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Why Patients Aren’t Getting the Shingles Vaccine

Four years ago at age 78, R., a retired professional known as much for her small-town Minnesotan resilience as her commitment to public service, developed a fleeting rash over her left chest. The rash, which turned out to be shingles, or herpes zoster, was hardly noticeable.

But the complications were unforgettable.

For close to a year afterward, R. wrestled with the searing and relentless pain in the area where the rash had been. “It was ghastly, the worst possible pain anyone could have,” R. said recently, recalling the sleepless nights and fruitless search for relief. “I’ve had babies and that hurts a lot, but at least it goes away. This pain never let up. I felt like I was losing my mind for just a few minutes of peace.”

Shingles and its painful complication, called postherpetic neuralgia, result from reactivation of the chicken pox virus, which remains in the body after a childhood bout and is usually dormant in the adult. Up to a third of all adults who have had chicken pox will eventually develop one or both of these conditions, becoming debilitated for anywhere from a week to several years. That percentage translates into about one million Americans affected each year, with older adults, whose immune systems are less robust, being most vulnerable. Once the rash and its painful sequel appear, treatment options are limited at best and carry their own set of complications.

While the search for relief costs Americans over $500 million each year, the worst news until recently has been that shingles and its painful complication could happen to any one of us. There were no preventive measures available.

But in 2006, the Food and Drug Administration approved a new vaccine against shingles. Clinical trials on the vaccine revealed that it could, with relatively few side effects, reduce the risk of developing shingles by more than half and the risk of post-herpetic neuralgia by over two-thirds. In 2008, a national panel of experts on immunizations at the Centers for Disease Control and Prevention went on to recommend the vaccine to all adults age 60 and older.

At the time, the shingles vaccine seemed to embody the best of medicine, both old school and new. Its advent was contemporary medicine’s elegant response to a once intractable, age-old problem. It didn’t necessarily put an end to the spread of disease, in this case chicken pox; but it dramatically reduced the burden of illness for the affected individual. And, most notably, its utter simplicity was a metaphoric shot-in-the-arm for old-fashioned doctoring values. Among the increasingly complex and convoluted suggestions for health care reform that were brewing at that moment, here was a powerful intervention that relied on only three things: a needle, a syringe and a patient-doctor relationship rooted in promoting wellness.

Not.

In the two years since the vaccine became available, fewer than 10 percent of all eligible patients have received it. Despite the best intentions of patients and doctors (and no shortage of needles and syringes), the shingles vaccine has failed to take hold, in large part because of the most modern of obstacles. What should have been a widely successful and simple wellness intervention between doctors and their patients became a 21st century Rube Goldberg-esque nightmare.

Last month in The Annals of Internal Medicine, researchers from the University of Colorado in Denver and the C.D.C. surveyed almost 600 primary care physicians and found that fewer than half strongly recommended the shingles vaccine. Doctors were not worried about safety — a report in the same issue of the journal confirmed that the vaccine has few side effects; rather, they were concerned about patient cost.

Although only one dose is required, the vaccination costs $160 to $195 per dose, 10 times more than other commonly prescribed adult vaccines; and insurance carriers vary in the amount they will cover. Thus, while the overwhelming majority of doctors in the study did not hesitate to strongly recommend immunizations against influenza and pneumonia, they could not do the same with the shingles vaccine.

“It’s just a shot, not a pap smear or a colonoscopy,” said Dr. Laura P. Hurley, lead author and assistant professor of medicine at the University of Colorado in Denver. “But the fact is that it is an expensive burden for all patients, even those with private insurance and Medicare because it is not always fully reimbursed.”

Moreover, many private insurers require patients to pay out of pocket first and apply for reimbursement afterward. And because the shingles vaccine is the only vaccine more commonly given to seniors that has been treated as a prescription drug, eligible Medicare patients must also first pay out of pocket then submit the necessary paperwork in order to receive the vaccine in their doctor’s office. It’s a complicated reimbursement process that stands in stark contrast to the automatic, seamless and fully covered one that Medicare has for flu and pneumonia vaccines.

Despite this payment maze, some physicians have tried to stock and administer the vaccine in their offices; many, however, eventually stop because they can no longer afford to provide the immunizations. “If you have one out of 10 people who doesn’t pay for the vaccine, your office loses money,” said Dr. Allan Crimm, the managing partner of Ninth Street Internal Medicine, a primary care practice in Philadelphia. Over time, Dr. Crimm’s practice lost thousands of dollars on the shingles vaccine. “It’s indicative of how there are perverse incentives that make it difficult to accomplish what everybody agrees should happen.”

