If You Have Rheumatoid Arthritis and You Smoke, Listen Up

Tossing your cigarettes may help control your rheumatoid arthritis, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in San Francisco, Calif.

Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.

Smoking is known to increase the risk and severity of RA. Smoking cessation has been shown to have a positive impact in slowing the progression of other diseases such as coronary disease and emphysema.

Researchers recently evaluated 14,847 patients with RA based on their smoking status. Of those, 65.4 percent were non-smokers, 22.1 percent were former smokers, and 12.5 percent were active smokers. Smoking cessation was defined as patient-reported cessation over two consecutive physician office visits, and independent variables in the study included patient age, gender, ethnicity, rheumatoid factor status, and use of different therapies for treating RA.

Researchers primarily monitored change in Clinical Disease Activity Index—a composite measure of disease activity in people with RA that assesses change over time— as well as other measures of disease activity including tender and swollen joint counts and laboratory tests.

Among 1,405 patients who smoked at enrollment into the registry, 21.1 percent successfully stopped smoking. In comparing this group to patients who continued to smoked, researchers found no significant differences in disease duration, rheumatoid factor or CCP status, non-biologic DMARD or biologic use. However, at the last follow-up visit, Clinical Disease Activity Index was higher among active smokers than among patients who had stopped smoking. Individual measures of active disease including swollen and tender joint counts and C-reactive protein were all lower in the patients who had stopped smoking.

These results suggest that stopping smoking can lessen RA disease activity over and above current medical treatment.

"While these results are preliminary, it seems that quitting smoking, which would have many other health benefits, also may benefit patients with rheumatoid arthritis,” explains Mark C. Fisher, MD, MPH; Research Fellow, NYU Medical Center; Hospital for Joint Disease, New York, N.Y. “RA patients who stop smoking may see an improvement in the number of joints that hurt them every day and in how they feel overall,” he says, noting that further research is necessary to confirm these early findings.

The ACR is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy and practice support that foster excellence in the care of people with or at risk for arthritis and rheumatic and musculoskeletal diseases. For more information on the ACR’s annual meeting, see www.rheumatology.org/annual.

Men Who Never Smoke Live Longer, Better Lives Than Heavy Smokers

Health-related quality of life appears to deteriorate as the number of cigarettes smoked per day increases, even in individuals who subsequently quit smoking, according to a report in the October 13 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Smoking has been shown to shorten men’s lives between seven and 10 years, according to background information in the article. It also has been linked to factors that may reduce quality of life, including poor nutrition and lower socioeconomic status.

Arto Y. Strandberg, M.D., of the University of Helsinki, and colleagues followed 1,658 white men born between 1919 and 1934 who were healthy at their first assessment, conducted in 1974. Participants were mailed follow-up questionnaires in 2000 that assessed their current smoking status, health and quality of life. Deaths were tracked through Finnish national registers.

During the 26-year follow-up period, 372 (22.4 percent) of the men died. Those who had never smoked lived an average of 10 years longer than heavy smokers (more than 20 cigarettes per day). Non-smokers also had the best scores on all health-related quality of life measures, especially those associated with physical functioning. Physical health deteriorated at an increasing rate as the number of cigarettes smoked per day increased, with heavy smokers experiencing a decline equivalent to 10 years of aging.

“Although many smokers had quit smoking between the baseline investigation in 1974 and the follow-up examination in 2000, the effect of baseline smoking status on mortality and the quality of life in old age remained strong,” the authors write. “In all, the results presented here are troubling for those who were smoking more than 20 cigarettes daily 26 years earlier; in spite of the 68.9 percent cessation rate during follow-up, 44.1 percent of the originally heavy smokers had died, and those who survived to the mean [average] age of 73 years had a significantly lower physical health-related quality of life than never-smokers.”

The findings may add to the view of smoking as a burden on society and might also encourage individual smokers to quit, the authors note. “The argument of better quality of life may be especially meaningful for the aging smoker but, as our results show, for the best health-related quality of life, the habit should not be started at all,” they write. “The highly addictive nature of nicotine is revealed by the persistence of the smoking habit in spite of the declining health-related quality of life among older heavy smokers. For those not able to quit smoking, reduction may also be beneficial because mortality [death] and health-related quality of life showed a dose-dependent trend according to the number of cigarettes smoked daily.”

