The American Heart Association has come out with new guidelines regarding the need for antibiotics and dental procedures to protect heart valves. They are based on clinical opinion (experts) but there is very little clinical evidence to show that antibiotics really do help. Are you surprised?
To be sure, the efficacy of antibiotics and the cost effectiveness of the antibiotics have never been proven. In only 4-7.5 % of cases, can we even site sequential relationships between the dental procedure and valve infections.
The infection that we are trying to prevent is called infective endocarditis. It is an infection on the heart valve that can be life threatening. There are about 10-20 thousand new cases of infective endocarditis every year and the mortality is 20-30%, making it a very serious infection.
In order for there to be an infection, the valve must have been the “victim” of an injury. Then, following the injury, bacteria must come along (from the blood) to seed the area.
Bacteria in the blood (bacteremia) is quite common. We “throw” bacteria into the blood when we do something as simple as brushing our teeth. It is thought to be more common when we have dental work. We are not sure how much bacteremia is necessary (how many bacteria need to be exposed to the damaged valve) in order to seed the valve and set the stage for the infection to propagate.
Here are the current recommendations (as of 2007).
Patients to consider for antibiotics should include:
1) A patient with a prosthetic valve (a valve replacement)
2) A patient with a previous history of endocarditis
3) Patients with specific congenital heart disease (ask me the specifics)
4) A patient who is has had a valvulopathy after cardiac transplantation.
The following are the recommendations for use:
1) Amoxicillin 2 grams in adults taken orally
2) Allergy to Penicillin - Clindamycin 600 mg or Azithromycin 50 mg also taken orally
If a patient cannot take oral medication, there are intramuscular or intravenous substitutes.
The bottom line here is those patients with a murmur DO NOT NEED any antibiotic. This is fabulous news but will undoubtedly stir the pot and many of the local dentists will have a tizzy. Have them call me. Those patients belonging to Choice Care can save themselves tons of trouble and time by just referring your dentist to our website or to my phone or email. As usual, we are happy to oblige.
Sunday, July 13, 2008
Bisphosphonates, The risks and benefits
Much has been written about the bisphosphonates (Fosamex, Actonel, Boniva) mostly in the lay press about the potential for osteonecrosis or bone death. Bisphosphonates are used as preventives against osteoporosis, or a loss of bone density. Osteoporosis has been linked to fracture and it is a condition that increases with age.
The incidence of osteonecrosis appears to be about 2-4% and occurs mostly in those treated with intravenous bisphosphonate. Further, it seems to occur more often in those treated with higher doses, patients, often with cancer. Those who have been on steroid drugs, are immunosuppressed, long time smokers and those with poor oral hygiene also seem to be at increased risk when taking the oral version of the drugs.
The bottom line: it is clear that there is minimal risk. Brushing your teeth, getting lots of weight bearing exercise, and taking your medications correctly (including calcium) seem to be the best means of minimizing your risk of both osteoporosis and the rare event of osteonecrosis secondary to bisphosphonate use either oral or intravenous.
The incidence of osteonecrosis appears to be about 2-4% and occurs mostly in those treated with intravenous bisphosphonate. Further, it seems to occur more often in those treated with higher doses, patients, often with cancer. Those who have been on steroid drugs, are immunosuppressed, long time smokers and those with poor oral hygiene also seem to be at increased risk when taking the oral version of the drugs.
The bottom line: it is clear that there is minimal risk. Brushing your teeth, getting lots of weight bearing exercise, and taking your medications correctly (including calcium) seem to be the best means of minimizing your risk of both osteoporosis and the rare event of osteonecrosis secondary to bisphosphonate use either oral or intravenous.
Nutrition after Gastric Bypass
Anemia and a variety of other nutrition issues are very common after gastric bypass surgery. Here are some tips.
Deficiencies in fat soluble vitamins are common after bypass surgery. The fat soluble vitamins are Vitamins A, D, E and K. Calcium and iron absorption are also problematic. That leaves bariatric patients with an increased risk of anemia and osteoporosis.
The surgery results in a reduction in the acid that is most prevalent in the stomach, hydrochloric acid. That makes it very difficult to absorb calcium as calcium carbonate. Calcium citrate is much more available for absorption and is the preferred form of calcium in bariatric patients.
Iron is also not absorbed very well because the duodenum is bypassed and that is where iron is absorbed. If patients consume calcium with vitamin C (ascorbic acid), there is a greater chance that the iron will be absorbed in the stomach.
There are also some medications that might be a problem in bypass patients. For instance, there may be a delay in the effectiveness after taking ambien, a sleeping pill that usually works immediately. It may take a little longer to get those eyes closed for the night but the problem can be minimized if the ambien is taken on an empty stomach.
Zocor is another medication that may be problematic. Another statin may have to be used.
Niacin should be taken with a low-fat snack.
Ramipril and enalapril, common blood pressure medications may not be as effective as other angiotensin converting enzyme inhibitors and they may need to be substituted.
Metformin is also not absorbed well and glucose should probably be followed closely.
Finally, metoprolol is absorbed very quickly in the stomach and duodenum generally but given the weight loss that occurs with the bypass may mean that fewer blood pressure medications will be necessary.
B12 should be taken in sublingual forms, eliminating the problem of Vitamin B12 deficiency.
While we don’t need a mega-doses of Vitamins, bypass patients should definitely take a multi-vitamin every day in order to be sure that they don’t be come deficient.
Deficiencies in fat soluble vitamins are common after bypass surgery. The fat soluble vitamins are Vitamins A, D, E and K. Calcium and iron absorption are also problematic. That leaves bariatric patients with an increased risk of anemia and osteoporosis.
The surgery results in a reduction in the acid that is most prevalent in the stomach, hydrochloric acid. That makes it very difficult to absorb calcium as calcium carbonate. Calcium citrate is much more available for absorption and is the preferred form of calcium in bariatric patients.
