Do adults really need tetanus booster shots?

If you haven’t had a tetanus booster shot in the past decade, your doctor may recommend getting one. Many people think of a tetanus shot as something you only need if you step on a rusty nail. Yet even in the absence of a puncture wound, this vaccine is recommended for all adults at least every 10 years. But why? A group of researchers recently questioned whether you need to repeat tetanus vaccines on a regular schedule.

What is a tetanus booster?

Booster shots are repeat vaccinations you receive after your first series of immunizations as a child. Protection from certain vaccines can wane over time, which is why doctors advise boosters. The tetanus vaccine is not just for tetanus though. It’s bundled with a vaccine for diphtheria and sometimes one for pertussis (the bacteria that causes whooping cough).

What are tetanus and diphtheria?

Tetanus and diphtheria are rare but serious diseases that can cause severe complications in those infected.

Tetanus, sometimes known as “lockjaw,” is an infection caused by a type of bacteria called Clostridium tetani. When this bacteria invades the body, it can produce a toxin that leads to painful muscle tightening and stiffness. In severe cases, it can lead to trouble breathing, seizures, and death. Tetanus does not spread from person to person. Usually it enters the body through contaminated breaks in the skin — stepping on a nail that has the bacteria on it, for example. There are about 30 reported cases of tetanus in the US each year. These cases almost always occur in adult patients who have never received a tetanus vaccine, or adults who have not been up to date on their 10-year booster shots.

Diphtheria is a bacterial infection caused by a type of bacteria called Corynebacterium diphtheriae. Diphtheria can cause a thick covering on the back of the throat and may lead to difficulty breathing, paralysis, or death. It typically spreads person-to-person. There have been fewer than five cases reported to the CDC in the past 10 years.

What are the current vaccine recommendations?

The Centers for Disease Control and Prevention (CDC) recommends tetanus vaccines for people of all ages. Adolescents and adults receive either the Td or Tdap vaccines. These vaccines protect over 95% of people from disease for approximately 10 years. Currently the CDC Advisory Committee on Immunization Practices recommends a booster shot every 10 years. Injury or wound management and pregnancy may affect this schedule.

What does the new study on tetanus boosters suggest?

A recent paper published in the journal Clinical Infectious Diseases suggested that tetanus and diphtheria booster vaccines are not necessary for adults who have completed their childhood vaccination series. This advice aligns with the current World Health Organization (WHO) recommendations. The researchers reviewed WHO data from 31 North American and European countries between 2001 and 2016, amounting to 11 billion person-years. (Person-years is a measurement that reflects the number of people in the study multiplied by years followed). After comparing the incidence of tetanus and diphtheria, they found no significant difference in disease rates in countries that require adults to receive booster shots compared with those that do not. Based on this, the authors suggest that childhood vaccination alone protects sufficiently against tetanus and diphtheria without booster shots.

So, what should you do?

The question of whether to have ongoing booster vaccines is more complicated than looking at frequency of a disease. The conclusions of this study focus on the lack of change in tetanus or diphtheria incidence rates among countries that routinely vaccinate children. However, other factors influence the number of cases, such as the overall amount of the bacteria in the environment, or wound management and hygiene measures.

Immunity from antibodies to tetanus and diphtheria may persist for many years. Over time, though, antibody levels  decrease. We know that even if antibodies are present, low levels may not always be protective. Even though this study was well executed and raises some important questions, further studies are needed to examine whether a childhood vaccination series offers lifelong protection without repeated adult boosters.

Even though it happens rarely, people can still get tetanus and experience serious or deadly effects. There is no cure for tetanus, and no definitive proof that you will have lifelong immunity with childhood vaccinations alone. So for now, the CDC continues to recommend booster vaccines every 10 years to help your immune system protect against these infections. If you have questions about the tetanus and diphtheria vaccine, talk to your doctor.

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Platelet-rich plasma: Does the cure for hair loss lie within our blood?

Platelet-rich plasma, or PRP, is derived from the bloodstream and has been used for years to treat musculoskeletal conditions, and more recently, skin conditions. Colloquially termed “vampire” treatments, PRP injected into the skin or used after microneedling (a technique that uses small needles to create microscopic skin wounds) may help to improve skin texture and appearance. Recently, PRP has garnered attention as a promising solution for one of the most challenging problems in dermatology: hair loss.