Additional papers related to smoking in the October 13 issue found that:

Offering smoking cessation counseling to hospitalized smokers appears to be effective as long as supportive contacts are offered for more than one month after discharge. Nancy A. Rigotti, M.D., of Massachusetts General Hospital and Harvard Medical School, Boston, and colleagues reviewed 33 trials of smoking cessation interventions that began during hospitalizations. Programs that offered telephone or in-person support lasting longer than one month improved smoking cessation rates six to 12 months after discharge. “Adding nicotine replacement therapy to counseling may further increase smoking cessation rates and should be offered when clinically indicated, especially to hospitalized smokers with nicotine withdrawal symptoms,” the authors write.

Hospital-based smoking cessation programs, along with referrals to cardiac rehabilitation, also appear to be associated with increased rates of quitting smoking following heart attack. Nazeera Dawood, M.D., M.P.H., at Emory University School of Medicine, Atlanta, and colleagues studied 639 patients who smoked at the time of their hospitalization for myocardial infarction (heart attack). Six months later, 297 (46 percent) had quit smoking. The odds of quitting were greater among patients who received discharge recommendations for cardiac rehabilitation and those who were treated at a facility offering an inpatient smoking cessation program; however, individual counseling was not associated with quit rates.

A pay-for-performance program may increase referrals to tobacco quitline services, particularly among clinics who have not previously participated in quality improvement activities. Lawrence C. An, M.D., of the University of Minnesota, Minneapolis, and colleagues randomly assigned 24 primary care clinics to participate in a program offering $5,000 for 50 quitline referrals. Between Sept. 1, 2005, and June 31, 2006, these clinics referred 11.4 percent of eligible smokers, compared with 4.2 percent among 25 clinics offering usual care. “Quitlines are widely available, and application of pay-for-performance strategies to encourage health care provider referral should be strongly considered by health care organizations seeking to reduce the health and economic burden of tobacco-related disease,” the authors write.

“Smoking remains the largest avoidable cause of death and disability in the United States, but it is a problem against which we are making steady albeit far too slow progress,” writes David M. Burns, M.D., Del Mar, Calif., in an accompanying editorial. “Smoking cessation is one of the most important changes needed to achieve the goal so often articulated by Dr. Ernst Wynder, one of the founders of the field of preventive medicine: die young as late in life as possible.”

Why Do Women Get More Cavities than Men?

Reproduction pressures and rising fertility explain why women suffered a more rapid decline in dental health than did men as humans transitioned from hunter-and-gatherers to farmers and more sedentary pursuits, says a University of Oregon anthropologist.

The conclusion follows a comprehensive review of records of the frequencies of dental cavities in both prehistoric and living human populations from research done around the world. A driving factor was dramatic changes in female-specific hormones, reports John R. Lukacs, a professor of anthropology who specializes in dental, skeletal and nutritional issues.

His conclusions are outlined in the October issue of Current Anthropology. The study examined the frequency of dental caries (cavities) by sex to show that women typically experience poorer dental health than men. Among research reviewed were studies previously done by Lukacs. Two clinical dental studies published this year (one done in the Philippines, the other in Guatemala) and cited in the paper, Lukacs said, point to the same conclusions and "may provide the mechanism through which the biological differences are mediated."

A change in food production by agrarian societies has been associated with an increase in cavities. Anthropologists have attributed men-women differences to behavioral factors, including a sexual division of labor and dietary preferences. However, Lukacs said, clinical and epidemiological literature from varied ecological and cultural settings reveals a clear picture of the impacts on women's oral health.

"The role of female-specific factors has been denied by anthropologists, yet they attain considerable importance in the model proposed here, because the adoption of agriculture is associated with increased sedentism and fertility," Lukacs said. "I argue that the rise of agriculture increased demands on women’s reproductive systems, contributing to an increase in fertility that intensified the negative impact of dietary change on women’s oral health. The combined impacts of increased fertility, dietary changes and division of labor during the move into agricultural societies contributed to the widespread gender differential observed in dental caries rates today."

