Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Do Botox injections help with migraines?

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There’s some evidence – though studies are mixed – that injections of Botox around the scalp, neck, and face can help some people with migraine headaches.

But scientists are still trying to figure out which patients might be most helped by the injections. So far, the data suggest that people with “imploding” headaches, which feel like the head is being crushed or those who describe their pain as “eye-popping,” may respond better to Botox than people with “exploding” headaches.

Botox (botulinum toxin type A) is approved by the US Food and Drug Administration for crossed eyes, uncontrollable blinking, a certain kind of neck pain, excessive underarm sweating, and for the temporary improvement of frown lines. Some insurers do not pay for Botox for migraines because it is an unapproved use.

Botox works by preventing release of a neurotransmitter called acetylcholine into the space where muscles meet nerves. This causes temporary paralysis.

Whether this is how Botox might work to relieve migraines is unclear, said Dr. David Buchholz, a neurologist at Johns Hopkins University. Buchholz does not use Botox for migraines because injections have to be repeated every few months and the cost is often prohibitive. “It would be thoroughly impractical to consider Botox as an answer for migraine,” he said.

But because Botox has few side effects, Dr. David W. Chen, a neurologist at Massachusetts General Hospital, said it can be a “good alternative” for patients who can’t tolerate other treatment.

Are estrogen patches, gels safer than pills after menopause?

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Probably, at least in terms of minimizing the risk of blood clots, according to a new study called ESTHER, published in February in the journal Circulation. The French researchers looked at 271 women ages 45 to 70 with deep vein blood clots and 610 women without, and correlated their risk with whether they used oral forms of hormone therapy, types delivered through the skin, or none at all.

They found that oral hormone users had four-times the risk of blood clots compared with non-hormone users and with those using transdermal preparations.

“The study is important,” said Dr. JoAnn Manson, chief of the division of preventive medicine at Brigham and Women’s Hospital in Boston and author of “Hot Flashes, Hormones and Your Health.” It adds to the mounting evidence that the route of administration of estrogen matters.

This study did not address whether transdermal estrogen might offset other risks of oral hormone use, such as an increased risk of breast cancer or stroke.

(A different study that looked at hormone pills, not patches, published earlier this month, suggested that starting hormone therapy right at the beginning of menopause does not increase the risk of heart attacks.)
In general, estrogen taken orally passes first through the liver, where it can increase the synthesis of clotting proteins and inflammatory markers and have other effects. The advantage of medications delivered through the skin is that they do not pass through the liver en route to the bloodstream.

A new study called KEEPS is also comparing oral estrogen to the patch as well as evaluating progesterone (Prometrium) to determine the effects of the hormones on plaque in artery walls, memory and cognitive function, blood clotting factors, glucose and lipid levels and other variables. The study (www.keepstudy.org; 617-732-9870) is still recruiting patients who are within three years of the onset of menopause.

How can I decide whether to take antidepressants?

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Untreated depression is a terrible disease, and antidepressants help millions of people. But they should be taken under tight medical supervision, said Dr. Alexander Bodkin, chief of clinical psychopharmacology research at McLean Hospital.

During the first few days of taking an SSRI-type antidepressant, many people feel intense agitation, even panic. This is actually “a sign that the SSRIs are on the way to making you better,” said Bodkin. But precisely because these feelings can be so scary, it is important for doctors to stay in close touch with patients and for patients to report any distress immediately.

Despite anecdotal reports of adverse reactions to antidepressants in children and adolescents, particularly SSRIs like Prozac and Zoloft, there are actually no cases of suicide related to taking antidepressants in all the pediatric clinical trial data that the US Food and Drug Administration re-evaluated in recent years, said Dr. John Mann, professor of psychiatry and radiology at Columbia University and director of research for the New York State Psychiatric Institute.

In a 2004 report, the FDA noted that spontaneous reports of suicidal thinking and nonfatal suicide attempts occurred at the rate of about 4 percent in young people taking antidepressants, and only 2 percent in those taking placebos. For this reason, the FDA made manufacturers put a “black box” warning on antidepressants for people up to age 18. But even during this time, noted Mann, who has done extensive research on the subject, “nearly all the suicides in children and adolescents were in people NOT taking antidepressants.”

