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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Reading What Your Doctor Is Reading

Update From the Medical Journals: August 2014

August 29, 2014

By Mary Pickett M.D.

Harvard Medical School

What's the latest news in the medical journals this month? Find out what your doctor is reading.

High-Dose Flu  Shot  Works Best for Older Adults

People over age 65 have a milder immune system boost from flu shots compared with younger people. For this reason, a high-dose form of the vaccine was developed a couple of years ago. The high-dose flu shot has 4 times the amount of flu protein. Studies have already shown that it triggers more antibody production in seniors. However, it also causes a higher rate of local reactions at the injection site, such as arm pain and skin redness. As a precaution, seniors are being asked to wait in their health care provider's office for about 30 minutes after getting the shot. This is to watch for signs of a serious reaction. Many people want to know whether the vaccine is truly more effective at preventing flu.

A study published in the New England Journal of Medicine on August 14 provides some answers. This study randomly assigned almost 32,000 men and women ages 65 and older to 2 groups. One group got the high-dose flu shot and the other group got the standard dose flu shot. Both shots protected against 3 strains of flu. (They were not the "quadrivalent" form of vaccine that was available last year.) Researchers checked in with the patients throughout flu season to see how many got the flu. The group that got the high-dose flu shot had 24% fewer cases of flu. They also had more antibodies against flu (presumably, antibodies that were stimulated by the vaccination) compared with the group that got the standard dose flu shot. Local reactions were more significant in the high-dose vaccine group, but dangerous reactions did not occur more frequently in that group compared with the standard dose vaccine group.

So far, high-dose flu shots protect against 3 flu strains each season. ("Quadrivalent" flu shots that offer protection against 4 strains of flu have not yet been made in the high-does version). The 3-strain high-dose vaccine has not yet been compared to a quadrivalent (4-strain) standard dose vaccine. Nonetheless, based on the impressive protection that the high-dose vaccine appeared to offer to older adults, most doctors will be recommending the 3-strain high-dose flu shot to seniors this year

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Ebola Epidemic Expands within West Africa

The U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have designated the largest outbreak of Ebola virus in history an international public health emergency. The outbreak has resulted in more than 3,000 cases and more than 1,500 deaths. Ebola virus causes an illness known as hemorrhagic fever. The outbreak is active in Guinea, Liberia, Nigeria and Sierra Leone. The virus is continuing to spread.

Communities, organizations and volunteers are providing help. For example:

  • Humanitarian aid organizations such as Doctors Without Borders, Samaritans Purse and the Red Cross have sent health care workers to West Africa. (In the case of Doctors Without Borders, more than 650 health workers are in West Africa). This has been high-risk work. Many health workers have become ill. By one estimate, they represent 10% of the Ebola cases during this outbreak.
  • Government organizations from developed countries have sent staff to assist, including the CDC. The WHO sent a regional director to affected countries in July to meet with political and health care leaders in the area as well as aid agencies. To prevent the spread of Ebola, the WHO is asking that special burial procedures be followed. The World Food Program and World Bank Group, as well as many private philanthropists, have pledged or provided funds for various supplies in the fight against Ebola.
  • Experts have published clear, detailed precautions that health care workers should take to prevent transmission when  caring for an Ebola patient. The recommendations also include how to decontaminate after contact with a patient.
  • Countries heavily affected by Ebola have closed schools, markets and stores to reduce the spread of infection.
  • Sick patients have been treated in carefully isolated treatment centers whenever possible. Some patients have remained at home against recommendations.
  • People exposed to a sick patient have been asked to remain on a "symptom watch" for 21 days. In some cases these individuals have been kept in quarantine.
  • Numerous airlines have stopped flying to affected countries; travel advisories and restrictions have been declared.
  • Several countries adjacent to affected nations have closed their shared borders. Along with airline restrictions, this is impacting the flow of humanitarian aid supplies and is impacting the trade economies of affected countries. It may also be preventing spread of the illness.
  • An experimental drug to treat Ebola has been given to some patients. It'stoo early to tell whether the drug is effective against Ebola.
  • Violence has erupted in areas, such as Liberia, where quarantine decisions and supply shortages have been a problem.