Iron is also not absorbed very well because the duodenum is bypassed and that is where iron is absorbed. If patients consume calcium with vitamin C (ascorbic acid), there is a greater chance that the iron will be absorbed in the stomach.
There are also some medications that might be a problem in bypass patients. For instance, there may be a delay in the effectiveness after taking ambien, a sleeping pill that usually works immediately. It may take a little longer to get those eyes closed for the night but the problem can be minimized if the ambien is taken on an empty stomach.
Zocor is another medication that may be problematic. Another statin may have to be used.
Niacin should be taken with a low-fat snack.
Ramipril and enalapril, common blood pressure medications may not be as effective as other angiotensin converting enzyme inhibitors and they may need to be substituted.
Metformin is also not absorbed well and glucose should probably be followed closely.
Finally, metoprolol is absorbed very quickly in the stomach and duodenum generally but given the weight loss that occurs with the bypass may mean that fewer blood pressure medications will be necessary.
B12 should be taken in sublingual forms, eliminating the problem of Vitamin B12 deficiency.
While we don’t need a mega-doses of Vitamins, bypass patients should definitely take a multi-vitamin every day in order to be sure that they don’t be come deficient.
New recommendations for PPD
There are new recommendations for those patients who turn PPD positive in their adult life and have a normal CXR. This is now called “latent tuberculosis.”
The recommendation is as follows:
1) All patients regardless of age should be treated with Isoniazid (INH) for 9 months.
2) Precautions should be taken regarding liver dysfunction and liver enzymes should be followed monthly.
3) Patients should be monitored carefully if they are on Coumadin or other drugs metabolized in the liver.
Dosing for INH is as follows [5 mg/kg PO/IM qd x6-9mo]
Max: 300 mg/day; Alt: 15 mg/kg PO/IM 2x/wk if therapy directly observed, max 900 mg/dose;
Info: to prevent progression in PPD-positive pts; give on empty stomach
The recommendation is as follows:
1) All patients regardless of age should be treated with Isoniazid (INH) for 9 months.
2) Precautions should be taken regarding liver dysfunction and liver enzymes should be followed monthly.
3) Patients should be monitored carefully if they are on Coumadin or other drugs metabolized in the liver.
Dosing for INH is as follows [5 mg/kg PO/IM qd x6-9mo]
Max: 300 mg/day; Alt: 15 mg/kg PO/IM 2x/wk if therapy directly observed, max 900 mg/dose;
Info: to prevent progression in PPD-positive pts; give on empty stomach
Tetanus - Do you need the vaccine? Why?
What causes tetanus?
Tetanus is caused by a toxin (poison) produced by
a bacterium, Clostridium tetani. The C. tetani bacteria
cannot grow in the presence of oxygen. They
produce spores that are very difficult to kill as they
are resistant to heat and many chemical agents.
How does tetanus spread?
C. tetani spores can be found in the soil and in the
intestines and feces of many household and farm
animals and humans. The bacteria usually enter the
human body through a puncture (in the presence of
anaerobic [low oxygen] conditions, the spores will
germinate).
Tetanus is not spread from person to person.
How long does it take to show signs of tetanus after
being exposed?
The incubation period varies from 3-21 days, with
an average of eight days. The further the injury site
is from the central nervous system, the longer the
incubation period. The shorter the incubation period,
the higher the risk of death.
What are the symptoms of tetanus?
The symptoms of tetanus are caused by the tetanus
toxin acting on the central nervous system. In the
most common form of tetanus, the first sign is spasm
of the jaw muscles, followed by stiffness of the neck,
difficulty in swallowing, and stiffness of the abdominal
muscles.
Other signs include fever, sweating, elevated blood
pressure, and rapid heart rate. Spasms often occur,
which may last for several minutes and continue for
3-4 weeks. Complete recovery, if it occurs, may take
months.
How serious is tetanus?
Tetanus has a high fatality rate; during 1998-2000,
the case-fatality rate for reported tetanus in the
United States was 18%.
What are possible complications from tetanus?
Laryngospasm (spasm of the vocal cords) is a complication
that can lead to interference with breathing.
Patients can also break their spine or long bones
from convulsions. Other possible complications include
hypertension, abnormal heart rhythm, and
secondary infections, which are common because of
prolonged hospital stays.
Obviously, the high possibility of death is a major
complication.
How is tetanus diagnosed?
The diagnosis of tetanus is based on the clinical signs
and symptoms only. Laboratory diagnosis is not useful
as the C. tetani bacteria often cannot be recovered
from the wound of an individual who has tetanus,
and conversely, can be isolated from the skin of
an individual who does not have tetanus.
What kind of injuries might allow tetanus to enter
the body?
Tetanus bacilli live in the soil, so the most dangerous
kind of injury involves possible contamination
with dirt, animal feces, and manure. Although we
have traditionally worried about deep puncture
wounds, in reality many types of injuries can allow
tetanus bacilli to enter the body. In recent years, a
higher proportion of cases had minor wounds than
had major ones, probably because severe wounds
were more likely to be properly managed. People
have become infected with tetanus following surgery,
burns, lacerations, abrasions, crush wounds,
ear infections, dental infections, animal bites, abortion,
pregnancy, body piercing and tattooing, and
injection drug use. People can also get tetanus from
splinters.
I stepped on a nail in our yard. What should I do?
Any wound that may involve contamination with
tetanus bacilli should be attended to as soon as possible.
Treatment depends on your vaccination status
and the nature of the wound. In all cases, the wound
should be cleaned. Seek treatment immediately and
bring your immunization record with you.
