy and resting cells become active, the result has long been thought to be a resumption of full-blown HIV infection.

That's why the cases of the Mississippi baby and the Visconti cohort are so striking -- they seem to defy that long-held dogma. The problem is that they also seem difficult to apply more generally.

Any cure for HIV will have to meet three characteristics, argued Carl Dieffenbach, PhD, of the National Institute of Allergy and Infectious Diseases in Bethesda, Md.

It must first of all be safe, he said in a closing talk to the cure symposium. Then it must be less difficult for patients than their current anti-HIV drug regimens.

And it must be scalable -- able to be used to treat not hundreds or even thousands of patients, but millions around the world, Dieffenbach said.

North American Correspondent for MedPage Today, is a three-time winner of the Science and Society Journalism Award of the Canadian Science Writers' Association. After working for newspapers in several parts of Canada, he was the science writer for the Toronto Star before becoming a freelancer in 1994. His byline has appeared in New Scientist, Science, the Globe and Mail, United Press International, Toronto Life, Canadian Business, the Toronto Star, Marketing Computers, and many others. He is based in Toronto, and when not transforming dense science into compelling prose he can usually be found sailing.

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New Guidelines Advocate Earlier HIV Treatment (CME/CE)

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Published: Jul 1, 2013

By Ed Susman, Contributing Writer, MedPage TodayReviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse PlannerNote that these new World Health Organization guidelines recommend treatment for HIV when CD4 counts fall below 500 cells/mm3.In addition, the guidelines recommend treatment of all those who are coinfected with HIV and either hepatitis B or tuberculosis.

KUALA LUMPUR -- New international guidelines suggest that people diagnosed with human immunodeficiency virus (HIV) be treated earlier in the course of the disease -- effectively making another 9.2 million people eligible for antiretroviral therapy, researchers said here.

Currently in the underdeveloped world, where HIV has devastated many nations, 9.7 million people out of an estimated 16.7 million who should be treated receive effective antiretroviral therapy, said Gundo Weiler, MD, PhD, medical and health policy adviser of the National German AIDS Organization in Berlin. But the impact of the new World Health Organization (WHO) guidelines will increase the number of patients who need to be treated to 25.9 million.

The major increase comes from earlier treatment -- commencing highly active antiretroviral therapy (HAART) when infected persons' CD4-positive cell counts drop below 500 cells/mm3, Weiler, who helped write the recommendations, said at the International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. The previous guidelines suggested treating patients once those immune system markers fell below 350 cells/mm3.

Weiler said the 2013 WHO guidelines would result in 3 million deaths due to HIV being avoided between 2013 and 2025 when compared with 2010 guidelines. The implementation of the guidelines also would reduce new HIV infections by 36% by 2025 compared with projections using the 2010 guidelines.

The change in definition of when to commence treatment adds 3.9 million persons to the "should be in treatment" statistics. The new guidelines also expand the use of antiretroviral therapy in children. Under the old guidelines, 1.2 million children needed to be in treatment; the new guidelines expand that to 2.6 million children.

The new guidelines suggests that all HIV-positive pregnant women, regardless of CD4 count, be placed on antiretroviral therapy -- adding 700,000 people to those needing treatment.

The new guidelines also advocate immediate treatment with HAART therapy for those 3.2 million people now coinfected with tuberculosis or hepatitis B infection.

All told, the new guidelines increase the numbers of patients needing HAART by 9.2 million.

Weiler said that by increasing contributions from governments and other agencies by 10% a year, it will be possible to have those patients under treatment by 2025. But because treatment reduces infections, after 2025, the number of patients living with HIV and the number of people on treatment will begin to merge.

"Generally, in the U.S. and Canada we are already using these guidelines to treat our patients," Julio Montaner, MD, professor of medicine at the University of British Columbia, Vancouver, told MedPage Today.

"What these guidelines will do, however, is to convince doctors who are on the fence about where to begin treatment to start treating their patients earlier," Montaner said.

He also said that in Europe -- especially in countries that are experiencing economic crises -- the guidelines will help convince those health providers to initiate HAART therapy earlier. Montaner did not participate in the WHO guideline-writing process.

The new guidelines recommend: Treating adults, adolescents, and older children earlier -- starting antiretroviral therapy in all individuals with a CD4 cell count of 500 cells/mm3 or less and giving priority to individuals with severe or advanced HIV disease and those with a CD4 cell count of 350 cells/mm3 of less.Starting antiretroviral therapy at any CD4 cell count for certain populations with HIV, including people with active tuberculosis disease, people with hepatitis B coinfection with severe chronic liver disease, HIV-positive partners in serodiscordant couples, pregnant and breastfeeding women, and children younger than 5 years of age.A new preferred first-line antiretroviral regimen harmonized for adults, pregnant and breastfeeding women and children ages 3 or older. That first-line therapy should be a fixed-dose combination of tenofovir plus lamivudine or emtricitabine plus efavirenz.Support to actively accelerate the phasing out of stavudine (d4T) in first-line regimens for adults and adolescents.