Platelets and hair growth: What’s the connection?

Platelets are one of four primary components of blood (the other three are red blood cells, white blood cells, and plasma). Platelets promote cell growth and regeneration. As the term “platelet-rich plasma” suggests, platelets are generally about five times more concentrated in PRP than in regular blood. This concentration of platelets is useful, because platelets secrete growth factors than are thought to assist in wound healing and tissue regrowth.

When it comes to hair loss, the theory is that platelets, injected deep into the scalp to reach the bottom of the hair follicle, may stimulate a specialized population of cells named dermal papilla cells, which play a critical role in hair growth.

Obtaining and injecting platelet-rich plasma

The process of obtaining PRP involves a blood draw and a centrifuge. To yield PRP, blood is drawn from your arm, then spun down in a centrifuge (a machine that spins at high speeds to help separate blood components). After centrifuging, the plasma rises to the top, and the lower part of the plasma is the PRP. Sometimes, a second spin is performed to increase the platelet concentration of the plasma.

Your own PRP is collected, then injected into multiple areas of hair loss across your scalp. The usual treatment plan involves three sessions, approximately one month apart, followed by maintenance sessions every three to six months to keep up the results.

Evidence for platelet-rich plasma is stronger for some types of hair loss than others

Most research on PRP for hair loss has focused on its use to treat androgenetic alopecia (AGA). Also known as hormone-related baldness, this is a condition that can affect both men and women. In men with AGA, hair loss typically occurs on the top and front of the head. In women, thinning occurs on the top and crown of the head and often begins with the center hair part growing wider. The evidence suggests that PRP may work best when it is combined with other treatments for AGA, such as topical minoxidil (Rogaine) or oral finasteride (Propecia), which is an anti-androgenic drug.

There is not enough evidence to make conclusions about the effectiveness of PRP for other types of hair loss, like telogen effluvium (stress-related hair loss), alopecia areata (autoimmune-related non-scarring hair loss), or forms of scarring hair loss.

Platelet-rich plasma hair loss therapy considered safe, but expensive

PRP injections are not suitable for everyone. These injections can be painful, for both your scalp and your wallet. One session can cost around $1,000, with a series of three treatments needed before improvement may be seen. These treatments are generally not covered by insurance.

PRP injections are considered safe when performed by a trained medical provider. Mild risks include pain, redness, headaches, and temporary hair shedding. PRP may not be appropriate for those with a history of bleeding disorders or autoimmune disease.

More research is needed

Providers currently use a variety of PRP harvesting and administration techniques. More research is needed to understand the best process for obtaining and injecting PRP. Further, more information is needed to understand how PRP helps regrow hair, and how useful it may be for less common types of hair loss.

Follow us on Twitter @NeeraNathanMD and @hairwithdrmare

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What to eat to reduce your risk of Alzheimer’s disease

Would you like reduce your risk of cognitive impairment, Alzheimer’s disease, and dementia? Researchers from around the world having been studying a variety of different factors that might reduce these risks and keep the brain healthy.

Old news: The Mediterranean diet is beneficial

One factor that a number of studies have converged on is a Mediterranean-style diet. This diet includes

• fish
• olive oil
• avocados
• fruits
• vegetables
• nuts
• beans
• whole grains
• red wine in moderation.

Now, if you’re like me and you happen to like all these foods, then you have all the information you need to eat a brain-healthy diet. On the other hand, if you’re not crazy about everything on the list, perhaps you would rather eat just the most important components. Researchers have, in fact, been trying to determine the key parts of this diet for a number of years.

For example, one study published in 2015 and updated in 2018 compared healthy older adults who followed a Mediterranean diet with extra olive oil or extra nuts versus a control reduced-fat diet. The enhanced Mediterranean diet groups fared equally well, and both had better cognitive performance outcomes than the reduced-fat diet group. No study, however, has been able to determine the critical components of the Mediterranean diet that makes it so good for your brain — until now.

The new study

Researchers at the National Institutes of Health recently published a study that evaluated the lifestyles of over 7,750 participants followed for five to 10 years. Participants filled out questionnaires to determine their eating habits, and had cognitive tests of memory, language, and attention administered over the phone. They used these data to determine the dietary factors most important in lowering your risk of cognitive impairment, as well as the dietary factors most important in lowering your risk of cognitive decline.