With wounds that involve the possibility of tetanus
contamination, a patient with an unknown or incomplete
history of tetanus vaccination needs a tetanus-
and diphtheria-containing shot (Td or Tdap)
and a dose of tetanus immune globulin (TIG) as
soon as possible.
A person with a documented series of three tetanusand
diphtheria-containing shots (Td or Tdap) who
has received a booster dose within the last ten years
should be protected. However, to ensure adequate
protection, a booster dose of vaccine may still be
given if it has been more than five years since the
last dose and the wound is other than clean and
minor.
Is there a treatment for tetanus?
There is no “cure” for tetanus once a person develops
symptoms, just supportive treatment and management
of complications. The best “treatment” is
prevention through immunization.
How common is tetanus in the United States?
Tetanus first became a reportable disease in the late
1940s. At that time, there were 500-600 cases reported
per year. After the introduction of the tetanus
vaccine in the mid-1940s, reported cases of tetanus
dropped steadily.
During 1990-2001, a total of 534 cases of tetanus
were reported. Most (56%) of these cases occurred
among adults age 19-64 years and 38% were among
persons age 65 years or older.
Almost all cases of tetanus are in persons who have
never been vaccinated, or who completed their
childhood series, but did not have a booster dose in
the preceding 10 years.
What is neonatal tetanus?
Neonatal tetanus is a form of tetanus that occurs in
newborn infants, most often through the use of an
unsterile cutting instrument on the unhealed umbilical
stump. These babies usually have no temporary
immunity passed on from their mother because their
mother hasn’t been vaccinated and therefore has no
immunity.
Neonatal tetanus is very rare in the United States
(three cases reported during 1990-2004), but is
common in some developing countries. It causes
more than 215,000 deaths worldwide per year.
Can you get tetanus more than once?
Yes! Tetanus disease does not cause immunity because
so little of the potent toxin is required to cause
the disease. Persons recovering from tetanus should
begin or complete the vaccination series.
When did tetanus vaccine become available?
The first tetanus toxoid (inactivated toxin) was produced
in 1924 and was used successfully to prevent
tetanus in the armed services during World War II.
In the mid-1940s, tetanus vaccine was combined
with diphtheria toxoid and inactivated pertussis
bacteria to make the combination DTP vaccine for
routine childhood immunization.
In 1991, DTaP vaccine was licensed in the United
States. The pertussis component of this vaccine is a
more purified “acellular” version, which produces
fewer side effects.
In 2005, two new tetanus toxoid-diphtheria-acellular
pertussis (Tdap) vaccines were licensed. These
vaccines are the first pertussis-containing vaccines
that can be given to persons older than 7 years.
What kind of vaccine is the tetanus toxoid?
The tetanus vaccine is an inactivated toxin (poison)
called a toxoid. It is made by growing the bacteria
in a liquid medium and purifying and inactivating
the toxin. Because it is not a live vaccine, a person’s
immunity tends to decline with time, which is why
booster doses are recommended.
What’s the difference between all the vaccines containing
tetanus toxoid?
It’s like alphabet soup!
Tetanus toxoid is available as a single shot (TT) but
it rarely is given that way as it’s best to also provide
needed protection against other diseases at the same
time.
Children younger than age seven years receive DTaP
(tetanus, diphtheria, and acellular pertussis). If they
cannot receive the pertussis component of the combined
vaccine, they can receive DT (diphtheria and
tetanus toxoids for pediatric use). DTaP also can be
given as part of two different combination vaccines;
one includes DTaP, inactivated polio vaccine, and
hepatitis B vaccine, and another contains DTaP and
Hib vaccine.
Children ages seven years and older and adults
should be given a different formulation (i.e., Td or
Tdap).
How is this vaccine given?
The DTaP, DT, Td, and Tdap preparations are all
given as an injection in the muscle.
Who should get this vaccine?
Infants should receive DTaP vaccine (or DT-pediatric
if they cannot receive the pertussis component)
as part of their routine immunization. Adults should
be given a routine booster dose of Td every 10 years.
Adults without documentation of ever receiving the
basic series of tetanus and diphtheria toxoids should
first receive a primary series of three doses, properly
spaced. A single dose of Tdap is recommended for
persons age 11 years and older in place of one of the
Td doses, preferably the first one.
How many doses of DTaP vaccine are needed?
The usual schedule for infants is a series of four
doses given at two, four, six, and 15-18 months of
age. A fifth shot, or booster dose, is recommended
at 4-6 years of age, unless the fourth dose was given
late (after the fourth birthday).
When should adolescents and adults get vaccinated
against tetanus? Should they get vaccinated with Td
or Tdap?
Immunization experts recommend that the first dose
of Tdap be given at age 11-12 as a booster during
the routine adolescent immunization visit if the adolescent
has finished the childhood DTaP schedule
and has not already received a dose of Td or Tdap.
Adults should continue to receive a booster dose of
Td every ten years. Adults age 19-64 years who have
never received Tdap should receive a single dose of
Tdap to replace a single dose of Td so they can boost
their resistance to pertussis as well.
If someone experiences a deep or puncture wound,
or a wound contaminated with dirt, an additional
booster dose may be given if the last dose was more
than five years ago. It is important to keep an up-todate
record of all immunizations so that repeat
doses don’t become necessary. Although it is vital to
be adequately protected against tetanus, receiving
more doses than recommended can lead to increased
local reactions, such as painful swelling of
the arm.
Who recommends this vaccine?
The Centers for Disease Control and Prevention
(CDC), the American Academy of Pediatrics (AAP),
the American Academy of Family Physicians (AAFP),
and the American College of Physicians (ACP) all
recommend this vaccine.
How safe is this vaccine?
Most children have no serious reactions from the
combined DTaP vaccine. The most common reactions
are local reactions at the injection site, such as
soreness, redness, and swelling, especially after the
fifth dose. Other possible reactions may include
fussiness, fever, loss of appetite, tiredness, and vomiting.