New figures from the Centers for Disease Control and Prevention show that in the months after negative stories about antidepressants first came to light, the number of youth suicides actually went up — from 1,601 in 2003 to 1,828 in 2004 — after many years of declining numbers. This rise in youth suicides parallels a 20 percent drop in antidepressant prescriptions, Mann said.

Are lubricants an alternative to knee surgery?

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They seem to help with knee pain, but only to a limited extent, for a limited time and in certain patients.

Injections can delay knee replacement surgery for as long as a year or two, said Dr. Donald T. Reilly [cq], an attending orthopedic surgeon at New England Baptist Hospital. That’s a decided advantage since artificial knees, like real ones, eventually wear out, he said.

And the injections, “seem to help” if osteoarthritis caused by wear and tear on a joint isn’t too severe. (They’re not designed for rheumatoid arthritis.)

But “the science behind this is not great,” Reilly said. “The actual mechanism of the supplements is not clear.” The injections seem to boost one of the constituents of synovial fluid, hyaluronic acid, but not other components.

The medications, with names like Synvisc, Orthovisc and Hylan G-F20, are supposed to supplement the thick or viscous synovial fluid found in normal knees for lubrication and cartilage nourishment. They can cost several hundred dollars for a series of three or more injections and may not be covered by insurance.

Overall, the benefits appear to be modest, said Dr. Paul Romain [cq], chief of rheumatology at the Cambridge Health Alliance. But the injections are worth asking about, he said, if you are unable to have surgery.

How should I dispose of unneeded or expired medicines?

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That depends on whom you ask.

Last year, for instance, the Harvard Heart Letter, a publication of Harvard Medical School, said neither flushing old drugs down the toilet nor putting them in the trash was a good method, because people and animals can get into the trash and drugs flushed away might end up in the water supply.

But this year, the White House Office of National Drug Control Policy contradicted much of that with new guidelines telling people to throw old medicines in the trash. It suggested mixing leftover drugs with undesirable substances like coffee grounds or kitty litter (it did not specify whether the kitty litter should be used or unused) and putting the result into containers so drugs could not be “diverted” to unsavory use. The federal guidelines also said some drugs SHOULD be flushed down the toilet, among them painkillers like Actiq and Duragesic Transdermal patches.

But that’s anathema to environmentalists. “We recommend not flushing any [medications] down the toilet,” said Athena Bradley, a projects manager at the Northeast Recycling Council, a nonprofit group with 10 member states. Instead, the group advocates community “take-back” centers or events that allow people to bring unused drugs to collection centers, an approach the government also likes.

Whatever you do, don’t try to return controlled substances like the sleeping pill Ambien to a pharmacy, said Karen Ryle, supervisor of outpatient pharmacy at Massachusetts General Hospital. They are not allowed to accept them because of rules on how drugs should be destroyed and accounted for.

How important is it to shop around when looking for a breast cancer surgeon?

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Nobody knows – yet – whether a woman’s chances of survival will be better if she takes the time to pick a breast surgeon carefully. But a new study of nearly 2,000 patients, published in January in the Journal of Clinical Oncology, does show that women who choose a surgeon carefully, as opposed to those who merely accept a referral from their health plans, were more likely to be treated by a surgeon who does a high volume of breast surgeries and to be cared for in a hospital with a comprehensive cancer program approved by the American College of Surgeons or a National Cancer Institute-designated cancer center.

Many women, especially if they are poorer or less educated, simply see whichever surgeon their plan suggests, regardless of whether that surgeon specializes in breast surgery or does a bit of everything, said Dr. Steven Katz, the study’s lead author and a professor of medicine and health management and policy at the University of Michigan.

“We found that women who were involved in the selection of a surgeon were more likely to see an experienced surgeon in a more comprehensive center,” said Katz. In general, the more a surgeon specializes, the better the outcome.