The guidelines also include new recommendations for testing for HIV.

Montaner reported commercial relationships with Abbott, Gilead Sciences, GlaxoSmithKline, and Merck.

Weiler reported no disclosures.

Primary source: International Aids Society
Source reference:
World Health Organization "Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV Infection" IAS 2013.

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5-Drug HIV Tx Given Early Cuts Viral Reservoir (CME/CE)

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Published: Jul 2, 2013 | Updated: Jul 2, 2013

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse PlannerNote that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.Patients with primary HIV infection receiving early treatment with five-drug highly active antiretroviral therapy (HAART) achieved lower cell-associated HIV-DNA levels and a better immune reconstitution than chronically infected patients on intensified long-term suppressive HAART.

KUALA LUMPUR -- For patients in the early stages of HIV infection, initial treatment with five antiretroviral drugs, rather than three, may be a first step toward remission, a researcher said here.

In 2-year results from a 7-year prospective trial, such intense therapy resulted in a sharp decline in HIV DNA that is integrated into cells, according to Eva Wolf, PhD, of MUC Research in Munich, Germany.

But in patients with chronic HIV infection who were also given an intensified regimen, there was no change over time in the so-called cell-associated or proviral DNA, Wolf reported at the 7th International AIDS Society Meeting on HIV Pathogenesis, Treatment, and Prevention.

The drop in proviral DNA was accompanied by a reconstitution of the immune system, Wolf told MedPage Today, and may be the first step toward remission or a "functional cure" -- the ability to control HIV replication without drug therapy.

In a French cohort of patients treated early in the course of HIV infection -- the so-called Visconti cohort -- the level of cell-associated DNA appears to be an important predictor of such a functional cure, she said.

The proviral DNA is thought to be an important part of the HIV reservoir, which forms the basis for the ability of the virus to rebound when antiretroviral therapy is stopped.

The Visconti cohort includes 14 people who were treated in the first weeks of their infection with standard antiretroviral therapy. When they later stopped therapy for various reasons, they did not have a viral rebound, although HIV was still present.

Wolf and colleagues hypothesized that intensified therapy might have a similar effect, and to test the idea, they enrolled 20 patients with primary infection as well as 20 with chronic infection, who had been on successful antiretroviral therapy for at least 3 years.

The early patients were given five drugs -- two nucleoside reverse transcriptase inhibitors, a protease inhibitor, the entry inhibitor maraviroc (Selzentry) and the integrase inhibitor raltegravir (Isentress).

The chronically infected patients remained on their stable regimen, Wolf said, with the addition of maraviroc and raltegravir.

The primary outcome measures were successful interruption of HIV replication and depletion of the proviral DNA, measured as copies per million peripheral blood mononuclear cells.

After 2 years of the study, she reported, the chronic patients had a slight but nonsignificant increase in proviral DNA. On the other hand, those with primary infection had a median decline of 1.4 log10 copies per million cells (P<0.001).

Whether that is sufficient to lead to a functional cure is an open question. Wolf said, and she and colleagues are considering "pulsed treatment" to see if there is viral rebound in the absence of antiretroviral drugs.

Outside experts, though, cautioned that intensified treatment has been tried before without a clear benefit.

First , "you can't compare the groups" because it's already known that people with chronic disease don't see a marked reduction in proviral DNA with additional therapy, commented Sharon Lewin, MD, of Monash University in Melbourne, Australia, a leader in research aimed at curing HIV.

"They've taken people with an established reservoir, added in extra drugs (and found) no change in DNA because you're already at steady state," Lewin told MedPage Today.

Meanwhile, those with primary infection already are known to have a better response even with three-drug therapy, she noted, based on a study in 2012 in Thailand.

"If you really want to say the extra drugs made a difference, you'd compare three drugs and five drugs," she said.

In fact, there is so far no evidence that so-called mega-HAART makes a difference in the size of the proviral DNA reservoir in early infection, commented John Frater, MD, PhD, of Oxford University. Frater was one of the leaders of the so-called Spartac trial that invesigated the effects of therapy in the early stages of HIV infection using three standard drugs.

That trial showed a benefit of early treatment in terms of improving immune function, and delaying the time that patients would need to go back on therapy after stopping. But it's not clear that adding drugs would have had an additional benefit, he told MedPage Today.

He and colleagues are currently planning a trial in which raltegravir will be added to standard therapy in early infection -- but not because the investigators think it will markedly affect the reservoir compared with three drugs. Instead, Frater said, they hope the rapid decline in viral replication associated with raltegravir might "tip the balance" and help limit the establishment of the reservoir.

