Likely, your gynecologist has you down for one. It’s not clear why she’s unaware of (or is she perhaps ignoring?) the fact that guidelines from 2003 recommend cervical cancer screening every THREE years if it’s done in conjunction with an HPV co-test.

The combination Pap and HPV test is approved for women 30 years and up, so it’s not meant to completely replace the Pap test. But the HPV component adds additional reassurance so screening can be delayed to every three years, according to Katherine Roland of the CDC, author of a recent study on uptake of the guidelines.

Roland said it’s still perfectly normal for a woman over 30 to be screened with a Pap only. But if the results are normal, the guidelines say the interval can be extended to two or three years — not just one — if you’ve had a previous history of normal Paps.

“However, you could give that same woman an HPV co-test, and if both of those test results were normal, you could extend her screening interval to three years, without considering her previous history,” Roland said.

Bottom line — if you’re over 30, there’s no need for an annual cervical cancer screen.

No, he wasn’t a fortune teller (“Your life will improve vastly if…”), though he could have been. Many of his skills would serve him well in that trade.

His forte was in “mind reading,” usually manifested in a card trick. I watched him correctly call at least 20 different cards for diners at a New Jersey restaurant who had been told to pick a card, any card.

Typically, he’d run down the list of numbers and faces out loud – “Ace, king, queen, jack, ten…” – at a pace so fast I thought it was just one of those distractions that kept your focus off the real work involved in the trick. He’d do the same thing with suits, calling out a list backwards and forwards, seemingly arbitrarily.

He was never wrong. I started to suspect that rundown was a bit more deliberate.

When the show was over, he sat down at our table. I wasn’t interested in his secrets; everyone knows magicians never give those up. If that list was purposeful, his talent sprang from his ability to read people exceedingly well.

I asked him how he got so good at that.

By watching people on the subway, he said. Or passersby in a park. Seeing what they notice, what they don’t. Then trying to figure out how, or why.

When he tried the trick on me (jack of clubs), I couldn’t help but wonder if there was more to it than that. He ran down the list of number and face cards. I caught myself diverting my eyes, somewhere between the 10 and the queen, but he could tell instantaneously by the timing of my blink that my card was a Jack.

I couldn’t even say what facial gesture (or perhaps it was just a tick) I might have made during the suits run that relayed “clubs,” but he caught it on the first pass. (There’s a reason I’ve never played Texas Hold’em, I guess).

In April, I read a piece in the New Yorker about David Eagleman, a neuroscientist who is studying time perception in drummers — pros like Coldplay’s Will Champion. The idea came from a producer who said U2’s Larry Mullen once noticed a six-millisecond offset in one of the band’s mixes.

Eagleman found that when asked to keep a steady beat, drummers were off by only by 10 milliseconds, while random controls waivered by about 35 milliseconds.

Similarly, one of the most important elements of flamenco is developing an ear for “compas,” or rhythm – and not just to prevent being off the beat by milliseconds. Palmas, or rhythmic hand-clappings, are just as important to the music and dance as other instruments. Flamenco musicians have an eerie ability to clap in between the main pulse of the rhythm (it’s called contratiempo), something they can fall into and out of mid-song.

Even watching flamenco up close, it is almost impossible to tell which musician or dancer is clapping to the straight beat, and who is clapping in contratiempo.

Likely, these flamencos have superior wiring to detect these variations, just like Eagleman’s drummers. Couldn’t magicians, then, have some neurological advantages in areas of visual perception?

That’s probably a question for Eagleman, or for the Macknik Lab at the Barrow Neurological Institute in Phoenix, which has focused on understanding, at a neurological level, how magicians manipulate flaws in standard human perception to make their magic happen.

I say it’s time to turn the microscopes (or fMRI scanners, in this case) on the magicians themselves.

If they’re not wired differently, perhaps those visual perception exercises can do the rest of us some good.

Or not. As I left the restaurant, I told our magician I was glad that not everyone was as perceptive as he was.

This blog was originally posted on MedPageToday.com.

The other day, The Lancet ran this study on monthly naltrexone (Vivitrol) for opioid addiction. However, that indication had been approved back in October — largely based on this lone study that hadn’t yet been subject to the scrutiny of scientific peers.

