Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

When should you go to the emergency room?

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The short answer is: Whenever you have an acute onset of something serious, such as sudden, severe bleeding, shortness of breath, palpitations (irregular heartbeat) or severe weakness, fatigue or pain.

You should also head right to the ER if you have sudden changes in vision, severe or persistent vomiting or diarrhea, if you are coughing or vomiting blood or if you have suicidal or homicidal feelings, according to new guidelines released in September by the American College of Emergency Physicians.

“I would rather see you for what turns out to be a stable situation than have you misdiagnose yourself and not come in. That heartburn could be a heart attack, that pulled muscle in your back could be an aneurysm [a potentially dangerous weakening of a blood vessel wall],” said Dr. Richard O’Brien, a spokesman for the emergency physicians’ group and an emergency physician at the Moses Taylor Hospital in Scranton, PA.

If you have time, call your own doctor on your way to the hospital, said Dr. Alasdair Conn, chief of the emergency service at Massachusetts General Hospital. He or she “can call ahead and give us a lot of information,” he said, and once you’re stabilized in the emergency department, you can be sent home safely if emergency physicians know your own doctor will see you the next day.

To speed up care in the emergency room, write out a little card with key information on it and keep it in your wallet. The card should include your medications, allergies to food and medications and whether you have a pacemaker or have had a joint replacement. It also helps to bring an adult family member or friend with you to be your advocate.

A final bit of advice: Try not to get acutely ill on a Thursday. “That’s the worst day for hospitals,” said Conn. Although it’s the lightest day in terms of the numbers of patients flocking to the ER (the heaviest is Monday), Thursday is when in-patient bed occupancy is highest, which creates a bottleneck for patients in the ER who need to be admitted.

Is there a way to spot bogus medical “warnings” before emailing them on to friends?

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Yes, and I’m more than happy to spread the word. Typically, these bogus medical alerts spread from woman to woman, the subtext being that the medical establishment is willfully withholding important information about scary things.

Things like — I kid you not — flesh-eating bananas, anti-perspirants that supposedly cause breast cancer and my all-time favorite: tampons containing asbestos and dioxin. For the record, the first has been debunked by the Centers for Disease Control, the second by me (Boston Globe, January 25, 2005) among others, the third by the US Food and Drug Administration.

To check out these email hoaxes and urban legends, the Harvard Women’s Health Watch helpfully suggests several websites. One is hoaxbusters.ciac.org run by the Computer Incident Advisory Capability of the Department of Energy. Another, truthorfiction.com is run by Rich Buhler, a journalist who says, on the site, that he has been debunking rumors and urban legends for more than 30 years. There’s also:

Does Cranberry Juice Prevent Urinary Tract Infections?

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Yes, say researchers who study the gorgeous berry — although the National Center for Complementary and Alternative Medicine, which is sponsoring several clinical studies, says the data are “not conclusive.”

The queen of cranberry science, Amy Howell , an associate research scientist at Rutgers University in Chatsworth, N.J., said that overall, research suggests that eight to 10 ounces a day of cranberry juice cocktail drink, sweetened with either sugar or artificial sweetener, has been shown clinically to reduce urinary tract infections by 50 percent.

For years, people thought cranberry juice might combat urinary tract infections by making urine more acidic, thus making it harder for bacteria to grow.

Now, thanks to the work of Howell and others, it is known that a chemical in cranberries called proanthocyanidin blocks infections by coating E. coli, the major culprit, so that it cannot stick to cells in the bladder. “If you prevent the adhesion, the bacteria won’t multiply and cause infection,” Howell said.

That’s why it’s no big deal, she said, that there were “negative” findings in a recent study published in the American Journal of Health-System Pharmacy. That study showed that drinking cranberry juice was no more effective at preventing bacterial growth in urine than drinking water, said Sophie Chang , a clinical pharmacist at Cedars-Sinai Medical Center in Los Angeles and one of the authors.

Since the cranberry compounds don’t kill bacteria, there is less of a chance that the bacteria will become resistant, as they would with the antibiotics that are used to treat infections, said Howell.

A similar version of proanthocyanidin is found in blueberries, said Dr. Kalpana Gupta , assistant professor of medicine at Yale University School of Medicine.

Until recently, scientists thought that once you get a urinary infection, you need antibiotics. But data released last week suggest that cranberry juice may help treat, as well as prevent, urinary infections.