Lukacs' meta-analysis looked at both prehistoric anthropological and modern health records. He repeatedly found that increases in cavities go in favor of women in adulthood. Lukacs' review found that women’s higher rates of cavities are influenced by three main changes:

• Female sex hormones. Citing his own research published in 2006, he notes that these hormones and associated physiological factors can significantly impact cavity formation. A study on animals published in 1954 found that female estrogens, but not male androgens, were correlated to cavity rates. He argues for a cumulative effect of estrogens, including fluctuations at puberty and high levels during pregnancy that both promote cavities and dietary changes.

• The biochemical composition and flow rate of saliva. Women produce less saliva than do men, reducing the removal of food residue from the teeth, and that during pregnancies the chemical composition changes, reducing saliva's antimicrobial capacity.

• Food cravings, immune response and aversions during pregnancy. Lukacs points to findings that women crave high-energy, sweet foods during the third trimester, as well as an aversion to meat in first trimesters.

How the factors combine to contribute to higher risk of cavities in women as they age is not fully documented or understood, he wrote. "However, if hormonal and physiological factors work in an independent or additive manner, their impact on women's oral health could be significant. The fact that women's caries experience increases with age at a greater rate than men's in diverse ethnic groups from different ecological and cultural settings supports this interpretation."

The Alexander von Humboldt Foundation, American Institute of Indian Studies, American Philosophical Society, L.S.B. Leakey Foundation, National Geographic Society, National Science Foundation and Wenner-Gren Foundation for Anthropological Research supported the project.

Free Clinics Now Providing Healthcare Solutions to the Uninsured

In over 66 communities across the country, 250,000+ retired physicians and 350,000 retired nurses are now providing a solution to the healthcare crisis. Volunteers in Medicine (VIM), an organization whose mission is to promote and guide the development of a national network of free clinics, is utilizing retired medical professionals and lay volunteers to care for the uninsured within a culture of caring.
Volunteers in Medicine (VIM) began in Hilton Head, South Carolina. In 1992, one out of three people who lived on Hilton Head Island had no access to health care. At the same time, a number of retired medical personnel (physicians, nurses, dentists) expressed an interest in finding a way to continue practicing their profession on a voluntary, part-time basis to help those without access to health care. So these two groups were brought together to create the first Volunteers in Medicine Clinic. Since then, 66 VIM free clinics have opened in 22 states across the country.

"No community can be truly healthy if a significant portion of the population is excluded from basic health care services," says Amy Hamlin, executive director of Volunteers in Medicine. "In the absence of a national health policy that includes health care for everyone, concerned citizens need to find other solutions to provide the medically under-served with the health care services they desperately need. Volunteers in Medicine delivers on such solution."

The statistics are staggering; 47 million people in this country have no medical insurance. Another 25 million are underinsured, up 60% in just four years with middle and higher income families comprising most of that increase. The impact on the infrastructure of towns and cities is equally staggering. When people are injured or sick, they can't work, effecting employers and their ability to provide goods and services. When people postpone seeking medical care, their medical conditions get worse and more costly to treat. And without adequate health insurance, emergency rooms become the default. This is particularly difficult, as emergency departments have seen cuts in reimbursements, while at the same time ER visits are at record highs across the country. This creates a cost-shift, which means higher premiums for everyone.

Even if everyone were to become insured tomorrow, there is not enough current or future primary care capacity to provide health care to all Americans. Over one-third of active physicians are over age 55 and with many choosing early retirement, there will be a deficit of primary care physicians by 2020. Faced with lower reimbursement rates, excessive work loads, and rising medical school costs, fewer graduates are choosing primary care. "Empowering retired physicians to practice the 'pure medicine' they crave without the 'business' of medicine is the common sense approach that Volunteers in Medicine provides. This is one solution to improving the long term health of our country," continued Hamlin.

Some 313,000 of the active physician population are over 55. This means that 36% of active physicians are set to retire by 2020 while at the same time there are only 105,000 physicians in residency training. Contrary to predictions in the 1980's and 1990's, there will not be a surplus of physicians in the 21st Century but rather we will face a physician shortage. "The statistics on current and projected physician numbers further support the ongoing effectiveness that the VIM model will have in improving the healthcare of our country long term," continued Hamlin.

Time Management -- Tips to Reduce Stress

Many women know the overwhelmed feeling caused by too much to do and too little time. Better time management can help you do more. And it has health benefits, such as less stress and a better quality of life.

