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Pisgah Family Health
Welcome Danielle Deines
As you may know, our nurse Tami Nicholson is expecting her second child in December.
To prepare for her maternity leave, we are training a nurse intern to cover her absence.
Danielle Deines will be working with Tami starting in September, and will be with us until Tami returns.
Danielle is already quite skilled in veterinary phlebotomy, so our patients with hairy arms will be her favorite subjects.
Danielle has resided in Western North Carolina for most of her life and is a graduate of Roberson High School. She is in her final semester of studies at Brevard College where she will receive her B.A. in Exercise Science and Health Science Studies. She has been a consistent Dean's List honoree and is conducting independent research in sports medicine for her Senior Project. In addition to her classroom work, she has been a member of the Tornado Cross Country and Track teams and earned Academic All-American honors in Cross Country. Outside of her collegiate education, Danielle has been working as a veterinary technician since 2002. She enjoys running, anything outdoors, music, spending time with family, and playing with her dogs.
During the Spring and Summer parents are often reminded that their schoolchildren need a Physical Exam for camp, sports, or school. The physical exam is intended to assess the child's safety and preparedness for these tasks. The exam also helps to assess age-appropriate development such as growth, learning, motor skills, and social skills. In older children we also try to assess health risks such as smoking, drug use, and school performance.
Here are some tips to streamline you child's physical:
August is National Immunization Month
August is the perfect time to remind family, friends, co-workers, and those in the community to catch up on their vaccinations. Parents are enrolling their children in school, students are entering college, and health care workers are preparing for the upcoming flu season.
Why are immunizations important?
Immunization is one of the most significant public health achievements of the 20th century. Vaccines have eradicated smallpox, eliminated wild poliovirus in the U.S. and significantly reduced the number of cases of measles, diphtheria, rubella, pertussis and other diseases. But despite these efforts, today tens of thousands of people in the U.S. still die from these and other vaccine-preventable diseases. Vaccines offer safe and effective protection from infectious diseases. By staying up-to-date on the recommended vaccines, individuals can protect themselves, their families and friends and their communities from serious, life-threatening infections.
Who should be immunized?
Getting immunized is a lifelong, life-protecting community effort regardless of age, sex, race, ethnic background or country of origin. Recommended vaccinations begin soon after birth and continue throughout life. Being aware of the vaccines that are recommended for infants, children, adolescents, adults of all ages and seniors, and making sure that we receive these immunizations, are critical to protecting ourselves and our communities from disease.
When are immunizations given?
Because children are particularly vulnerable to infection, most vaccines are given during the first five to six years of life. For certain vaccines, booster immunization are recommended throughout life. A Tetanus booster is recommended every 10 years for adults. Pneumonia vaccine is recommended for adults with lung disease, splenectomy, or those over 65. Flu vaccine is recommened in October or November for those with asthma or other chronic health problems, infants, and adults over 65. Certain vaccines are recommended for travelers to foreign countries.
HPV infection is the most common sexually transmitted infection (STI) in the United States (U.S.), with approximately 20 million Americans currently infected. Each year, an additional 6.2 million people become newly infected.1 As many as half of those infected with HPV are adolescents and young adults, ages 15-24 years. 2
While most HPV infections are asymptomatic and transient, HPV is of clinical and public health importance because persistent infection with certain oncogenic types can lead to cervical cancer. Cervical cancer is one of the most common cancers in women worldwide. Certain oncogenic types also have been associated with other, less common anogenital cancers. Moreover, non-oncogenic HPV types can cause genital warts and, rarely, respiratory tract warts in children.
On June 8, 2006, an HPV vaccine was licensed by the Food and Drug Administration (FDA) for use in females, ages 9-26 years. Another HPV vaccine is in the final stages of clinical testing, but not yet licensed. These vaccines offer a promising new approach to the prevention of HPV and associated conditions.
Genital HPV Infection
Over 30 types of HPV infect mucosal surfaces, including the anogenital epithelium (i.e., cervix, vagina, vulva, rectum, urethra, penis, and anus).