Cognitive impairment versus cognitive decline

Let’s take a moment to unpack these terms. Let’s say you want to know what your risk is 10 years from now.

• Cognition is a shorthand way of saying thinking, memory, language, attention, visuospatial, and other mental abilities.
• Your risk of cognitive impairment is the risk that 10 years from now, your cognition will be worse than your peers.
• Your risk of cognitive decline is the risk that 10 years from now, your cognition will be worse than it is now.

Fish helps you think — and keeps your thinking strong

What did the researchers find? Fish was the single most important dietary factor in lowering the risk of cognitive impairment. Vegetables were second best, and all other foods showed smaller, insignificant effects. Moreover, of all the foods evaluated, only fish was associated with a lower risk of cognitive decline. Eating fish lowered the risk of both cognitive impairment and cognitive decline.

The take-home lesson

To reduce your risk of cognitive impairment and decline, eat a Mediterranean-style diet including fish several times per week. There are lots of good fish to eat, including Atlantic mackerel, black sea bass, catfish, clams, cod, crab, crawfish, flounder, haddock, lobster, salmon, sardines, scallops, shrimp, skate, sole, squid, tilapia, trout, and canned light tuna. Just be careful about fish that may have high levels of mercury, such as swordfish and bigeye tuna; these fish should only be eaten occasionally. The FDA has a good guide to help you know the best fish to eat.

Your mother was right

Did your mother ever tell you that fish was good for you? Mine did. In fact, she always used to say, “Fish helps you think.” She knew it all along; it just took the scientific community 50 years to catch up to her and prove it.

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Your headaches are getting worse. Do you need an imaging test?

Headache is a very common condition that affects up to 60% of the world’s population. In general, headache can be classified into two main categories: primary and secondary headaches. A primary headache is related to increased sensitivities, but not structural alterations of brain tissues. Common primary headaches are migraine with and without aura, tension-type headache, and trigeminal autonomic cephalalgias (headaches, such as cluster headache, that also involve facial pain and autonomic symptoms such as tear production and nasal congestion). Secondary headaches have various underlying causes including structural vascular disorders, tumor, trauma, seizure, substance use, infection, metabolic problems, or autoimmune diseases.

Headaches have many possible causes, and proper management requires accurate diagnosis. Primary headaches are typically managed with some combination of preventive and symptom-relieving medications. Secondary headaches may be treated by addressing the underlying cause.

When do I need to see a doctor for my headaches?

Seeing a medical provider is strongly recommended if headaches become more frequent, last longer, change patterns, or increase in intensity. For a new headache visit, health care providers typically perform physical and neurological examinations to determine the cause of the headache.

A primary care provider (PCP) would be the first contact for mild headache symptoms that have been worsening. Your PCP would likely refer you to a neurologist if your headaches did not respond to medications, or if he or she suspected a secondary headache. Sudden onset of severe headache should prompt a visit to the emergency department.

Which imaging tests help headache management?

Many providers would consider ordering brain imaging studies, such as CT scans and MRIs, to help them diagnose worsening headache. CT scan is an x-ray-based imaging study. It is an excellent initial imaging test for detecting bleeding, skull fractures, and space-occupying lesions such as tumors. CT scans do expose patients to a low dose of radiation so their use should be limited, because the effects of radiation exposures add up over time and could reach a harmful level.

In contrast, MRI uses a magnetic field to generate imaging without radiation. It produces more detailed images than CT scans, especially of the brain, the meninges (the membranes that enclose the brain and spinal cord), nerves, and blood vessels. However, MRI cannot be performed in people with pacemakers or other electronic implants.

In certain conditions that involve bleeding, blood clots, or abnormal vascular structures, tests known as arteriograms and venograms may be necessary for detailed structural analysis of blood vessels.

What are the red flags for an imaging study?

It is understandable that people with increasingly severe headaches would want to have brain imaging to determine the underlying causes. But most headaches that are categorized as primary (based on a person’s headache history and physical and neurological evaluation) do not require brain imaging studies. Brain scans are much more effective for identifying underlying causes of secondary headaches.