The use of the more purified DTaP instead of
DTP has decreased these reactions substantially.
For adults receiving Td vaccine, localized non-serious
side effects are common (redness, soreness, etc.)
but are generally self-limiting and require no treatment.
What side effects have been reported with this vaccine?
Moderate to serious reactions are uncommon with
DTaP vaccine. Such reactions include crying for
three hours or more (up to about one child out of
1,000) and high fever (about one child out of
16,000). Most of these side effects are believed to be
due to the pertussis component of the vaccine, and
a child experiencing such a reaction may still be able
to be protected against tetanus and diphtheria with
the DT vaccine. More serious reactions, such as seizures,
are so rare that it is hard to tell if they are
caused by the vaccine.
As mentioned above, adults who received more than
the recommended doses of Td vaccine can experience
increased local reactions, such as painful swelling
of the arm. This is due to the high levels of tetanus
antibody in their blood.
The most frequently reported side effects following
vaccination with Tdap were headache, generalized
body aches, and tiredness.
Some of my patients describe having had a severe
reaction to something they were given for tetanus
many years ago. What could this be?
The allergic reactions these people experienced may
have actually been serum sickness, a reaction to
equine antitoxin. Equine antitoxin was the only
product available for the prevention of tetanus prior
to the mid 1940s. It was used for postexposure prophylaxis
until the late 1950s, when tetanus immune
globulin was introduced. Tetanus toxoid has never
contained any horse protein.
How effective is tetanus-diphtheria toxoid (Td)?
Td is close to 100% effective for persons receiving
the correct primary series (as a child or adult) and
a routine booster dose every ten years. It is felt that
Tdap vaccine will provide the same level of protection.
Who should NOT receive tetanus toxoid?
People who had a serious allergic reaction to one
dose of tetanus toxoid should not receive another.
Persons with a moderate or severe acute illness
should postpone receiving the vaccine until they are
improved. Most reactions to the combined DTaP
vaccine are due to the pertussis component. Please
see the “Pertussis” section for more information on
possible precautions to the use of this vaccine.
Can the vaccine cause tetanus?
No.
Tetanus is caused by a toxin (poison) produced by
a bacterium, Clostridium tetani. The C. tetani bacteria
cannot grow in the presence of oxygen. They
produce spores that are very difficult to kill as they
are resistant to heat and many chemical agents.
How does tetanus spread?
C. tetani spores can be found in the soil and in the
intestines and feces of many household and farm
animals and humans. The bacteria usually enter the
human body through a puncture (in the presence of
anaerobic [low oxygen] conditions, the spores will
germinate).
Tetanus is not spread from person to person.
How long does it take to show signs of tetanus after
being exposed?
The incubation period varies from 3-21 days, with
an average of eight days. The further the injury site
is from the central nervous system, the longer the
incubation period. The shorter the incubation period,
the higher the risk of death.
What are the symptoms of tetanus?
The symptoms of tetanus are caused by the tetanus
toxin acting on the central nervous system. In the
most common form of tetanus, the first sign is spasm
of the jaw muscles, followed by stiffness of the neck,
difficulty in swallowing, and stiffness of the abdominal
muscles.
Other signs include fever, sweating, elevated blood
pressure, and rapid heart rate. Spasms often occur,
which may last for several minutes and continue for
3-4 weeks. Complete recovery, if it occurs, may take
months.
How serious is tetanus?
Tetanus has a high fatality rate; during 1998-2000,
the case-fatality rate for reported tetanus in the
United States was 18%.
What are possible complications from tetanus?
Laryngospasm (spasm of the vocal cords) is a complication
that can lead to interference with breathing.
Patients can also break their spine or long bones
from convulsions. Other possible complications include
hypertension, abnormal heart rhythm, and
secondary infections, which are common because of
prolonged hospital stays.
Obviously, the high possibility of death is a major
complication.
How is tetanus diagnosed?
The diagnosis of tetanus is based on the clinical signs
and symptoms only. Laboratory diagnosis is not useful
as the C. tetani bacteria often cannot be recovered
from the wound of an individual who has tetanus,
and conversely, can be isolated from the skin of
an individual who does not have tetanus.
What kind of injuries might allow tetanus to enter
the body?
Tetanus bacilli live in the soil, so the most dangerous
kind of injury involves possible contamination
with dirt, animal feces, and manure. Although we
have traditionally worried about deep puncture
wounds, in reality many types of injuries can allow
tetanus bacilli to enter the body. In recent years, a
higher proportion of cases had minor wounds than
had major ones, probably because severe wounds
were more likely to be properly managed. People
have become infected with tetanus following surgery,
burns, lacerations, abrasions, crush wounds,
ear infections, dental infections, animal bites, abortion,
pregnancy, body piercing and tattooing, and
injection drug use. People can also get tetanus from
splinters.
I stepped on a nail in our yard. What should I do?
Any wound that may involve contamination with
tetanus bacilli should be attended to as soon as possible.
Treatment depends on your vaccination status
and the nature of the wound. In all cases, the wound
should be cleaned. Seek treatment immediately and
bring your immunization record with you.
With wounds that involve the possibility of tetanus
contamination, a patient with an unknown or incomplete
history of tetanus vaccination needs a tetanus-
and diphtheria-containing shot (Td or Tdap)
and a dose of tetanus immune globulin (TIG) as
soon as possible.
A person with a documented series of three tetanusand
diphtheria-containing shots (Td or Tdap) who
has received a booster dose within the last ten years
should be protected. However, to ensure adequate
protection, a booster dose of vaccine may still be
given if it has been more than five years since the
last dose and the wound is other than clean and
minor.
Is there a treatment for tetanus?