He added it's still not known how small the reservoir of proviral DNA has to be to allow patients to go off therapy and it is still not possible to measure the size of the reservoir accurately. "The errors in our assays are enormous," he said.

The study was supported by AbbVie; Merck, Sharp & Dohme; and Pfizer/ViiV Healthcare.

Wolf made no disclosures.

Lewin has reported grant support from Gilead and Merck.

Frater has not reported recent financial links with industry.

Primary source: International AIDS Society
Source reference:
Wolf E, et al "5-drug HAART during primary HIV infection leads to a reduction of proviral DNA levels in comparison to levels achievable during chronic infection" IAS 2013; Abstract MOPE097.

North American Correspondent for MedPage Today, is a three-time winner of the Science and Society Journalism Award of the Canadian Science Writers' Association. After working for newspapers in several parts of Canada, he was the science writer for the Toronto Star before becoming a freelancer in 1994. His byline has appeared in New Scientist, Science, the Globe and Mail, United Press International, Toronto Life, Canadian Business, the Toronto Star, Marketing Computers, and many others. He is based in Toronto, and when not transforming dense science into compelling prose he can usually be found sailing.

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Low-Dose Drug Combo Safe in Kids with HIV (CME/CE)

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Published: Jul 5, 2013

By Ed Susman, Contributing Writer, MedPage TodayReviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San FranciscoThis study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.A low-dose treatment regimen with lopinavir/ritonavir antiretroviral therapy appears to have similar efficacy with fewer adverse events than standard dosing in HIV-infected children.Note that children treated with the lower dose of the protease inhibitor had significantly lower cholesterol and triglyceride levels.

KUALA LUMPUR -- A low-dose treatment regimen with lopinavir/ritonavir antiretroviral therapy appears to have similar efficacy with fewer adverse events than standard dosing in HIV-infected children, researchers said here.

In the intention-to-treat analysis, 89 of 101 children (88.1%) on the low-dose regimen achieved undetectable viral loads using the 50 copies/ml assay (P=0.38) compared with 90 of 98 children treated with the standard dose of lopinavir/ritonavir (Kaletra), said Thanyawee Puthanakit, MD, from Chulalongkorn University in Bangkok, and colleagues.

"This study demonstrated non-inferiority in virologic efficacy of low dose compared to standard dose lopinavir/ritonavir tablets as maintenance therapy," she reported at the International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention.

In terms of adverse effects, the study showed that children treated with the lower dose of the protease inhibitor had significantly lower cholesterol levels. She said that 34.4% of children on the standard dose had cholesterol levels greater than 200 mg/dl at the end of the 48 week trial compared with 20.6% of children treated with the low-dose regimen (P=0.03).

In addition, triglyceride levels greater than 150 mg/dl were observed among 60.4% of the children on the standard dosing regimen and in 44.3% of those on the low dose of lopinavir/ritonavir (P=0.03), Puthanakit reported.

"This dosing regimen conferred adequate lopinavir blood level with reduced drug cost, and reduced potential long-term complications such as dyslipidemia," she said.

"Lopinavir/ritonavir is the most commonly used HIV regimen used in children," Puthanakit pointed out.

In the trial, which was conducted from December to June 2011, the children assigned to the standard, weight-based dose received an average of 284 mg/m2 twice daily. The children in the low-dose group received an average of 210 mg/m2. The lower dose represents about 70% of the recommended treatment dose in the U.S., Puthanakit said.

Of the 199 patients in the study, seven children in both arms were lost to follow-up.

The average age of the children was 13.2 years and their CD4-positive cell counts was 786 cells/mm3. All were on protease inhibitor regimens. The background nucleoside reverse transcriptase inhibitors included zidovudine and lamivudine; zidovudine and didanosine; lamivudine and tenofovir; lamivudine alone; and lamivudine and didanosine.

The study was devised as a way to deliver maintenance therapy for children whose HIV was well controlled, with all of the children at baseline having undetectable HIV plasma viral loads using the 50 copies/mm3.

Puthanakit noted that the study results could only be generalized to children with controlled, undetectable viral loads and should not, at this time, be expanded to include children with high viral loads who may just be beginning antiretroviral therapy.

Diana Gibb, MD, from the Medical Research Council Clinical Trials Unit in London also cautioned that the results "would not apply to the use of liquid lopinavir/ritonavir therapy since this study was done with tablets that have a higher bioavailability."

Puthanakit concurred, noting that her study did not include infants and young children who are treated with liquid formulations of the antiretroviral regimen.

The study was part of the long-standing HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT).

The study was funded by Thai governmental agencies.

Puthanakit and Gibb reported no conflicts of interest.

Primary source: International AIDS Society
Source reference:
Puthanakit T, et al "A randomized study comparing low dose versus standard dose lopinavir/ritonavir among HIV-infected children with virological suppression" IAS 2013; Abstract MOAB0101.

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