Several evidenced-based guidelines, including guidelines which were published in the Journal of the American College of Radiology in November 2019, can help providers decide when and which imaging studies are appropriate.

These guidelines describe certain red flags that warrant the use of brain imaging during the initial headache evaluation. They are summarized into five main categories:

• a primary headache with abnormal findings on clinical examinations. Abnormal findings may include abnormal vital signs (blood pressure, pulse, body temperature, oxygen saturation); changes in mental alertness or memory loss; and neurological deficits such as visual, coordination, sensory, or motor impairments.
• sudden severe (thunderclap) headache, often described as “the worst headache of a person’s life” that doesn’t respond to drug treatment
• new headache with swelling of the optic disc, an area on the retina where it meets the optic nerve
• new or progressive headaches in people with a history of recent head injury, cancer, immunosuppression, pregnancy, or age older than 50; and in patients with headaches that are worsened after exertion, when they change position, and whose headaches are accompanied by a whooshing or pulsating sound
• new suspected trigeminal autonomic headaches.

If a headache falls into these categories, having brain imaging studies would help early diagnosis and timely intervention of a secondary headache, in order to reduce the possibility of severe complications or death.

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All rise now — just how fit are you?

How fit are you, really? Fitness is not always best measured by parameters like your weight, your ability to run a 5K, or whether you can do 10 push-ups. Instead, one test of fitness is how well you can stand from a seated position.

Try this: Rise from the floor without using your hands

Before you start: Keep in mind that this test is not for everyone. For instance, someone with a sore knee, arthritis, poor balance, or another kind of limitation would have difficulty doing the test with little or no assistance.

Instructions: Sit on the floor with your legs crossed or straight out. Now stand up again. (This may not an easy movement for many people, so for safety do this with someone next to you.)

How did you do? Did you need to use your hands or knees? Could you not get up at all?

Now, do the test again, only this time grade your effort. Beginning with a score of 10, subtract one point if you do any of the following for support when you both sit and stand:

• use your hand
• use your knee
• use your forearm
• use one hand on the knee or thigh
• use the side of your leg
• lose your balance at any time.

For example, if you sat with no problem, but had to use either a hand or a knee to get up, take off one point. If you had to use both your hands and knees, deduct four points (two points each).

If you can sit and stand with no assistance, you scored a perfect 10. If you could not get up at all, your score is zero. Ideally, you want a score of eight or higher. (For the record, the first time I tried, I got a seven.)

What the no-hands test tells us about fitness

“The sit-and-rise movement — sometimes also referred to as the no-hands test — can reveal much about your current strength, flexibility, and overall wellness,” says Eric L’Italien, a physical therapist with Harvard-affiliated Spaulding Rehabilitation Center.

Performing the sit-and-rise test requires leg and core strength, balance and coordination, and flexibility. But if you struggle, that does not necessarily mean you are out of shape.

“Think of it as a way to highlight areas of your physical health you should address,” says L’Italien. Even if you currently do reasonably well on the test, practicing it regularly can find weak spots before they become worse.

Three exercise that can improve your performance

If you need to improve your performance, here are three exercises L’Italien recommends that can help improve your score — and ultimately your fitness. He recommends adding them to your regular workout routine. If you are just starting out, perform them twice a week and build from there.

Lunges. The simple lunge helps with both leg strength and balance.

• Stand with your feet shoulder-width apart.
• While keeping your abdomen tight and your back in an upright position, step forward with one leg until your knee is aligned over the front of your foot. The trailing knee should drop toward the floor.
• Hold for a few seconds and return both legs to the starting position. Repeat with the opposite leg.
• Do five to 10 repetitions with each leg to make a set. Do two to three sets.

Modification: Stand next to a wall for hand support if needed. For an extra challenge, hold small hand weights during the movements.

Hamstring stretch. Tight hamstrings are a significant contributor to poor flexibility among older adults.

• Lie on your back and place a strap, belt, or towel around one foot.
• Holding the strap, gently pull the leg back until you feel a stretch in the back of the leg.
• Hold the stretch for 30 seconds and then release. Switch to the other leg and repeat.

Plank. This can help strengthen a weak core.