There is no “cure” for tetanus once a person develops
symptoms, just supportive treatment and management
of complications. The best “treatment” is
prevention through immunization.
How common is tetanus in the United States?
Tetanus first became a reportable disease in the late
1940s. At that time, there were 500-600 cases reported
per year. After the introduction of the tetanus
vaccine in the mid-1940s, reported cases of tetanus
dropped steadily.
During 1990-2001, a total of 534 cases of tetanus
were reported. Most (56%) of these cases occurred
among adults age 19-64 years and 38% were among
persons age 65 years or older.
Almost all cases of tetanus are in persons who have
never been vaccinated, or who completed their
childhood series, but did not have a booster dose in
the preceding 10 years.
What is neonatal tetanus?
Neonatal tetanus is a form of tetanus that occurs in
newborn infants, most often through the use of an
unsterile cutting instrument on the unhealed umbilical
stump. These babies usually have no temporary
immunity passed on from their mother because their
mother hasn’t been vaccinated and therefore has no
immunity.
Neonatal tetanus is very rare in the United States
(three cases reported during 1990-2004), but is
common in some developing countries. It causes
more than 215,000 deaths worldwide per year.
Can you get tetanus more than once?
Yes! Tetanus disease does not cause immunity because
so little of the potent toxin is required to cause
the disease. Persons recovering from tetanus should
begin or complete the vaccination series.
When did tetanus vaccine become available?
The first tetanus toxoid (inactivated toxin) was produced
in 1924 and was used successfully to prevent
tetanus in the armed services during World War II.
In the mid-1940s, tetanus vaccine was combined
with diphtheria toxoid and inactivated pertussis
bacteria to make the combination DTP vaccine for
routine childhood immunization.
In 1991, DTaP vaccine was licensed in the United
States. The pertussis component of this vaccine is a
more purified “acellular” version, which produces
fewer side effects.
In 2005, two new tetanus toxoid-diphtheria-acellular
pertussis (Tdap) vaccines were licensed. These
vaccines are the first pertussis-containing vaccines
that can be given to persons older than 7 years.
What kind of vaccine is the tetanus toxoid?
The tetanus vaccine is an inactivated toxin (poison)
called a toxoid. It is made by growing the bacteria
in a liquid medium and purifying and inactivating
the toxin. Because it is not a live vaccine, a person’s
immunity tends to decline with time, which is why
booster doses are recommended.
What’s the difference between all the vaccines containing
tetanus toxoid?
It’s like alphabet soup!
Tetanus toxoid is available as a single shot (TT) but
it rarely is given that way as it’s best to also provide
needed protection against other diseases at the same
time.
Children younger than age seven years receive DTaP
(tetanus, diphtheria, and acellular pertussis). If they
cannot receive the pertussis component of the combined
vaccine, they can receive DT (diphtheria and
tetanus toxoids for pediatric use). DTaP also can be
given as part of two different combination vaccines;
one includes DTaP, inactivated polio vaccine, and
hepatitis B vaccine, and another contains DTaP and
Hib vaccine.
Children ages seven years and older and adults
should be given a different formulation (i.e., Td or
Tdap).
How is this vaccine given?
The DTaP, DT, Td, and Tdap preparations are all
given as an injection in the muscle.
Who should get this vaccine?
Infants should receive DTaP vaccine (or DT-pediatric
if they cannot receive the pertussis component)
as part of their routine immunization. Adults should
be given a routine booster dose of Td every 10 years.
Adults without documentation of ever receiving the
basic series of tetanus and diphtheria toxoids should
first receive a primary series of three doses, properly
spaced. A single dose of Tdap is recommended for
persons age 11 years and older in place of one of the
Td doses, preferably the first one.
How many doses of DTaP vaccine are needed?
The usual schedule for infants is a series of four
doses given at two, four, six, and 15-18 months of
age. A fifth shot, or booster dose, is recommended
at 4-6 years of age, unless the fourth dose was given
late (after the fourth birthday).
When should adolescents and adults get vaccinated
against tetanus? Should they get vaccinated with Td
or Tdap?
Immunization experts recommend that the first dose
of Tdap be given at age 11-12 as a booster during
the routine adolescent immunization visit if the adolescent
has finished the childhood DTaP schedule
and has not already received a dose of Td or Tdap.
Adults should continue to receive a booster dose of
Td every ten years. Adults age 19-64 years who have
never received Tdap should receive a single dose of
Tdap to replace a single dose of Td so they can boost
their resistance to pertussis as well.
If someone experiences a deep or puncture wound,
or a wound contaminated with dirt, an additional
booster dose may be given if the last dose was more
than five years ago. It is important to keep an up-todate
record of all immunizations so that repeat
doses don’t become necessary. Although it is vital to
be adequately protected against tetanus, receiving
more doses than recommended can lead to increased
local reactions, such as painful swelling of
the arm.
Who recommends this vaccine?
The Centers for Disease Control and Prevention
(CDC), the American Academy of Pediatrics (AAP),
the American Academy of Family Physicians (AAFP),
and the American College of Physicians (ACP) all
recommend this vaccine.
How safe is this vaccine?
Most children have no serious reactions from the
combined DTaP vaccine. The most common reactions
are local reactions at the injection site, such as
soreness, redness, and swelling, especially after the
fifth dose. Other possible reactions may include
fussiness, fever, loss of appetite, tiredness, and vomiting.
The use of the more purified DTaP instead of
DTP has decreased these reactions substantially.
For adults receiving Td vaccine, localized non-serious
side effects are common (redness, soreness, etc.)
but are generally self-limiting and require no treatment.
What side effects have been reported with this vaccine?