Daniel Wolfe, PhD, of the Open Society Institute in New York, and colleagues pointed this out in an accompanying editorial: “The FDA’s assessment … was based on then-unpublished evidence from this trial,” they wrote.

Granted, the monthly shot has been approved since 2006 for alcohol addiction treatment. Still, Wolfe and colleagues were concerned that the data were severely flawed. For one, the treatment wasn’t compared against other standards such as methadone or buprenorphine. Nor did it look at post-treatment opioid overdose, a major concern with naltrexone.

Something similar occurred earlier this month with the investigational weight loss combination of phentermine and topiramate (Qnexa). The Lancet just published data that the FDA had already relied on to make a decision about the drug six months earlier.

Though an advisory committee recommended against approval, it still made that decision based on unpublished data.

Perhaps it could be taken that advisory committee review is a form of peer review in its own right. In fact, that’s the position put forward by the agency when asked for comment on the issue, in this emailed statement:

“The Agency often reviews data that have not been published and our review is much more extensive than what happens during the peer review process. We have access to the original protocol and all amendments, we have access to the original statistical analysis plan and all revisions, and most importantly, we have access to all the data and can do all our own analyses to confirm what is reported by the sponsor and also to explore the data and any concerns raised by them in great detail.”

Still, monthly naltrexone was okayed for opioid dependence despite the flaws noted in the Wolfe editorial.

The only thing this after-the-fact publication seems to generate is more media attention for the compound — and perhaps for those approved, a boost in sales, as well as in the company’s stock.

This blog was originally posted on MedPageToday.com.

Though researchers have long suspected that patients who become addicted to opioid painkillers progress to heroin (OxyContin’s opioid cousin) because it’s significantly cheaper, the first bits of supporting data may be trickling in.

Last summer, a University of Buffalo survey of 75 detox patients found that 40% had initially become hooked on legitimately prescribed drugs. The overwhelming majority of them — 92% — said they eventually bought illegal drugs, usually heroin, for superior cost-effectiveness.

Caleb Banta-Green, PhD, MPH, of the Alcohol & Drug Abuse Institute at the University of Washington in Seattle, has also been following the problem closely in his state. He’s part of a National Institute on Drug Abuse epidemiology group that files semi-annual reports on drug use in major cities around the country.

He’s previously presented data showing 39% of heroin users in surveyed in May 2009 in Seattle reported getting started with a prescription opiate.

For the next meeting, Banta-Green is preparing an analysis of police evidence databases that shows an increase in heroin use in smaller cities.

The databases, which log drugs police seize as evidence, showed a 10-fold rise in pharmaceutical evidence between 2000 and 2009. During that time, heroin use, which was already high, more than doubled — and became especially prevalent in smaller towns.

“There’s a demand for heroin where there wasn’t one before,” Banta-Green says. Whether that’s a result of greater abuse of prescription painkillers, “we just don’t know yet.”

Richard Ries, MD, also of the University of Washington, said the trend may even accelerate in years to come, as greater restrictions on prescribing opioid painkillers (the FDA is developing a risk evaluation and mitigation strategy [REMS] for long-acting opioids) translate to higher prices.

Ries said while OxyContin used to go for $80 for an 80-mg pill (the going rate is typically a dollar a milligram, experts say), the price has since doubled to $160.

Banta-Green cautions that it’s hard to get good data on the actual street prices of drugs, which fluctuate based on a whole slew of different variables, including geography. But simple googling reveals that heroin goes for, on average, $100 per gram. Sketchy message boards suggest new heroin users can get about 20 highs from a full gram. OxyContin can’t match that.

“It’s an unintended consequence” of trying to bring the prescription painkiller epidemic under control, Ries says. “But it is absolutely happening. Over the next five years we’re going to see heroin dependency go up.”

Something physicians might want to keep an eye on as they wait for the data to catch up.

This blog originally appeared on MedPageToday.com.

“The Roentgen is obsolete, even here,” says John Williams, PhD, a nuclear physicist at the University of Arizona. That’s a jab at the fact that we Americans still can’t sever our ties with Rems, even though the world has moved on to Sieverts — much like our reluctance to loosen our grip on the standard system.