• Lie face down with your forearms resting on the floor.
• Raise up your body, so it forms a straight line from your head and neck to your feet.
• Tighten your abs and try to hold this position for 10 seconds.
• Rest and then repeat. Do two to three planks in total. Work up to holding each plank for 30 seconds or longer.

Modification: To make the exercise easier, do it while leaning against a counter or table at a 45-degree angle. You can also hold the plank from a full push-up position.

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Go to the hospital if you need emergency care, even in the era of COVID-19

In the era of COVID-19, the hospital must be a place of mystery to those on the outside. I imagine some think it’s bustling with activity, with caregivers scurrying around at a frenetic pace. Of course, we’ve seen video on the news from hard-hit New York City or Lombardy, Italy, when they were at their initial peak of the COVID-19 epidemic. But the reality is that, in most hospitals around the country, it is actually somewhat calmer than usual.

This calm makes sense given the mandate for social distancing, working from home, and canceling nonessential activities. What doesn’t make sense is this: in the emergency departments where I work, daily patient visits have significantly decreased. These days, we are now treating about half the number of patients that we usually do. Although we are busy with COVID-19 patients, the absence of patients with the typical reasons for emergency department (ED) visits, like chest pain, abdominal pain, and headache are way down. This has left us scratching our heads, thinking “where are they?”

People report avoiding emergency departments over fear of COVID-19

A recent article in the Journal of the American College of Cardiology describes a nearly 40% reduction in use of cardiac catheterization labs to treat acute severe heart attacks, which is shocking. This phenomenon occurred in Italy as well, where admissions for heart attacks decreased markedly. Although staying at home is likely to reduce visits for trauma — like falls or car accidents — it shouldn’t affect the rate of heart attacks, right?

A new poll from the American College of Emergency Physicians and Morning Consult may explain where the patients are: at home. About four out of every five adults in the survey said they are concerned about contracting COVID-19 from another patient or visitor if they need to go to the ED, and over half thought they might get turned away for care. About three-quarters of the people in the survey were concerned about overstressing the healthcare system by coming to the ED.

Although we appreciate the sensitivity about burdening the system, it is important for people not to delay medical care when it truly could be an emergency. If you think you are having a heart attack or stroke, for example, delaying treatment could drastically worsen the condition. Despite any hesitation you may feel, do not delay getting emergency medical care if you experience symptoms like chest pain, neurologic changes, severe abdominal pain, or other worrisome changes in your health.

Emergency departments have made changes to keep you safe

If you require an ambulance, call 911. The medics will likely be wearing masks and face shields, regardless of what your symptoms are, to protect both you and them. If you arrive on your own, you should expect some additional questions about COVID-19 symptoms and exposures, so that the hospital staff knows where to safely place you in the ED. In the hospitals where I work, all staff members are required to wear a mask at all times. The people caring for you will likely be wearing personal protective equipment (PPE) like gowns and face shields. We have also constructed walls around several of the beds that used to be separated only by curtains, as a further precaution.

There are additional changes to expect, all to ensure that you and the community are safe. It is possible that you will be asked to wear a mask. And it is unlikely that a visitor will be able to enter the hospital with you, so bring a phone and charger. Overall, the staff will try to minimize the time they spend in the room with you. For example, I now do my initial evaluation in person with full PPE, but then call the patient on the phone in their room to report on follow-up information, when possible.

Some consultants are only seeing emergency patients by telehealth, meaning that you might see some providers on a tablet computer instead of in person. By doing so, we limit the chance of giving you COVID-19, and vice versa. Rest assured, we have access to every test and treatment needed for emergency conditions, and will treat you for your condition. And after each patient leaves their room, we decontaminate it extensively to prepare for the next patient.

If you need to be admitted to the hospital, you may be tested for COVID-19, even if you don’t have symptoms. Patients with a diagnosed case or symptoms suggesting COVID-19 may go to a special pathogens unit, while others may go to a non-COVID floor. And even on the non-COVID floors, the staff takes the utmost precautions to avoid spreading the disease.

Delaying medical care can greatly worsen your outcome. Hospitals are here and ready to care for you in a time of emergency, whether it is related to COVID-19 or not.

For more information on coronavirus and COVID-19, see the Harvard Health Publishing Coronavirus Resource Center.

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