Moderate to serious reactions are uncommon with
DTaP vaccine. Such reactions include crying for
three hours or more (up to about one child out of
1,000) and high fever (about one child out of
16,000). Most of these side effects are believed to be
due to the pertussis component of the vaccine, and
a child experiencing such a reaction may still be able
to be protected against tetanus and diphtheria with
the DT vaccine. More serious reactions, such as seizures,
are so rare that it is hard to tell if they are
caused by the vaccine.
As mentioned above, adults who received more than
the recommended doses of Td vaccine can experience
increased local reactions, such as painful swelling
of the arm. This is due to the high levels of tetanus
antibody in their blood.
The most frequently reported side effects following
vaccination with Tdap were headache, generalized
body aches, and tiredness.
Some of my patients describe having had a severe
reaction to something they were given for tetanus
many years ago. What could this be?
The allergic reactions these people experienced may
have actually been serum sickness, a reaction to
equine antitoxin. Equine antitoxin was the only
product available for the prevention of tetanus prior
to the mid 1940s. It was used for postexposure prophylaxis
until the late 1950s, when tetanus immune
globulin was introduced. Tetanus toxoid has never
contained any horse protein.
How effective is tetanus-diphtheria toxoid (Td)?
Td is close to 100% effective for persons receiving
the correct primary series (as a child or adult) and
a routine booster dose every ten years. It is felt that
Tdap vaccine will provide the same level of protection.
Who should NOT receive tetanus toxoid?
People who had a serious allergic reaction to one
dose of tetanus toxoid should not receive another.
Persons with a moderate or severe acute illness
should postpone receiving the vaccine until they are
improved. Most reactions to the combined DTaP
vaccine are due to the pertussis component. Please
see the “Pertussis” section for more information on
possible precautions to the use of this vaccine.
Can the vaccine cause tetanus?
No.
Vitamin D... an excellent review
This is an excellent review of Vitamin D and how it works. It is written by an endocrinologist.
Vitamin D Deficiency and Thyroid Disease
Theodore C. Friedman, M.D., Ph.D.
Vitamin D deficiency and thyroid diseases
Vitamin D is an important vitamin that not only regulates calcium, but also has many other
beneficial actions. Not many endocrinologists realize this, but several articles published
over 20 years ago showed that patients with hypothyroidism have low levels of vitamin D.
This may lead to some of the bone problems related to hypothyroidism. It was thought that
one of two mechanisms may explain the low levels of vitamin D in patients with
hypothyroidism, 1) the low levels of vitamin D may be due to poor absorption of vitamin D
from the intestine or 2) the body may not activate vitamin D properly. Other articles have
demonstrated that patients with Graves disease also have low levels of Vitamin D.
Importantly, both vitamin D and thyroid hormone bind to similar receptors called steroid
hormone receptors. A different gene in the Vitamin D receptor was shown to predispose
people to autoimmune thyroid disease including Graves’ disease and Hashimoto’s
thyroiditis. For these reasons, it is important for patients with thyroid problems to
understand how the vitamin D system works.
Sources of Vitamin D
Vitamin D is really two different compounds, cholecalciferol (vitamin D2), found mainly in
plants and ergocalciferol (vitamin D3), found mainly in animals. Both of these hormones
are collectively referred to as vitamin D, and they can either be obtained in two ways. One
is by exposure of the skin to the ultraviolet (UV) rays of sunlight or also from dietary intake.
Vitamin D is found naturally in fish (such as salmon and sardines) and fish oils, eggs and
cod liver oil. However most Vitamin D is obtained from foods fortified with Vitamin D,
especially milk and orange juice. Interestingly, as breast feeding has become more popular,
the incidence of Vitamin D deficiency has increased as less fortified milk is consumed.
Vitamin D deficiency may also occur in patients with malabsorption from their intestine,
such as in the autoimmune disease called Celiac Disease, which occurs frequently in
patients with thyroid problems. Multivitamins also contain Vitamin D, as does some
calcium supplements like Oscal-D and Citracal plus D..
Different Forms of Vitamin D and How To Diagnose Vitamin D
Vitamin D itself is inactive and needs to get converted in the liver to 25-hydroxy vitamin D
(25-OH vitamin D) and then in the kidney to 1, 25-hydroxy vitamin D. It is only the 1, 25-
OH vitamin D which is biologically active. This form of vitamin D acts to allow for
absorption of calcium from the intestinal tract. Therefore, patients with low vitamin D
levels will have low calcium and in severe cases get rickets (in children) or osteomalacia (in
adults) which is when the bone bows out and is poorly formed. In mild cases of vitamin D
deficiency, osteoporosis occurs.
The conversion from the 25-OH vitamin D to the 1, 25-OH vitamin D that occurs in the
kidney is catalyzed by parathyroid hormone, also called PTH. Therefore, patients with low
vitamin D levels will have relatively high PTH levels along with low calcium levels. This is
similar to patients with primary hypothyroidism having elevated TSH levels while having
normal thyroid hormone levels. Additionally, the 25-OH vitamin D form which is the
storage form and is much more abundant that the 1, 25-OH vitamin D form which, although
is active, is less abundant. Therefore, in states of vitamin D deficiency, low levels of 25-OH
vitamin D are found, but the 1, 25-OH vitamin D levels are either normal or actually slightly
high. They are slightly high because the excess PTH that is stimulated by the low 25-OH
vitamin D levels stimulates the conversion up to 25-OH vitamin D to the 1, 25-OH vitamin
D. Thus, patients that are vitamin D deficient usually have a low 25-OH vitamin D level, a
high PTH level, a low normal calcium, and a normal or an elevated 1, 25-OH vitamin D
level.