Just days ago, before I started contributing reporting on the Japanese nuclear disaster, I had no idea that Rems were passe and measuring dose in Roentgens would be the fashion faux-pas equivalent of wearing a poodle skirt and saddle shoes to work today.

Because most of you probably don’t deal with radioactivity on a daily basis — aside from those in nuclear medicine, of course — I figured I ought to share what I’ve learned, so you can fact-check the scores of reports you’ll (unfortunately) be seeing in the news over the next couple of weeks.

Grays, Rads, Rems, Sieverts. Those are the units that most commonly crop up. The first two — Grays and Rads — are plain old units of dose. They tell you just how much energy has been absorbed by the targeted material, according to Kirby Kemper, PhD, a physicist at Florida State University.

Now, if you want to assess the biological damage to tissue caused by the radiation, you measure in Rems, or, more fashionably, Sieverts. Williams says that one Rad dose delivers one Rem of equivalent effect, while one Gray delivers one Sievert (When converting within dose units, one Gray equals 100 Rads, and one Sievert equals 100 Rems).

In order to keep damage equal — since some radioactive particles are more dangerous than others — you have to figure in the “quality factor” here as well. That way one Sievert of X-rays ultimately does the same harm as one Sievert of more potent alpha particles, for instance.

So which unit does one pick for which situation? The choice is often arbitrary.

“Tohoku Power [operator of the Onagawa nuclear power plant] uses Grays in its environmental reports, but Tokyo Electric Power uses Sieverts,” Williams says. “The U.S. Nuclear Regulatory Commission most often uses Rems, unless talking to an international audience, for whom Sieverts would be mandatory.”

To add to reporters’ burdens of getting the units correct, conversion often comes into play, and becomes more challenging because all of these measures also have their usual prefixes — mega, kilo, milli, micro, nano, etc.

And exposure is often associated with a rate, typically per hour.

Williams decries media reports that leave off this critical piece of information, because hourly rates can be erroneously compared with annual regulatory limits, or common annual background values.

But it’s not just the media that appear to be confused.

“There are so many different common ways to use these units incorrectly,” Williams says, “that their use in a document is often an almost infallible guide to the technical competence of the author.”

I think a good reference, though, is the NRC’s tenet that humans get about 3 milliSieverts of annual background radiation. That includes both cosmic rays and what we absorb from eating on granite countertops.

According to an earlier New York Times report citing peaks of 1,000 microSieverts per hour, an exposed worker could get a third of that typical annual exposure in just one hour. That’s if I’m doing my calculations correctly. I’ll stop there; I don’t want to reveal too much.

This post originally appeared on medpagetoday.com.

Only two weeks earlier, on Sept. 3, 2009, a total of 18 former drug addicts were murdered at a different rehab center in that city, in a similar fashion.

The trend hasn’t stopped, with addiction center killings occurring as recently as last month. There are a host of theories as to why the slayings may occur — turf wars, owed money — but nearly all of them still remain unexplained.

From an outsider’s perspective, the cartels seem to be sending a message: stay addicted. They want to keep their countrymen hooked in order to feed their economy. Addiction rates, then, must be raging in Mexico, and spiraling out of control. Right?

One national report from 2008 seemed to say so. It showed a 51% increase in the number of Mexicans self-reporting as addicts from a previous study six years earlier.

But a recent commentary in the Lancet says that’s not the case. Author Mary Cuddehe points out that the report found just 5.2% of Mexicans experimented with illegal drugs, while a WHO report issued around the same time found that 42% of Americans experimented with marijuana, and 16% dabbled in cocaine.

Somewhat surprised about the statistics, I started asking around. Michael Escamilla, MD, chair of the psychiatry department of Texas Tech University in El Paso — right across the border from Juarez — said there’s no doubt that addiction rates in Mexico are much lower than those in the U.S.

Escamilla pointed to his own research among Hispanic schizophrenia patients in Mexico, southern Texas, and southern California. Being born in Mexico and still living there was “protective” against higher rates of abuse, he and colleagues reported last year in Schizophrenia Research. Those who migrated to the U.S. were more likely to abuse drugs, and those born in the U.S. had the highest rates of all.