Genital HPV can be divided into “high-risk” (i.e., oncogenic or cancer-associated) types, and “low-risk” (i.e., non-oncogenic) types. HPV 16 and 18 are the most common high-risk types found in cervical cancer. HPV 6 and 11 are the most common low-risk types found in genital and respiratory tract warts.
Natural history of HPV
Over half of sexually active women and men are infected with HPV at some point in their lives.3 Approximately 90% of women with HPV infection become HPV-negative within two years.4 The gradual development of an effective immune response is thought to be the likely mechanism for HPV DNA clearance. However, it is also possible that the virus remains in a non-detectable dormant state and then reactivates many years later.
Many women with transient HPV infections may develop mild cytologic (Pap test) abnormalities that spontaneously regress.
About 10% of women infected with HPV develop persistent HPV infection. Women with persistent high-risk HPV infection are at greatest risk for developing high-grade cervical cancer precursor lesions (cervical intra-epithelial neoplasia or CIN 2,3) and cancer.
Persistent infection with high-risk types of HPV is associated with almost all cervical cancers. The age-adjusted incidence rate for invasive cervical cancer in the U.S. was 8.7 per 100,000 women in 2002 (most recent year for which data are available).5 In that same year, 3,952 women died from this disease in the U.S.
Persistent infection with high-risk types of HPV is also associated with cancers of the vulva, vagina, penis and anus. However, these cancers are considerably less common than cervical cancer.
Genital HPV infection with low-risk types of HPV is associated with genital warts in men and women. About 1% of sexually active adults in the U.S. have visible genital warts at any point in time.2
Very rarely, perinatal transmission of low-risk HPV infections can result in respiratory tract warts in infants and children, a condition known as recurrent respiratory papillomatosis (RRP).
Prevention of Cervical Cancer
Cervical cancer once claimed the lives of more American women than any other type of cancer. But over the last 40 years, widespread cervical cancer screening using the Pap test and treatment of pre-cancerous cervical abnormalities have resulted in a marked reduction in cervical cancer incidence and mortality in the U.S. HPV DNA testing is now widely used with Pap smears for cervical cancer screening and management.
Today, as many as 82% of women in the U.S. have been screened with a Pap test in the past three years. Despite this, screening programs are not reaching all women in the U.S. It is estimated that half of the women diagnosed with cervical cancer have never been screened for cervical cancer, and an additional 10% have not been screened in the previous five years.
A quadrivalent HPV vaccine (manufactured by Merck) has recently been licensed by the FDA for females ages 9-26 years. The vaccine protects against four types of HPV (6,11,16,18), including two that cause 70% of cervical cancers and two that cause 90% of genital warts. The vaccine has been tested in over 11,000 females (ages 9-26 years).
This vaccine is made from non-infectious HPV-like particles (VLP), composed of the major capsid protein. There is no thimerosal or mercury contained in the vaccine.
The vaccine should be delivered through a series of three intra-muscular injections over a six-month period (at 0, 2, and 6 months).
Clinical trials in females (ages 16-26 years) have demonstrated 100% efficacy in preventing cervical precancers caused by the targeted HPV types. The vaccine has also been found to be almost 100% effective in preventing vulvar and vaginal precancers and genital warts caused by the targeted HPV types. The vaccine has no therapeutic effect on HPV-related disease; it does not protect from disease due to HPV types already acquired.
Efficacy studies for the vaccine in males are ongoing. Data will be available in the next few years.
The vaccine appears to be safe and there are no serious side effects. Adverse reactions are mainly injection site pain. This reaction is common but mild.
The duration of protection is unclear. Current studies indicate the vaccine is effective for five years. There is no evidence of waning immunity during that time period. This information will be updated as additional data regarding immunity become available.
The CDC Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination for 11-12 year-old girls and catch-up vaccination for 13-26 year-old females.
Ideally, the vaccine would be administered before onset of sexual activity. However, females who are sexually active may also benefit from vaccination. Those who have not been infected with any vaccine HPV type would receive the full benefit of vaccination. Those who have already been infected with one or more HPV type would still get protection from the vaccine types they have not yet acquired. Few young women are infected with all four vaccine HPV types (6,11,16,18).