Even bypassing direct reimbursement is fraught with complications for doctors and patients. A third of the physicians surveyed in the University of Colorado study resorted to “brown bagging,” a term more frequently used to describe insurers who have patients carry chemotherapy drugs from a cheaper supplier to their oncologists’ offices. In the case of the shingles vaccine, the study doctors began writing prescriptions for patients to pick up the vaccine at the pharmacy and then return to have it administered in their offices. However, the shingles vaccine must be frozen until a few minutes before administration, and a transit time greater than 30 minutes between office and pharmacy can diminish the vaccine’s effectiveness.

Dr. Crimm and the physicians in his office finally resorted to what another third of the physicians in the study did: they gave patients prescriptions to have the vaccine administered at pharmacies that offered immunization clinics. But when faced with the added hassles of taking additional time off from work and making a separate trip to the pharmacy, not all patients followed through. “Probably about 60 percent of our patients finally did get the vaccine at the pharmacy,” Dr. Crimm estimated. “This is as opposed to 98 percent of our patients getting the pneumonia and influenza vaccines, immunizations where they just have to go down the hall because we stock it, roll up their sleeves then walk out the door.”

With all of these barriers, it comes as no surprise that in the end only 2 percent to 7 percent of patients are immunized against shingles. “There’s just so much that primary care practices must take care of with chronic diseases like obesity and diabetes and heart disease,” Dr. Hurley noted. “If a treatment isn’t easy to administer, then sometimes it just falls to the bottom of the list of things for people to do.”

“Shingles vaccination has become a disparity issue,” Dr. Hurley added. “It’s great that this vaccine was developed and could potentially prevent a very severe disease. But we have to have a reimbursement process that coincides with these interventions. Just making these vaccines doesn’t mean that they will have a public health impact.”

Exercising for Weight Loss (Sex Health Guru)

Running at the fitness club

Exercising for Weight Loss (Sex Health Guru)

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Physical exercise is any bodily activity that enhances or maintains physical fitness and overall health. It is performed for many different reasons. These include strengthening muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance and for enjoyment. Frequent and regular physical exercise boosts the immune system, and helps prevent the “diseases of affluence” such as heart disease, cardiovascular disease, Type 2 diabetes and obesity. It also improves mental health and helps prevent depression. Childhood obesity is a growing global concern and physical exercise may help decrease the effects of childhood obesity in developed countries.

Types of exercise

Exercises are generally grouped into three types depending on the overall effect they have on the human body:

Flexibility exercises, such as stretching, improve the range of motion of muscles and joints.

Aerobic exercises, such as cycling, swimming, walking, rowing, running, hiking or playing tennis, focus on increasing cardiovascular endurance.

Anaerobic exercises, such as weight training, functional training or sprinting, increase short-term muscle strength.

Categories of physical exercise

Aerobic exercise

Anaerobic exercise

Strength training

Agility training

Sometimes the terms ‘dynamic’ and ‘static’ are used. ‘Dynamic’ exercises such as steady running, tend to produce a lowering of the diastolic blood pressure during exercise, due to the improved blood flow. Conversely, static exercise (such as weight-lifting) can cause the systolic pressure to rise significantly (during the exercise).

Exercise benefits

thumb|right|200px|A common [[elliptical trainer|elliptical training machine.]] Physical exercise is important for maintaining physical fitness and can contribute positively to maintaining a healthy weight, building and maintaining healthy bone density, muscle strength, and joint mobility, promoting physiological well-being, reducing surgical risks, and strengthening the immune system.

Exercise also reduces levels of cortisol, thereby benefiting health. Cortisol is a stress hormone that builds fat in the abdominal region, making weight loss difficult. Cortisol causes many health problems, both physical and mental.

Frequent and regular aerobic exercise has been shown to help prevent or treat serious and life-threatening chronic conditions such as high blood pressure, obesity, heart disease, Type 2 diabetes, insomnia, and depression. Strength training appears to have continuous energy-burning effects that persist for about 24 hours after the training, though they do not offer the same cardiovascular benefits as aerobic exercises do.