In Mexico, addiction rates “are increasing, but they are still low — especially compared to countries like the U.S.,” Escamilla told me.

It makes sense. More Mexicans than Americans live in poverty. The narcos can fetch a higher price for their product across the border (and researchers tell me that cheap inhalants — sniffing glue or paint, for instance — are the more popular drugs among Mexican young people).

But Luis Carcoba, MD, also a psychiatrist at Texas Tech in El Paso, who worked in Juarez for several years beginning in 2000, said the national rates aren’t reflective of the situation along the border.

In Juarez, the proportion of people who’ve tried illegal drugs jumps four-fold, to nearly 20% — a closer rival to U.S. experimentation rates. Numbers are likely similar in Tijuana, he said.

Getting treatment in these locations is also far more challenging than it is for anyone attempting to recover in the U.S. Although addicts here may have to deal with stigma, help-seekers in Juarez face severe intimidation.

Carcoba cites a close friend and official government source who prefers to remain anonymous: “He mentioned that after the massacres at the rehab centers, attendance at other centers declined about 35% to 40%.”

Even when patients do make it to rehab centers, their treatment options are limited. Many receive psychotherapy alone, although Juarez now has four methadone clinics, Carcoba says. Other effective pharmacotherapies, like buprenorphine or naltrexone, are often too expensive.

Although the situation along the border seems to be growing more anarchic every day, John Roache, PhD, of the University of Texas Health Sciences Center in San Antonio, says it’s clear that both countries’ addiction woes would benefit from squelching Americans’ thirst for drugs. That means putting better prevention programs and wider use of good treatment options at the top of the domestic agenda.

“We Americans shouldn’t view Mexico as the drug-addicted state,” Roache says. “The problem is here in the U.S.”

This blog was originally posted on MedPageToday.com.

Invariably, over gingerbread cookies, a controversial subject like childhood vaccination or homeopathy will pop up, and I take up the usual defense, explaining what the scientific literature says or doesn’t say.

Of course I’m met with the retort that studies are funded by drug companies and are thus inherently biased. (Not necessarily stated in those terms, of course — certainly not when it’s coming from your friends and family from northern New Jersey.)

I never win trying to explain that they’re making sweeping generalizations, or that I like to believe scientists are ethical people who are more interested in seeking truth than money. And now a series of stories in the popular media have called attention to even more flaws — some really peculiar ones, actually — in the scientific method, making my case even harder to defend.

In the November issue of The Atlantic, David Freedman focuses on the work of John Ioannidis, MD, of the University of Ioannina in Greece, who is most famous for a 2005 JAMA study that found that just over 40% of the 49 most influential randomized controlled trials in medicine have had their findings contradicted.

Freedman writes that Ioannidis and colleagues “have shown, again, and again, and in many different ways, that much of what biomedical researchers conclude in published studies — conclusions that doctors keep in mind when they prescribe antibiotics or blood pressure medication, or when they advise us to consume more fiber or less meat, or when they recommend surgery for heart disease or back pain — is misleading, exaggerated, and often flat-out wrong.”

Great. I can hear my uncles now, glancing up from the TV with the football game on: “See! What the bleep do experts know,” serving up the butter-versus-margarine saga as their best evidence.

Freedman goes on to discuss the influence of conflicts of interest and publication bias, and points out that many findings are later refuted.

In the Dec. 13 New Yorker, powerhouse science writer Jonah Lehrer focuses on that last caveat in his piece “The Truth Wears Off”, honing in on a problem that’s been popping up not just in medical science, but in a range of fields from psychology to ecology: the “decline effect” — the idea that findings that once seemed “proven” true by early studies just can’t be replicated.

Perhaps it’s some combination of publication bias, or selective reporting, or regression to the mean. Researchers aren’t sure, Lehrer writes.

“Just because an idea is true doesn’t mean it can be proved. And just because an idea can be proved doesn’t mean it’s true,” he concludes. “When the experiments are done, we still have to choose what to believe.”