Dr. Michele Gadd a breast cancer surgeon at Massachusetts General Hospital, used to perform different kinds of surgery but concluded she “could only do one well” and now does exclusively breast surgery. She suggested that women looking for a breast cancer surgeon ask whether the doctor specializes in breast surgery, how many mastectomies (removal of the whole breast) the surgeon does in a month – ideally, the answer is 5 or more, and how many lumpectomies (removal of just the cancerous lump) they do – ideally 15 or so per month.

In addition, she suggested that women ask the surgeon about recurrence rates, “skin-sparing” mastectomies (in which the breast is removed, but the skin is saved for a better cosmetic result), nipple-sparing procedures, “sentinel node” biopsies (in which just one or a few lymph nodes are removed, not all the nodes in the armpit) and about “neo-adjuvant therapy,” in which a woman gets chemotherapy before surgery.

As for whether choosing a surgeon carefully improves outcomes, Katz said his team is about to study that.

Can you tell from the labels on cosmetics whether the products contain ingredients that may be harmful?

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In most cases, no, although a coalition of environmentalists known as the Campaign for Safe Cosmetics is trying to change this, with some success.

In 2005, one of the members of the campaign, the Environmental Working Group, a Washington, D.C. -based watchdog organization, issued a report in which it compared ingredients in 7,500 personal care products against lists of known or suspected chemical health hazards. It found that one in every 120 cosmetic items, including shampoos, lotions, makeup foundations and lip balms contained known or probable carcinogens.

In January, the safe cosmetics campaign announced that more than 500 cosmetics and body care products companies have signed a pledge to replace potentially harmful ingredients with safer alternatives. The companies include The Body Shop and Burt’s Bees, “but the mainstream companies have not [signed the pledge], so we are disappointed by that,” said Stacy [cq] Malkan [cq], a campaign spokesperson.

The Cosmetic, Toiletry and Fragrance Association, a trade group, said that “thousands of scientific studies have been done on cosmetics and their ingredients” and that the industry determines the products “are safe before they are sold to consumers.”

California recently enacted a law requiring manufacturers selling cosmetics in that state to disclose to the state department of health services a list of any products containing chemicals identified as potentially causing health problems, according to the environmental working group. Other states are considering similar actions.

Government oversight of the cosmetics industry is minimal. The US Food and Drug Administration is not authorized to approve cosmetics before they go on the market, although products that consumers think of as cosmetics like sunscreen and anti-dandruff shampoo are actually classified as over-the-counter drugs and hence must get FDA approval. In 2005, the agency said it was setting cosmetic safety as a top priority, but it has taken limited action since then.

Is sedation safe for kids undergoing dental procedures or medical tests like MRI?

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Generally, yes. But better monitoring of children during these procedures is essential, as the death last fall of a 5-year-old Chicago girl following sedation for dental work shows.

Late last year, shortly after the girl’s death, two major groups, the American Academy of Pediatrics and the American Academy of Pediatric Dentistry, came out with joint guidelines that had long been in the works to make pediatric sedation safer.

The primary author of these, and previous, guidelines, Dr. Charles Cote, a pediatrician and anesthesiologist at Massachusetts General Hospital, said that the new guidelines represent “a huge step in the right direction.” In part, he said, that’s because they make clear that medical personnel administering sedation to children should follow the same rules whether the procedure takes place in a hospital or in a private medical or dental office.

The guidelines do not have the force of law, but many states use the guidelines in creating laws governing practice.

Children often need drugs to reduce anxiety, provide pain relief, or reduce movement during normal dental procedures such as filling a cavity, and some medical tests, like MRIs. The problem, said Cote, is that a child may become more deeply sedated than the doctor or dentist intended and therefore must be monitored very carefully until fully awake.

The new guidelines make clear that the person doing the procedure must have “advanced airway training” (be able to clear an obstruction in a child’s airway and, if necessary, be able to pump air into a child’s lungs with a bag and mask) and use a pulse oximeter to check oxygen levels in the blood as well as other measures to make sure the child is breathing, said Dr. Stephen Wilson, a spokesman for the American Academy of Pediatric Dentistry and chairman of the division of pediatric dentistry at Cincinnati Children’s Hospital Medical Center.