There’s now a vaccine against shingles. Should I get it?

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If you’re 60 or over, you should strongly consider getting the new vaccine, which was approved recently by the US Food and Drug Administration.

“Shingles is an underrecognized, serious neurological disease that can lead to an extremely painful condition called post-herpetic neuralgia,” said Dr. Anne Louise Oaklander, a shingles expert and associate professor of neurology at Harvard Medical School. The new vaccine, called Zostavax, appears to reduce the risk of both shingles and the neuralgia and seems to be quite safe, said Oaklander, who has no financial ties to the manufacturer, Merck & Co. Shingles, which affects an estimated 1 million people per year, is caused by reactivation of a herpes virus called varicella zoster, the same virus that causes chicken pox. Virtually every American adult has been exposed to chicken pox and therefore is at risk for shingles. After this infection, the virus hides in nerve cells, then can emerge years or decades later, typically showing up on only one side of the body along the tract of a nerve, often in a belt-like pattern around the torso or in a nerve near one eye.

The $150 vaccine is covered by some insurers and also by Medicare Part D, said Dr. Jeffrey Kelman, a chief medical officer for beneficiary choices at the Center for Medicare and Medicaid Services, the government agency that administers Medicare.

The FDA cautions that people who are allergic to neomycin or any component of the vaccine should not receive Zostavax, nor should people with weakened immune systems, because the vaccine is made from live virus. An immunization committee for the federal Centers for Disease Control and Prevention is expected to discuss guidelines for use of the vaccine in October.

Shingles can, and should, be treated with anti-viral drugs such as acyclovir, valacyclovir, and famcyclovir. But it’s far better to prevent it in the first place, said Dr. Richard T. Johnson, a distinguished service professor of neurology at Johns Hopkins School of Medicine. “People over 60 should definitely consider the vaccine, because post-shingles pain increases with age.”

Is estrogen good for the skin?

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Yes, but rare is the doctor who would prescribe it just for this purpose.

In test tube and animal studies, estrogen has been shown to “make the skin better hydrated through the increase of natural hyaluronic acid,” said Yale dermatologist Dr. Lisa Donofrio. It also makes the dermis, the middle layer of skin tissue, “thicker through increased collagen and improves wound healing.”

In a paper published last year in the journal Fertility and Sterility, Dr. Zoe Draelos, a clinical associate professor of dermatology at Wake Forest University in Winston-Salem, N.C., wrote that there is “no doubt that hormone therapy is effective for improving the appearance of aging skin.”

Despite its potential, said Draelos, who conducts research for cosmetic companies, manufacturers shy away from making creams containing estrogen alone or in combination with another hormone, progesterone. In part, she said, this is because both hormones “have been shown to promote broken blood vessels in the skin.”

But there are other reasons not to take estrogen just for the skin. An estrogen pill can increase the risk of blood clots and stroke, said Dr. Alan Altman, a menopause expert in Brookline. After seven years of treatment with an estrogen-only pill, there appears to be no increased risk of breast cancer, but the risk increases within 4-5 years on estrogen plus progestin, said Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women’s Hospital.

Dr. Rebecca Kazin, an assistant professor of dermatologist at Johns Hopkins University, said “I don’t prescribe estrogen orally or topically for cosmetic purposes because of the ethical issues.” It’s true, she said, that the skin of women who take hormones for medical reasons — such as to combat hot flashes and vaginal dryness — “will likely look better. But don’t go on it just for the skin benefit.”

I’ve heard that Fosamax, the osteoporosis drug, can damage the jaw. Is that true?

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In rare cases, bisphosphonates, the class of medicines to which Fosamax belongs, have been linked to the death of jaw bone tissue. But the bisphosphonates mostly likely to cause this tissue death are the intravenous forms, such as Zometa or Aredia, which are given to cancer patients to retard the spread of tumors in the bone.

The pill form of bisphosphonates like Fosamax, Actonel and Boniva, used to treat osteoporosis, may also raise the risk of jaw necrosis, but extremely rarely.I’ve heard that Fosamax, the osteoporosis drug, can damage the jaw. Is that true?