The October issue of Mayo Clinic Women’s HealthSource offers tips to improve time management. The recommendation is to try one strategy for two to four weeks to see if it helps. If it does, add another. If not, try a different one. Here’s a few to consider:

Plan each day. A schedule minimizes conflicts and last-minute rushes. Write a to-do list with the most important tasks at the top. Even if you don’t get through the list, you’ll know time was spent constructively.

Say no to nonessential tasks. Let priorities determine your schedule rather than letting guilt have the final say.

Delegate. Consider what you can eliminate or delegate from your to-do list. Be willing to let others do tasks differently from how you do them.

Take time to do a quality job. Doing something right the first time may take more time up front, but errors caused by rushing may require longer to correct.

Practice the 10-minute rule. Work on dreaded tasks for 10 minutes each day. Once a task is started, you may be able to finish it.

Evaluate how you are spending your time. Keep a diary for three days to track tasks. Look for time that could be used more wisely, freeing up time to spend exercising or with family and friends.

Get plenty of exercise and sleep. Improved focus and concentration help increase efficiency, so you can complete tasks in less time.

Take a time management course. Employers, community colleges and community education programs often offer these classes.

Take a break when needed. Too much stress can derail attempts at getting organized. When you need a break, take one. Take a walk. Do some quick stretches. Take time for a day of relaxation when you need it.

If you are too frazzled to manage your time better, and life feels out of control, ask for help. Consider discussing your situation with a doctor or mental health professional.



Mayo Clinic Women’s HealthSource is published monthly to help women enjoy healthier, more productive lives. Revenue from subscriptions is used to support medical research at Mayo Clinic. To subscribe, please call 800-876-8633, extension 9751, or visit http://www.bookstore.mayoclinic.com.

Infants Can Tell Happy Songs from Sad

A new study shows that 5-month-old babies can distinguish an upbeat tune, such as “Ode to Joy” from Beethoven’s Ninth Symphony, from a lineup of gloomier compositions.

By age 9 months, babies can do the opposite and pick out the sorrowful sound of Beethoven’s Seventh Symphony from a pack of happy pieces.

The musical experiments offer another example of how babies make sense of the world long before they can talk, says Brigham Young University psychology professor and study author Ross Flom.

“One of the first things babies understand communicatively is emotion, so for them the melody is the message,” Flom said. “Our study showed that by nine months, babies are categorizing songs as happy or sad the same way that preschoolers and adults do.”

The results of the musical study will be published in the upcoming issue of the academic journal Infant Behavior and Development.

Given the challenge of peering inside babies’ minds, the researchers designed experiments that take advantage of what babies say with their eyes.

First they displayed an emotionally-neutral face for the baby while music played. When the baby looked away from the face, the music stopped and the researchers queued up a new song from a playlist of five happy and five sad songs. For each song, observers recorded how long the baby paid attention to the face. The babies that noticed a switch from happy to sad, or vice versa, stared at the face three to four seconds longer than usual because of their heightened interest.

This method of measuring how long it takes for babies to get bored is the same principle behind a 2007 study published in the journal Science that shows 4- and 6-month-old babies from English-only households can tell different languages are being spoken simply by watching and not hearing the person speaking.

“People of all ages reveal quite a bit through what they choose to look at and how much time they spend attending to that event,” Flom said. “The only trick is to come up with the right presentation to test an idea about how and what babies learn.”

The researchers selected songs with the greatest consensus as happy or sad based on ratings by average adults and children.

BYU music professor Susan Kenney, who was not involved with the study, noted some of the technical differences between the happy and sad songs the babies heard.

“The happy songs were all in major keys with fairly short phrases or motives that repeated,” Kenney said. “The tempo and melodic rhythms were faster than any of the sad selections, and the melodies had a general upward direction. Four of the sad songs were in minor keys and all had a slower beat and long melodic rhythms. For an infant to notice those differences is fascinating.”

Flom says this period of learning about emotion in sounds is a natural step before learning to talk.

“Infants master so many things in such a short time frame,” Flom said. “I can’t think of a better line of inquiry than how infants learn so much so quickly.”

Douglas Gentile of Iowa State University and Anne Pick of the University of Minnesota are co-authors on the study.