Parents should ask their child’s dentist or doctor if he or she follows the new guidelines, which are available at www.aapd.org

Is the sensation of “pins and needles” in the feet or hands a sign of something serious?

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Usually, no, but it can be. Most cases of that tingling sensation, which some lay people incorrectly call “numbness,” occur when a foot or hand “falls asleep,” said Dr. Ahmet Hoke, director of the neuromuscular division of neurology at Johns Hopkins School of Medicine.

If you sit on your feet, for example, that puts so much pressure on feet nerves that they temporarily become electrically unstable, sending off impulses to the brain when they shouldn’t. Typically, this feeling goes away within minutes of changing position. Carpal tunnel syndrome, in which nerves in the wrist are compressed, can produce longer-lasting tingling sensations. And an extreme example of pins and needles is “Saturday night palsy,” when a person becomes drunk and sleeps so heavily in one position that it can take weeks for crushed nerves to recover.

But a pins and needles feeling “is serious when there’s no good explanation for why it just happened, when it lasts longer than a few minutes or when it’s distributed all over the body in a way that wouldn’t make sense from some kind of mechanical injury,” said Dr. Lee Schwamm, vice chairman of the department of neurology at Massachusetts General Hospital.

A pins and needles sensation that can’t be explained and doesn’t resolve quickly may be a sign of one of the 100-plus types of peripheral neuropathy, in which nerves in the limbs are damaged. .

A tingling sensation in the leg can also be a sign of damage or pressure on the sciatic nerve, which runs from the lower back down the leg, or from a slipped disc in the spine. Numbness and tingling in a large region of the body, such as from the waist down, can also be a sign of serious inflammation in the spinal cord; and numbness or tingling, especially if accompanied by weakness, can be a sign of stroke if it occurs suddenly and on only one side of the body.

Bottom line: If the pins and needles go away, not to worry. If it persists, call a doctor.

Should I go to one of these new “retail health clinics” in shopping malls and drug stores?

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Yes, if you’re positive that you have a relatively minor problem – like a sore throat, ear ache or bladder infection – and if you follow some common sense guidelines from physician groups such as the American Medical Association (www.ama-assn.org), the American Academy of Family Physicians (www.aafp.org) and the American Geriatrics Society (www.american geriatrics.org ).

These little clinics are springing up all over – though more slowly in New England – with names like Take Care Health Centers, MinuteClinic, RediClinic, MiniMedCare and the like. They offer quick diagnoses and treatment for simple problems and often have ties to nearby drug stores. They’re typically staffed by nurse practitioners.

Some clinics can do simple blood tests, but they usually do not have X-ray machines. Do NOT use one of these clinics if you have new major symptoms such as chest pain, shortness of breath, or leg swelling (a possible sign of a blood clot in the leg or heart failure) or if there is a change in a longstanding medical problem for which you’re already seeing a regular doctor.

“Retail clinics are probably a good option for certain types of health care problems,” said Dr. Jane Potter [cq], president of the American Geriatrics Society. “But this is not a substitute, for people with chronic health conditions, for seeing a doctor.

Dr. Lawrence Earl, president of MiniMedCare, a convenience care provider based in Chester, N.J., which will open its first clinic this spring, said services are limited to minor problems like bladder infections, ear aches and sore throats. Mini clinics do not treat broken bones or do X rays and can only do the simplest blood tests. Often the clinics are located right next to pharmacies. “Pharmacies create the hosts,” he said. “We need only a small space and typical retail spaces available are too large,” he said. Some retail health shops take insurance and some don’t, with typical visits costing $50 to $60.

An article last week in the New England Journal of Medicine touted the potential benefits of retail health shops, including the observation that many patients seem quite able to diagnose the simple kind of problems that the clinics are designed to treat. Some doctors, however, worry about the lack of follow-up and the potential competition with their own practices.

My take on this? If you are extremely sure that all you have is a sore throat or bladder infection and have few serious health problems, try a retail health shop. But if you have any doubts about what ails you or if you have a complicated medical situation, see a real doc.