Bisphosphonate drugs block the normal “turnover” of bone cells, the process by which bone is continuously destroyed, then re-made. With this turnover blocked, tiny fractures may not be able to heal after trauma — whether it’s trauma from chewing hard or from tooth extraction. And because bone is not turning over, infections in the mouth (which is loaded with bacteria), may not heal properly, further damaging the jaw.

In a paper published in May in the Annals of Internal Medicine, researchers from Brigham and Women’s Hospital and elsewhere searched the medical literature for cases of jaw necrosis linked to bisphosphonates. The team identified 368 cases in the last couple of years — 94 percent of which occurred in patients taking the intravenous drugs. Most of these people had breast cancer that had spread, or multiple myeloma, another type of cancer.

Still, because the link has only recently come to light, “the concern is that the 368 figure is an underestimate” of the problem, said Dr. Sundeep Khosla, an endocrinologist at the Mayo Clinic in Minnesota and chairman of a task force recently convened by the American Society for Bone and Mineral Research to look into the issue.

Some patients are suing Merck & Co., the maker of Fosamax. But the company, on its website, noted that as of March, 2006, jaw necrosis probably occurs in less than one in every 100,000 patient-treatment years. Last year, the US Food and Drug Administration asked Merck, and the other makers of oral bisphosphonates to mention the jaw necrosis risk on its product labels.

If you are already taking bisphosphonates and are worried about jaw necrosis, consult a dentist. If you are about to start taking bisphosphonates, try to get dental work done before you start, said Dr. Jon Giles, an instructor in rheumatology at Johns Hopkins University.

Is it OK to feed kids the same healthy foods every night?

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No. Variety matters, and it’s especially important to get variety in vegetables.

Kids can be balky eaters, but, ideally, they should learn to enjoy a wide range of foods in order to get all the nutrients they need, said Jeanne Cox, a pediatric nutritionist at Johns Hopkins Hospital in Baltimore. Feeding kids green beans every night, for instance, means they are not getting other nutrients they need. “They need broccoli, carrots, the orange and yellow vegetables in addition to the dark green,” said Cox.

The best approach, she said, is to offer small portions of a healthy protein, such as meat, fish, eggs, or poultry, along with a healthy starch like whole grain rice or even potatoes or pasta, and a vegetable and a fruit. At any given meal, the child may eat only vegetables or only starch or protein, “but in the long run, it evens out,” she said. The key is to keep presenting a variety of foods and to let kids pick from that selection.

“It takes an average of 15 tries per new food” to get a child to accept it, said Jan Hangen, a clinical nutrition specialist at Children’s Hospital in Boston.

The reason kids should “eat the rainbow,” she said, is that plants of different colors have different phytonutrients, the natural chemicals in food that are essential for health. “We know that people who eat a variety of colors tend to remain healthy,” she said, even though scientists are still working to figure out exactly what each phytonutrient does.

Frozen veggies, by the way, are fine. “Unless you’re buying food at a farm stand,” said Hangen, “the frozen vegetables are best because they are fast frozen right from the field.” The “fresh” vegetables from supermarkets often “spend a lot of time on the truck, even though they look beautiful.”

If you can’t get help from doctors for chronic headaches and facial pain, should you see a dentist?

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Absolutely. Roughly 15 million Americans suffer from a cluster of symptoms including jaw pain, ear pain, headaches (especially near the temples) and neckaches. This syndrome used to be called TMJ, for temporomandibular joint problems. It is now called TMD, for temporomandibular dysfunction.

“If a person has a severe headache, it’s considered a migraine, and the person is given a prescription and sent on his way,” said Dr. Robert S. Rosenbaum, a Boston dentist who specializes in orofacial pain dentistry and is past president of the American Academy of Orofacial Pain. “The problem is, most headaches are not migraines, so what happens is the patient flounders from physician to physician.”

There are several treatment options. One is a small, plastic device that is worn in the mouth like a retainer that helps reposition the jaw so that tense jaw muscles can relax, thus easing jaw and headache pain. The device can cost as much as $1,000.

Another is physical therapy, including ultrasound, massage and “myofascial release,” in which a therapist puts gentle pressure on the skin over the jaw muscle for about 10 minutes, until muscles relaxes. “This is probably the single most effective physical therapy technique,” said Rosenbaum. Prescription muscle relaxants also can help, as can antidepressant drugs (because many people with chronic pain also have depression). As a last resort, there’s surgery, but in rare cases, that can lead to permanent nerve pain.