Effect on the immune system

Although there have been hundreds of studies on exercise and the immune system, there is little direct evidence on its connection to illness. Epidemiological evidence suggests that moderate exercise appears to have a beneficial effect on the human immune system while extreme exercise appears to impair it, an effect which is modeled in a J curve. Moderate exercise has been associated with a 29% decreased incidence of upper respiratory tract infections (URTI), but studies of marathon runners found that their prolonged high-intensity exercise was associated with an increased risk of an infection, although another study did not find the effect. Immune cell functions are impaired following acute sessions of prolonged, high-intensity exercise, and some studies have found that athletes are at a higher risk for infections. The immune systems of athletes anf nonathletes are generally similar. Athletes may have slightly elevated NK cell count and cytolytic action, but these are unlikely to be clinically significant.

Supplementation with the antioxidants vitamin C and E has been found to decrease the release of interleukin-6 (IL-6), which would be expected to decrease the depression of the immune system. Further, vitamin C supplementation has been associated with lower URTIs in marathon runners. However, the decreased release of IL-6 limits the anti-inflammatory effect of exercse and could limit the positive adaptation effects of exercise.

Biomarkers of inflammation such as C-reactive protein, which are associated with chronic diseases, are reduced in active individuals relative to sedentary individuals, and the positive effects of exercise may be due to its anti-inflammatory effects. The depression in the immune system following acute bouts of exercise may be one of the mechanisms for this anti-inflammatory effect.

Breathing

Active exhalation during physical exercise helps the body to increase its maximum lung capacity. This results in greater efficiency, since the heart has to do less work to oxygenate the muscles, and there is also increased muscular efficiency through greater blood flow. Consciously breathing deeply during aerobic exercise helps this development of the heart and lungs.

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Pumping Heart

Human_healthy_pumping_heart

Pumping Heart

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A pump is a device used to move fluids, such as gases, liquids or slurries. A pump displaces a volume by physical or mechanical action. One common misconception about pumps is the thought that they create pressure. Pumps alone do not create pressure; they only displace fluid, causing a flow. Adding resistance to flow causes pressure. Pumps fall into two major groups: positive displacement pumps and rotodynamic pumps. Their names describe the method for moving a fluid.

A positive displacement pump causes a fluid to move by trapping a fixed amount of it then forcing (displacing) that trapped volume into the discharge pipe. A positive displacement pump can be further classified according to the mechanism used to move the fluid:

Rotary-type, for example, the lobe, external gear, internal gear, screw, shuttle block, flexible vane or sliding vane, helical twisted roots (e.g. the Wendelkolben pump) or liquid ring vacuum pumps.

Positive displacement rotary pumps are pumps that move fluid using the principles of rotation. The vacuum created by the rotation of the pump captures and draws in the liquid. Rotary pumps are very efficient because they naturally remove air from the lines, eliminating the need to bleed the air from the lines manually. Positive displacement rotary pumps also have their weaknesses. Because of the nature of the pump, the clearance between the rotating pump and the outer edge must be very close, requiring that the pumps rotate at a slow, steady speed. If rotary pumps are operated at high speeds, the fluids will cause erosion, much as ocean waves polish stones or erode rock into sand. Rotary pumps that experience such erosion eventually show signs of enlarged clearances, which allow liquid to slip through and detract from the efficiency of the pump. Positive displacement rotary pumps can be grouped into three main types. Gear pumps are the simplest type of rotary pumps, consisting of two gears laid out side-by-side with their teeth enmeshed.

The gears turn away from each other, creating a current that traps fluid between the teeth on the gears and the outer casing, eventually releasing the fluid on the discharge side of the pump as the teeth mesh and go around again. Many small teeth maintain a constant flow of fluid, while fewer, larger teeth create a tendency for the pump to discharge fluids in short, pulsing gushes. Screw pumps are a more complicated type of rotary pumps, featuring two screws with opposing thread —- that is, one screw turns clockwise, and the other counterclockwise. The screws are each mounted on shafts that run parallel to each other; the shafts also have gears on them that mesh with each other in order to turn the shafts together and keep everything in place. The turning of the screws, and consequently the shafts to which they are mounted, draws the fluid through the pump. As with other forms of rotary pumps, the clearance between moving parts and the pump’s casing is minimal. Moving vane pumps are the third type of rotary pumps, consisting of a cylindrical rotor encased in a similarly shaped housing. As the rotor turns, the vanes trap fluid between the rotor and the casing, drawing the fluid through the pump.

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