Appropriate efforts are underway in this severe epidemic. Similar help is needed in West Africa. The epidemic is still expanding.

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More News In Brief

  • Low Vitamin D Is Associated with Risk for Dementia. A study, published in Neurology on August 6, has shown that low vitamin D is associated with a higher risk for dementia. This study didn't prove that low vitamin D was the cause. So doctors are uncertain how much attention to give these findings. The study included 1,658 people older than 65 (the average age was 73 at the study start). Their vitamin D levels were tested at the start of the study. No one had dementia at that time because people with dementia were excluded from participating. Six years later, 171 people in the group (about 10%) had developed dementia. People who had low vitamin D levels at the start of the study appeared to have twice as many cases of dementia as people who had high vitamin D levels. Sources of vitamin D include certain foods, sun exposure and vitamin supplements. Some researchers think vitamin D may play a role in clearing harmful amyloid proteins from the brain. It is also possible that people who are developing dementia absorb or store vitamin D differently. We can expect more research to better understand the connection between vitamin D and brain function.
  • NSAIDs May Help Prevent Recurrence in Breast Cancer Patients. A study of 440 women with breast cancer found that daily use of NSAIDs (ibuprofen, aspirin and others) was linked to a lower recurrence rate of cancer. This benefit seemed to be most significant among women who were overweight or obese. About half of the women in the study were overweight or obese. These women had a 52% lower recurrence rate if they took a daily aspirin or other NSAID. Women whose cancer came back appeared to have a delay in the timing of recurrence, if they took aspirin or any other NSAID. This study was published by Cancer Research on August 14. 

    All of the women in this study had breast cancer that was estrogen receptor positive, meaning these cancers could be stimulated by estrogen. The majority of the women were taking anti-estrogen hormone medicine, such as tamoxifen, to prevent recurrence of breast cancer. Researchers wonder if NSAIDS may work on their own, or possibly may make this medicine more effective. It's possible that inflammation (which is reduced by NSAIDs) contributes in some way to cancer growth, but we will need more research to understand this possible connection. Using aspirin or other NSAIDs on a daily basis has some risks, so speak to a doctor before using aspirin or other NSAIDs in this way.

  • Repeated Blood Transfusions Prevent Strokes in Children with Sickle Cell Disease. On August 7, the New England Journal of Medicine reported on an aggressive therapy for children with sickle cell disease: monthly blood transfusions. Sickle cell disease causes anemia. It also causes blood cells that are misshapen and more likely to trigger blood clots. This can cause small silent strokes in 1 out of every 3 children with sickle cell. 

    In this study, 196 children with MRI findings of a stroke were divided into 2 groups. One group was treated with a blood transfusion every month for 3 years. The other group was not. Both groups had follow-up MRI scans of the brain.They also had intelligence testing. The group that had blood transfusions had less than half the number of new strokes, compared with the other group. Intelligence testing at the end of the study did not show a difference between the groups. The group that got the blood transfusions also had fewer episodes of pain and shortness of breath, which can occur in sickle cell disease. However, there were complications from repeated transfusions that make it hard to decide if this treatment approach is sensible. Repeated transfusions may be worth considering for sickle-cell patients with severe symptoms and stroke, but they are probably not practical for everyone. 

  • Pediatricians Recommend Later School Start Times for Teens. The journal Pediatrics published a new recommendation from the American Association of Pediatrics (AAP) on August 25. It says that middle and high schools should start later in the day and end later. This would be more in sync with teens biological sleep patterns. Most adolescents aren't getting enough sleep. They need between 8.5 and 9.5 hours of sleep each night. Teenagers have a shift in their natural sleeping patterns. They tend to go to stay up later and wake up later. Adequate sleep prevents excess weight gain, reduces risk for depression, improves grades and lowers the risk of car accidents. The group is asking middle and high schools to consider starting classes at 8:30 or later. Teenagers can hope that their school administrators read and consider this article.

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Mary Pickett, M.D., is an associate professor at Oregon Health Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a lecturer for Harvard Medical School and a senior medical editor for Harvard Health Publications.

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