Some dentists, like Dr. James Zonghetti of Braintree, use computerized images to assess the degree of misalignment of the jaw.

Although insurers typically pay for treatment of musculoskeletal disorders of other joints in the body — elbows, knees, hips – they don’t typically pay for TMD treatments, said Rosenbaum

Does Vitamin D reduce the risk of cancer?

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Several recent studies presented at meetings of the American Association for Cancer Research and the American Society of Clinical Oncology suggest that adequate consumption of vitamin D- which most Americans do not get – is linked to lower risks of breast cancer.

One study, from researchers at the University of California, San Diego, looked at pooled data on 1,760 women and found that the highest level of vitamin D consumption was correlated with a 50 percent lower risk of breast cancer. To achieve this level of vitamin D, a person would have to consume at least 1,000 International Units of vitamin D a day, well beyond the current recommended levels of 200 IUs a day for children and people up to age 50, 400 IUs for people aged 51 to 70, and 600 IUs for people over 70.

In another study, researchers at Mount Sinai Hospital in Toronto interviewed 576 patients with breast cancer and 1,135 people without and found that those who had had frequent sun exposure as teenagers or young adults had a 35 to 40 percent reduced risk of breast cancer. (Sunlight helps the skin produce vitamin D.) Yet another study found vitamin D deficiency is highly prevalent among pre-menopausal women with early stage breast cancer. On the other hand, a study that was part of the government-sponsored Women’s Health Initiative found that calcium and vitamin D supplements did not reduce breast cancer risk in post-menopausal women, although when women randomized to get the supplements did get breast cancer, their tumors were smaller than those of women not taking supplements.

Dr. Michael F. Holick, a vitamin D expert and professor of medicine, physiology and biophysics at Boston University Medical Center, said that other studies suggest that vitamin D can also help prevent colon, ovarian and prostate cancer.

People can get vitamin D by “sensible” sun exposure (5 to 10 minutes several times a week without sunscreen), supplements and a diet rich in fortified cereals, milk and oily fish. Holick recommends at least 1,000 International Units of vitamin D a day, preferably the strong form, called D3, not D2, the kind that is in most supplements.

“While these studies certainly suggest that getting adequate vitamin D is important,” said Dr. Kala Visvanathan, a cancer specialist and epidemiologist at the Johns Hopkins Bloomberg School of Public Health, “it is not clear that taking extra is beneficial or whether dose should be altered, depending on age.”

Vitamin D in very high doses can be toxic. The Institute of Medicine, an arm of the National Academy of Sciences, is expected to decide within the next several years whether to recommend increased intakes of vitamin D. Currently, the institute sets the upper limit for consumption at 2,000 IUs a day.

Do nasal steroids taken for allergies cause eye problems?

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Steroids, especially those inhaled through the mouth to control asthma and those taken orally or intravenously for other conditions such as arthritis and emphysema, can cause side effects in the eye, including cataracts and glaucoma. But steroids such as Flonase that are sniffed just through the nose appear to be fairly safe for the eye.

In fact, the most common side effects of nasal steroids are a burning sensation in the nose or bleeding, especially if steroids are sprayed directly on the septum, the cartilage-based tissue that divides the two nostrils, said Dr. Ralph Metson, a sinus surgeon at the Massachusetts Eye and Ear Infirmary. To avoid these problems, he said, simply spray toward the outside of the nostrils, not toward the septum.

Although oral steroids can increase the risk for cataracts (a clouding of the lens in the eye), nasal steroids do not, according to a major British study of more than 88,000 patients using nasal steroids, more than 98,000 taking oral steroids and another 98,000-plus who were not taking any steroids. The researchers reported their findings in the Journal of Allergy and Clinical Immunology in 2000.

As for glaucoma, a build-up of pressure inside the eye, a small study of 12 patients published in the same journal in 2005 by researchers from the Vanderbilt Eye Institute found that patients who already have glaucoma may have their condition worsen with nasal steroids. This is reversible when nasal steroids are discontinued, the authors said.

Dr. Harry Quigley, director of the glaucoma service at the Wilmer Eye Institute at Johns Hopkins University, said this and other studies suggest that doctors who are prescribing nasal steroids for people with allergies or sinusitis should ask whether patients – or close family members – have glaucoma before prescribing the drug.