Managing Gas Isn't Rocket Science

Daily flatulence is normal and necessary. In fact, the average person passes gas about 14 times per day (the human body produces one to three liters daily). However, every body behaves differently and some experience more gas than others. If you are one of those unlucky few, follow these recommendations from gastroenterologist Patricia Raymond, MD on how to minimize it:


Rocket

Keep a gas diary - If gas has become more than just an occasional nuisance, try to determine if your gas is related to a particular food by noting the volume of gas within six hours of your last meal. It takes about a full six hours for portions of a meal to be released as gas, so if you have a particularly gassy sensation, it might not be that snack you just ate, but the meal you had earlier in the day. If you find that you are gassy, note all items in your last several meals to crosscheck against other meal periods where you experience gas.

Determine odor - Non-smelling flatulence results from swallowed air, which is symptomatic of chewing gum, drinking through straws, sucking on hard candies or nervousness, rather than something you've eaten. Foul-smelling flatulence is related to the breakdown of actual foods as they go through the intestinal tract. If nutrients are poorly absorbed, they 'feed' bacteria in the gut, which then produces the smelly flatulence.


Deactivate gas fast - Dr. Raymond suggests taking CharcoCaps® Homeopathic Formula products as a natural and safe way to relieve gas/flatulence. The activated charcoal/carbo vegetabilis in CharcoCaps is commonly used by people suffering from gas discomfort, pressure and bloating, since it serves to adsorb the gas, reducing both the gas and its smell.


Certain foods in moderation - Certain foods have a higher propensity to produce gas, since they are poorly absorbed by individuals, while others cause gas in just about everyone. They include beans, cabbage, onions, Brussels sprouts, cauliflower, broccoli, asparagus and corn; fruits such as pears, apples, prunes and peaches; whole grain products and oats; milk, ice cream and cheese; and carbonated drinks, fruit juices and alcohol.


Walk it off - Instead of keeping still after a meal, get moving: take a post-dinner stroll, do some chores around the house, or walk the dog. Not only is this a nice excuse for a bit of exercise, but it will keep your body moving and gas flowing.


Consult your doctor - If excessive or malodorous gas persists, see a doctor. What's making your belly bloat might not be gas, but a symptom of an underlying condition, such as irritable bowel syndrome (IBS), celiac disease, pancreatic insufficiency or lactose intolerance. A gastroenterologist can make these determinations and prescribe proper diet and/or medication.

You can also become friends with Gary Gasman the CharcoCaps spokesman on Facebook.

Hip Fracture: What Women Need to Know

Love them or hate them, a woman’s hips are a vital part of her daily life, and keeping them healthy is important. Fracturing a hip can be incredibly serious. Only one in four women with a broken hip makes a full recovery and one out of four women over 50 who suffer a hip fracture dies within one year. Furthermore, more than 352,000 people in the U.S. suffer hip fractures each year, 90 percent as a result of a fall. Despite these statistics, awareness and concern of the risks associated with hip fracture remains low, according to Donnica Moore, M.D., president of the Sapphire Women's Health Group and nationally renowned women’s health expert.

“Having healthy hips is vitally important to anyone who wants to live a healthy, active life,” says Dr. Moore. “However, there is still room for most women to educate themselves on hip fracture and how to lower their risks.”

According to a recent survey commissioned by GlaxoSmithKline Consumer Healthcare among women aged 45 to 64, 80 percent of those polled said that they do not worry about hip fracture. Also, although 92 percent noted that hip fracture could lead to the loss of the ability to walk properly or at all, many did not realize some other serious consequences associated with it.

To help women increase their knowledge of hip health and share vital information about the condition with other women that they care about, Os-Cal has created a new online resource, www.oscal.com/bumpitup. This new Web site also helps women learn more about the risks of hip fracture and how to protect their hips, and features hip fracture facts, ways to reduce risk, questions to ask the doctor, information about calcium and vitamin D and useful tools like a calcium calculator and a fracture risk calculator. Each woman who passes along hip health information to a friend will receive a downloadable $3 coupon for any Os-Cal product, and visitors to the site can also enter a sweepstakes for a chance to win a trip to Hollywood.