While it is possible that vaccination of males with the quadrivalent vaccine may offer direct health benefits to males and indirect health benefits to females (through herd immunity), there are not yet data to confirm this. No efficacy data are available for use in males. This information will be available in the future.
The retail price of the vaccine is $120 per dose ($360 for full series).
If the ACIP recommends the vaccine for routine use, federal health programs such as Vaccines for Children (VFC) will cover the HPV vaccine for persons less than 19 years of age who are VFC eligible.
Although an effective HPV vaccine is a major advance in approaches to the prevention of genital HPV and associated diseases, it will not replace other prevention strategies since vaccines will not work for all genital HPV types. Vaccinated women will still need regular cervical cancer screening since the vaccine will NOT provide protection against all types of HPV that cause cervical cancer, and since some women may not receive the full vaccine series (or they may not receive them at appropriate intervals). Vaccinated women should still practice protective sexual behaviors (e.g., abstinence, monogamy, limiting the number of sex partners, and/or using condoms, which is associated with lower rates of genital warts and cervical cancer10 ), since the vaccine will not prevent all HPV types—nor will it prevent other STIs.
A bivalent HPV vaccine (being developed by GlaxoSmithKline) is in the final stages of testing in females and may be available soon. This vaccine would protect against the two types of HPV (16,18) that cause 70% of cervical cancers.
Additional Sources of Information
September is Gynecologic Cancer Awareness Month
Ovarian cancer, the most serious of the gynecologic
malignancies, usually arises on the surface of the
*Ovarian cancer ranks fifth as a cause of cancer deaths among women, and causes more deaths than any other cancer of the female reproductive system. It is estimated there will be more than 25,000 new cases diagnosed and approximately 16,000 deaths from ovarian cancer in the United States during 2004.
Most uterine cancers begin in the lining of the
uterus (endometrium) after menopause, when a
woman's menstrual cycle ends and the endometrium
flattens out. Uterine cancer occurs when cells in the
endometrium lining grow out of control and invade
the muscle of the uterus.
*Cancer of the endometrium is the most common cancer of the female reproductive organs. It is estimated that 40,320 new cases will be diagnosed and approximately 7,000 deaths from uterine cancer in 2004.
Cervical cancer is caused by abnormal cellular
changes in the cervix and is the only gynecologic
cancer that can be prevented by regular cervical
* An estimated 10,520 cases of invasive cervical cancer are expected to be diagnosed and approximately 3,900 deaths in 2004. Deaths in the U.S. from cervical cancer have dropped dramatically due to the use of regular Pap Smears. The use of the HPV vaccine is expected to reduce incidence of this cancer even further.
Vulvar cancer appears as lesions on the surface of
the vulva or labia.
Vaginal cancer is very rare. It is usually diagnosed in elderly women with abnormal bleeding and is treated with radiation.
Fallopian Tube Cancer
Cancers rarely develop in the fallopian tubes. Treatments and risk factors for fallopian tube cancer are similar to ovarian cancer.
September is Prostate Cancer Awareness Month. If you are a man over 50, you should consider an annual exam for prostate cancer.
What is the prostate?The prostate is a gland in the male reproductive system. The prostate makes and stores a component of semen and is located near the bladder and the rectum. The prostate surrounds part of the urethra, the tube that empties urine from the bladder. A healthy prostate is about the size of a walnut. If the prostate grows too large, the flow of urine can be slowed or stopped.
What is prostate cancer?Except for skin cancer, cancer of the prostate is the most common malignancy in American men. It is estimated that nearly 221,000 men in the United States will be diagnosed with prostate cancer in 2003. In most men with prostate cancer, the disease grows very slowly. The majority of men with low-grade, early prostate cancer (confined to the gland) live a long time after their diagnosis. Even without treatment, many of these men will not die of the prostate cancer, but rather will live with it until they eventually die of some other, unrelated cause. Nevertheless, nearly 29,000 men will die of prostate cancer in 2003.