Believe? But it’s science. I’m not supposed to have to believe.

I’ve always been comfortable with the fact that truth is nebulous, and science is a messy process. The caveats highlighted in these two stories are a part of that, to be sure.

Science is, after all, merely a human construct. But sometimes it’s frightening to think that in some cases, we’re standing on a house of cards.

So for those who want to talk about butter and margarine this year, I’ll say, no thanks. Just pass the fruitcake. I’m hungry.

This blog was originally published on MedPageToday.com.

We had only been at her Long Island home for about five minutes when she asked me. Cameraman Bjoern Kils was just starting to unpack his gear, and I had only begun to take in the scene: an organized, welcoming space with a yellow-walled kitchen, a wooden table with red chairs and red placemats, and a funky red couch in the adjacent living room.

Red is thought to be good luck among the Chinese, a culture well represented in Carolyn Alfieri’s home. Years ago, she majored in Chinese studies, and once worked at an art museum. She used to play violin. You could say that was how the trouble started, that the violin was what brought us there.

Her question didn’t catch me off guard, but it made me realize that I hadn’t done enough research.

Sure, I’d read a good portion of the literature and interviewed several experts on addiction. But this was my first encounter with a patient, someone who struggled with this condition for some 10 years. And she was just preparing me: You think you know, but you have no idea.

She was right. My mind’s Google query flashed with a few unbreakable habits, but nothing that interfered with daily living. All I could muster was “No.”

No matter, because we weren’t there to talk about me. We were interviewing Carolyn for a segment we were co-producing with ABC News on treatment for opioid addiction, a growing problem across the country.

Her voice was the last we needed to complete the story. It was the one that resonated the loudest. Not because of her experience with addiction itself — panhandling, being arrested for forging prescriptions, learning how to crush and inject OxyContin from an article in TIME magazine — but because of what she taught me about recovery.

It’s easy to think that once someone finally gets herself to a 12-step program, or to the door of a methadone clinic, her battle is won. Far from it. Carolyn’s greatest lesson was that even with the assistance of great drugs like buprenorphine, recovery largely depends on the patient’s will.

I learned this through her tale of relapse. Her first run with buprenorphine was unsuccessful. After she got a package from an old friend, she fell back into old habits — habits that had been ingrained for nearly a third of her lifetime. They began when she was prescribed Tylenol III for pain that resulted from playing the violin.

Perhaps she played to escape the fate of those closest to her. Dad was an alcoholic. Mom popped pills. A brother had a gambling problem. She swore she wouldn’t go down those roads. Then she needed stronger medicine — Vicodin, then Percocet, then OxyContin.

I also learned this from a book recommendation that Carolyn gave me: The Addict, by Dr. Michael Stein. The physician-author describes a year-long experience with Lucy, another patient addicted to opioid painkillers. Even as Lucy tried to help herself, she struggled with remnants of her old life — ex-boyfriends, dealers, places that triggered cravings — that kept holding her back.

Many of the experts I spoke with touted buprenorphine as highly effective. And it clearly does work wonders. Carolyn has now been clean since Jan. 31, 2008, a date tattooed on her arm, with the help of a daily orange pill she slips under her tongue. She speaks at local support group meetings and keeps a blog of her experiences.

However, it can only work if the patient is willing. Addicts are defined by being unwilling to admit they have a problem. Carolyn was willing to tell her story under bright lights with camera rolling.

(I thought of those bad habits that popped up during my mental Google. I would hardly admit to those. How brave do you have to be to admit that you abuse drugs?)

But I think it also takes a willing physician to treat these patients. How frustrated Stein was when Lucy skipped her buprenorphine so she could use Vicodin during a family event she didn’t want to be present at. Yet he still took her back in and tried again. She remained sober, at least until the end of the book.

Several addiction specialists told me primary care physicians may be reluctant to treat addicts. But I think that anyone who is up for the challenge will enjoy it. How rewarding to be able to give those who are willing a chance at a better life.

Thanks to Carolyn for giving not only me a chance to hear her story — but also the nine million viewers who heard it on World News. Hopefully, those who needed to, heeded her message.

This blog was originally posted on MedPageToday.com.