Dr. Friedman usually recommends measuring PTH, calcium, and 25-OH vitamin D to
determine if a patient does have vitamin D deficiency. The 25-OH vitamin D assay has a
normal range of approximately 20-60 ng/dL. However, this range may be too low for many
patients. Additionally, the assay may not be that good at measuring the low levels of
vitamin D. In general, Dr. Friedman would recommend treatment of patients that have a 25-
OH vitamin D of less than 30 ng/dL, but these patients should have a PTH in the high
normal range. Optimal levels of 25-OH Vitamin D for patients with thyroid diseases are
probably 35-60 ng/dL It is unclear what to do with a patient with a PTH in the high normal
range and a completely normal 25-OH vitamin D level or the other way around for patients
with a low 25-OH vitamin D level but a completely normal PTH level.
Treatment of Vitamin D Deficiency
There are several ways to correct for the depletion of vitamin D, and these would involve
either increasing sunlight exposure or increasing dietary intake. In general, Dr. Friedman
feels there is an ongoing battle between endocrinologists and dermatologists about sunlight
exposure, and mild sunlight exposure probably does not have that much of an increased risk
of skin cancer yet would be helpful to prevent vitamin D deficiency. Because of our busy
schedule, many of us do not go outside during the day much and our sunlight exposure is
minimal. Blacks and other dark skinned patients absorb less Vitamin D and need more
sunlight exposure. Dr. Friedman recommends a patient to be exposed to the sun for 15-30
minutes a day, especially in the morning, to correct for vitamin D deficiency. However, in
northern latitudes, little light of the proper wavelength goes through the atmosphere in the
winter, so this exposure needs to occur in the spring and summer at which time stores of
vitamin D are built up. The body has mechanisms so that too much vitamin D can not be
synthesized by prolonged sun exposure. An alternative is to go to a tanning salon for
approximately three times. Another alternative for replacing mild vitamin D deficiency is to
take two multivitamins a day. Each multivitamin contains 400 international units of vitamin
D so a total of 800 international units of vitamin D will correct mild cases of low vitamin D
levels. For more severe levels, the patient can take 50,000 international units of vitamin D
orally once or twice a week. This needs to be given by a prescription. If this treatment
regimen is used, the patient needs to be monitored carefully with calcium and 25-OH
vitamin D levels to make sure the patient is not over replaced with vitamin D. The patient
may need this level of treatment for approximately three months and should be checked
monthly. The main side effect of vitamin D therapy is overtreatment leading to
hypercalcemia.
Patients with kidney problems cannot convert vitamin D to the active 1, 25-OH vitamin D
levels and need to take calcitriol which is 1, 25-OH vitamin D. Additionally, patients with
hypoparathyroidism are usually placed on the calcitriol as well.
Conclusion
Vitamin D appears to have many effects besides being related to calcium and bone health.
Some patients with low vitamin D levels have fatigue and bone pain, which is easily
reversible with proper replacement of vitamin D. Vitamin D may protect against heart
disease and some types of cancer. Vitamin D may also have some role in regulating the
immune system and also reducing blood sugar levels in patients with diabetes. Proper
vitamin D levels are needed to prevent osteoporosis. In conclusion, proper vitamin D levels
are essential for one’s health, especially if you have thyroid problems. Unless a patient is
exposed to sunlight or foods containing vitamin D, screening for Vitamin D deficiency is
recommended for all thyroid patients.
This article is not intended to offer medical advice and is offered for information purposes
only. Do not act or rely upon information from this article without seeking professional
medical advice. For more information about Dr. Friedman or to schedule an appointment,
please go to goodhormonehealth.com
Vitamin D Deficiency and Thyroid Disease
Theodore C. Friedman, M.D., Ph.D.
Vitamin D deficiency and thyroid diseases
Vitamin D is an important vitamin that not only regulates calcium, but also has many other
beneficial actions. Not many endocrinologists realize this, but several articles published
over 20 years ago showed that patients with hypothyroidism have low levels of vitamin D.
This may lead to some of the bone problems related to hypothyroidism. It was thought that
one of two mechanisms may explain the low levels of vitamin D in patients with
hypothyroidism, 1) the low levels of vitamin D may be due to poor absorption of vitamin D
from the intestine or 2) the body may not activate vitamin D properly. Other articles have
demonstrated that patients with Graves disease also have low levels of Vitamin D.
Importantly, both vitamin D and thyroid hormone bind to similar receptors called steroid
hormone receptors. A different gene in the Vitamin D receptor was shown to predispose
people to autoimmune thyroid disease including Graves’ disease and Hashimoto’s
thyroiditis. For these reasons, it is important for patients with thyroid problems to
understand how the vitamin D system works.
Sources of Vitamin D
Vitamin D is really two different compounds, cholecalciferol (vitamin D2), found mainly in
plants and ergocalciferol (vitamin D3), found mainly in animals. Both of these hormones
are collectively referred to as vitamin D, and they can either be obtained in two ways. One
is by exposure of the skin to the ultraviolet (UV) rays of sunlight or also from dietary intake.
Vitamin D is found naturally in fish (such as salmon and sardines) and fish oils, eggs and
cod liver oil. However most Vitamin D is obtained from foods fortified with Vitamin D,
especially milk and orange juice. Interestingly, as breast feeding has become more popular,
the incidence of Vitamin D deficiency has increased as less fortified milk is consumed.
Vitamin D deficiency may also occur in patients with malabsorption from their intestine,
such as in the autoimmune disease called Celiac Disease, which occurs frequently in
patients with thyroid problems. Multivitamins also contain Vitamin D, as does some
calcium supplements like Oscal-D and Citracal plus D..
Different Forms of Vitamin D and How To Diagnose Vitamin D
Vitamin D itself is inactive and needs to get converted in the liver to 25-hydroxy vitamin D
(25-OH vitamin D) and then in the kidney to 1, 25-hydroxy vitamin D. It is only the 1, 25-
OH vitamin D which is biologically active. This form of vitamin D acts to allow for
absorption of calcium from the intestinal tract. Therefore, patients with low vitamin D
levels will have low calcium and in severe cases get rickets (in children) or osteomalacia (in
adults) which is when the bone bows out and is poorly formed. In mild cases of vitamin D
deficiency, osteoporosis occurs.