Who is at risk for prostate cancer?All men are at risk. The most common risk factor is age. More than 70 percent of men diagnosed with prostate cancer each year are over the age of 65. African American men have a higher risk of prostate cancer than white men. Dramatic differences in the incidence of prostate cancer are also seen in different countries, and there is some evidence that a diet higher in fat, especially animal fat, may account for some of these differences. Genetic factors also appear to play a role, particularly for families in whom the diagnosis is made in men under 60 years of age. The risk of prostate cancer rises with the number of close relatives who have the disease.
What are the symptoms of prostate cancer?Prostate cancer often does not cause symptoms for many years. By the time symptoms occur, the disease may have spread beyond the prostate. When symptoms do occur, they may include: If the cancer is caught at its earliest stages, most men will not experience any symptoms. Some men, however, will experience symptoms that might indicate the presence of prostate cancer, including:
What conditions can cause these symptoms?As men get older, their prostate may grow bigger and block the flow of urine or interfere with sexual function. This common condition, called benign prostatic hyperplasia (BPH), is not cancer, but can cause many of the same symptoms as prostate cancer. Although BPH may not be a threat to life, it may require treatment with medicine or surgery to relieve symptoms. An infection or inflammation of the prostate, called prostatitis, may also cause many of the same symptoms as prostate cancer. Again, it is important to check with a doctor.
Can prostate cancer be found before a man has symptoms?Yes. Two tests can be used to detect prostate cancer in the absence of any symptoms. One is the digital rectal exam (DRE), in which a doctor feels the prostate through the rectum to find hard or lumpy areas. The other is a blood test used to detect a substance made by the prostate called prostate specific antigen (PSA). Together, these tests can detect many “silent” prostate cancers, those that have not caused symptoms. At present, however, it is not clear whether routine screening saves lives. The benefits of screening and local therapy (surgery or radiation) remain unclear for many patients. Because of this uncertainty, the National Cancer Institute is currently supporting research to learn more about screening men for prostate cancer. Currently, researchers are conducting a large study to determine whether screening men using a blood test for PSA and a DRE can help reduce the death rate from this disease. They are also assessing the risks of screening. Full results from this study, the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial or PLCO, are expected by 2015.
How reliable are the screening tests for prostate cancer?Neither of the screening tests for prostate cancer is perfect. Most men with mildly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal levels of PSA. Also, the DRE can miss many prostate cancers. The DRE and PSA test together are better than either test alone in detecting prostate cancer.
How is prostate cancer diagnosed?The diagnosis of prostate cancer can be confirmed only by a biopsy. During a biopsy, a urologist (a doctor who specializes in diseases of urinary and sex organs in men, and urinary organs in women) removes tissue samples, usually with a needle. This is generally done in the doctor’s office with local anesthesia. Then a pathologist (a doctor who identifies diseases by studying tissues under a microscope) checks for cancer cells. Prostate cancer is described by both grade and stage. Grade describes how closely the tumor resembles normal prostate tissue. Based on the microscopic appearance of tumor tissue, pathologists may describe it as low-, medium-, or high-grade cancer. One way of grading prostate cancer, called the Gleason system, uses scores of 2 to 10. Another system uses G1 through G4. In both systems, the higher the score, the higher the grade of the tumor. High-grade tumors generally grow more quickly and are more likely to spread than low-grade tumors. Stage refers to the extent of the cancer. Early prostate cancer, stages I and II, is localized. It has not spread outside the gland. Stage III prostate cancer, often called locally advanced disease, extends outside the gland to the seminal vesicles. Stage IV means the cancer has spread to lymph nodes and/or to other tissues or organs.
What can I do?If you have any of the above symptoms, call your doctor. Men who are asymptomatic, and with no family history of early prostate cancer, should have routine screening beginning at age 50. Screening is begun earlier if there is a strong family history of early disease. Screening includes a rectal examination and a blood test called PSA. This is usually performed as part of the annual physical.
For more health information, check out these links:
About our Newsletter
Dr. Curran and the staff at Pisgah Family Health are proud to publish the Pisgah Family Health News to our patients. Our goal is to provide regularly updated information about the office and current medical topics. We plan to publish a new issue each quarter with breaking news. The newsletters will also be archived on our website, http://www.pisgahfamilyhealth.com/.
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