Never having heard of this test before, I did a little digging, and found an interesting story. The medical literature on the utility of KIF6 as a marker for heart disease was a bit scant. So if I were a physician, I might have been a bit hesitant to run it.

Lo and behold, a behemoth of a study (69 authors signed their name to the work) came out last week finding absolutely no link between KIF6 and heart disease.

Dr. Eric Topol, a genetic medicine specialist at Scripps in California, told me he thought the KIF6 test should be taken off the market.

My question is, how did it get there in the first place?

There are’s no regulation for genetic testing. I’m sure you’ve heard of the gene testing kits being pulled off of Walgreens shelves once the chain learned that they weren’t regulated.

Oh, and that spit vile you’re sending to 23andMe or Navigenics or deCODE? Not regulated. One geneticist once described it to me as the “Wild West.”

But ah, the power of marketing. I’m sure many a Celera rep — yes, that’s Celera, of the Human Genome Project — dropped in at primary care practices around the country to convince docs to use KIF6 to help them decide whether or not to put patients on statins.

I should stop. Science is a process, and this study certainly isn’t the final word on KIF6. But I think a quote from an editorial Topol wrote accompanying the latest study sums it up appropriately:

“We know from previous experience that a positive association between a genetic variant and a common disease, such as coronary disease, needs to be consistently observed in many human population studies before it can be believed.”

Key word: BEFORE. As in — BEFORE you start telling people like my dad, who had hardly any other risk factors for heart disease, that they need statins.

None of my physicians has yet converted to electronic health records. I dream of the day when my PCP can pull up my chart on her iPad, accessing all of the important information (allergies, family history) before making a diagnosis.

That doesn’t look like it will happen any time soon. Despite many incentives — including about $40 billion of the $787 billion stimulus bill — doctors are hesitant to create EHRs. It takes a lot of time and money to convert tens of thousands of file-folder records into bits of electronic data. And perhaps patients complain about security issues.

I am not one of those patients. If I need to reference proof of my childhood allergies, I want to be able to do it right from my iPhone, right in my doctor’s office — rather than wait days for a release from my pediatrician.

So I’ve decided to take charge of putting all of my healthcare records — all the ones I can accumulate, anyway — into a PHR, a personal (electronic) health record.

First step: choose between Google and Microsoft. Google Health and Microsoft HealthVault appear to offer similar health-storing technologies. You can manually enter data on blood pressure, lipids, blood glucose, exercise, and allergies, based on your own data collection. Both ask that you enter your physician’s contact information.

Both have partnerships with myriad health providers, such as Blue Cross Blue Shield and Quest Diagnostics, that you can supposedly search for your healthcare information as long as your physician participates.

But neither appears to offer a dedicated virtual drawer for the paper files that I plan to scan and upload. Both allow for uploading of files, but Google warns of a four-megabyte limit per document, and HealthVault a 3.5 MB limit. I’m not sure my entire pediatric medical record will fit into such a small PDF file, and I am not keen on the idea of copying each page individually. Hopefully those limits aren’t overall storage limits, either.

Of course, there’s also the challenge of obtaining those paper records to begin with. I assume my pediatrician has long since put my files in storage. Even when I do get them, which could take months, how long will it take me to scan and upload every page? And then to have to do that for multiple providers? I can understand why physicians find the conversion task so daunting. (Perhaps every patient should be charged with converting their own!)

Security, of course, is one of my main concerns. While HealthVault’s name alone sounds more secure, both services “place the security burden on the user, and have specific language in their respective use agreements that hold them harmless for any breach of data caused by a compromise of a user account,” according to an InfoWeek story.

Those accounts do get compromised. I once had a hacker break into my gmail account, and it took six days for Google to determine that someone had indeed hijacked my account and was using it to steal my Ebay and Amazon passwords.

Even more concerning would be if someone broke into my health vault to deny me a job or insurance coverage.

Ultimately, my support of technology and convenience outweigh my worry. Hopefully my work will one day benefit one of my physicians (and collaterally, myself). Though by the time I’m middle-aged, I hope many of them will have implemented their own EHR.

Now to find the number for Valley Pediatrics…