The conversion from the 25-OH vitamin D to the 1, 25-OH vitamin D that occurs in the
kidney is catalyzed by parathyroid hormone, also called PTH. Therefore, patients with low
vitamin D levels will have relatively high PTH levels along with low calcium levels. This is
similar to patients with primary hypothyroidism having elevated TSH levels while having
normal thyroid hormone levels. Additionally, the 25-OH vitamin D form which is the
storage form and is much more abundant that the 1, 25-OH vitamin D form which, although
is active, is less abundant. Therefore, in states of vitamin D deficiency, low levels of 25-OH
vitamin D are found, but the 1, 25-OH vitamin D levels are either normal or actually slightly
high. They are slightly high because the excess PTH that is stimulated by the low 25-OH
vitamin D levels stimulates the conversion up to 25-OH vitamin D to the 1, 25-OH vitamin
D. Thus, patients that are vitamin D deficient usually have a low 25-OH vitamin D level, a
high PTH level, a low normal calcium, and a normal or an elevated 1, 25-OH vitamin D
level.
Dr. Friedman usually recommends measuring PTH, calcium, and 25-OH vitamin D to
determine if a patient does have vitamin D deficiency. The 25-OH vitamin D assay has a
normal range of approximately 20-60 ng/dL. However, this range may be too low for many
patients. Additionally, the assay may not be that good at measuring the low levels of
vitamin D. In general, Dr. Friedman would recommend treatment of patients that have a 25-
OH vitamin D of less than 30 ng/dL, but these patients should have a PTH in the high
normal range. Optimal levels of 25-OH Vitamin D for patients with thyroid diseases are
probably 35-60 ng/dL It is unclear what to do with a patient with a PTH in the high normal
range and a completely normal 25-OH vitamin D level or the other way around for patients
with a low 25-OH vitamin D level but a completely normal PTH level.
Treatment of Vitamin D Deficiency
There are several ways to correct for the depletion of vitamin D, and these would involve
either increasing sunlight exposure or increasing dietary intake. In general, Dr. Friedman
feels there is an ongoing battle between endocrinologists and dermatologists about sunlight
exposure, and mild sunlight exposure probably does not have that much of an increased risk
of skin cancer yet would be helpful to prevent vitamin D deficiency. Because of our busy
schedule, many of us do not go outside during the day much and our sunlight exposure is
minimal. Blacks and other dark skinned patients absorb less Vitamin D and need more
sunlight exposure. Dr. Friedman recommends a patient to be exposed to the sun for 15-30
minutes a day, especially in the morning, to correct for vitamin D deficiency. However, in
northern latitudes, little light of the proper wavelength goes through the atmosphere in the
winter, so this exposure needs to occur in the spring and summer at which time stores of
vitamin D are built up. The body has mechanisms so that too much vitamin D can not be
synthesized by prolonged sun exposure. An alternative is to go to a tanning salon for
approximately three times. Another alternative for replacing mild vitamin D deficiency is to
take two multivitamins a day. Each multivitamin contains 400 international units of vitamin
D so a total of 800 international units of vitamin D will correct mild cases of low vitamin D
levels. For more severe levels, the patient can take 50,000 international units of vitamin D
orally once or twice a week. This needs to be given by a prescription. If this treatment
regimen is used, the patient needs to be monitored carefully with calcium and 25-OH
vitamin D levels to make sure the patient is not over replaced with vitamin D. The patient
may need this level of treatment for approximately three months and should be checked
monthly. The main side effect of vitamin D therapy is overtreatment leading to
hypercalcemia.
Patients with kidney problems cannot convert vitamin D to the active 1, 25-OH vitamin D
levels and need to take calcitriol which is 1, 25-OH vitamin D. Additionally, patients with
hypoparathyroidism are usually placed on the calcitriol as well.
Conclusion
Vitamin D appears to have many effects besides being related to calcium and bone health.
Some patients with low vitamin D levels have fatigue and bone pain, which is easily
reversible with proper replacement of vitamin D. Vitamin D may protect against heart
disease and some types of cancer. Vitamin D may also have some role in regulating the
immune system and also reducing blood sugar levels in patients with diabetes. Proper
vitamin D levels are needed to prevent osteoporosis. In conclusion, proper vitamin D levels
are essential for one’s health, especially if you have thyroid problems. Unless a patient is
exposed to sunlight or foods containing vitamin D, screening for Vitamin D deficiency is
recommended for all thyroid patients.
This article is not intended to offer medical advice and is offered for information purposes
only. Do not act or rely upon information from this article without seeking professional
medical advice. For more information about Dr. Friedman or to schedule an appointment,
please go to goodhormonehealth.com
Thursday, July 10, 2008
The Best Living Will
I, , being of sound mind and body, do not wish to be kept alive indefinitely by artificial means. Under no circumstances should my fate be put in the hands of pinhead politicians who couldn't pass ninth-grade biology if their lives depended on it, or lawyers / doctors interested in simply running up the bills. If a reasonable amount of time passes and I fail to ask for at least one of the following:
Glass of wine
chocolate
Margarita
chocolate
sex
Cold Beer
chocolate
Chicken fried steak
cream gravy
chocolate
Mexican food
chocolate
sex
chocolate
Pizza
chocolate
ice cream
sex
chocolate
sex
Chocolate
Sex
Chocolate
It should be presumed that I won't ever get better. When such a determination is reached, I hereby instruct my appointed person and attending physicians to pull the plug, reel in the tubes, let the 'fat lady sing,' and call it a day!
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