Role of Calcium and Vitamin D

While about three out of four women said they consider taking care of their hips an important part of their healthcare regimen, not enough are taking the proper steps to do so. For instance, while taking a calcium and vitamin D supplement like Os-Cal is one of the best ways to keep bones strong, about a third of women 45 to 64 said they do not currently take one. Of those that do take calcium supplements, only about one out of six is taking them properly, in twice daily doses.

“Adequate calcium intake is one of the best defenses against hip fracture,” says Dr. Moore. “And while many people assume they take in enough calcium, more than 75 percent of all Americans are not getting enough in their diet.”

According to the National Institutes of Health (NIH), vitamin D is also essential for efficient calcium absorption – without it, bones can become thin and brittle. And like calcium, many people do not get enough. More than 70 percent of women 51 to 70 and almost 90 percent of women over 70 are vitamin D deficient.

"Even when women try to get enough calcium and vitamin D through diet, it's still usually not enough," says Dr. Moore. "Women can make simple choices in order to take a more active role in managing their bone health, and taking a calcium supplement like Os-Cal is a great first step."

Exercise Helps Reduce Pain, Disability After Lower Back Surgery

Lumbar spine (lower back) surgery is a common treatment for a herniated or “slipped” disk, and patients need to know whether it is better to sit still or get moving during their recovery period.

An updated review from the Netherlands suggests that exercise programs starting four to six weeks after the operation could lead to more rapid pain relief and a quicker recovery from disability — without increasing the risk of additional surgery.

“Many people are operated on because of a herniated lumbar disc but there is still controversy with regard to rehabilitation,” said lead author Raymond Ostelo, Ph.D., at the VU University Medical Center in Amsterdam. “[Although] many different rehabilitation programs are available and prescribed for patients, some surgeons say that patients don’t need rehabilitation programs at all once they are discharged from the hospital.”

However, the review findings support a more active approach.

“In general, it appears that patients who participated in exercise programs recovered somewhat faster than those who received no treatment and that patients who participated in high-intensity programs reported slightly less short-term pain and disability than those in low-intensity programs,” Ostelo said.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The updated review included 14 randomized controlled trials involving 1,927 participants.

There was a great deal of variation in the programs available following surgery, ranging from only stretching and strength training at home to 90 minutes of intensive aerobic, strength and stretching exercises three times a week.

The amount of support that patients received also varied widely: from a single two-hour training session to multiple visits with a team that included physiatrists, physical and massage therapists, and social workers. Because of the large differences in treatments, the authors were unable give guidance on which kind of exercise program works better.

None of the studies reported an increase in the number of patients who required additional surgery. There were also no indications that patients should restrict their activity after surgery.

“Given the ongoing controversy regarding the type — if any — and timing of rehabilitation programs, this review highlights that it seems to be a good idea to follow an exercise program and return to daily activities as soon as possible,” Ostelo said.

“It is hard to make sweeping generalizations about all the different types of back surgeries that are done,” said Joel Press, M.D., an associate professor of physical medicine and rehabilitation at Northwestern University’s Feinberg School of Medicine in Chicago. “These results show that there was no evidence suggesting that exercise programs were increasing the rates of re-operation. Sitting too long often will hurt the patient more than getting up and moving.”

Why Women's Feet Hurt More in Autumn

Fall is not a fun time of year for women like Elaine Powers.

In the summer months, "like everybody else, I like to wear flip-flop sandals, open-toed shoes, a nice pedicure with good nail polish," she says.

But as autumn arrives, the 49-year-old South Carolina hospice nurse is making the annual changeover to closed-in shoe styles more appropriate to the cooler weather. It's a transition many women are making in their wardrobes. But it's more painful for women like Powers, and not because she's a slave to foot fashion. Powers has bunions.

"Even after you take your shoes off, or put your feet up, it's just a throbbing… It's almost like every time your heart beats, that bunion throbs," she says.

Women with bunions are a common sight in the waiting rooms of many foot and ankle surgeons during this time of year, according to the 6,000-member American College of Foot and Ankle Surgeons (ACFAS).

St. Louis foot and ankle surgeon Karl Collins, DPM, FACFAS, gives two additional reasons for this annual trend. One is financial. Women are closer to meeting insurance deductibles near the end of the year.

"The other thing is, people are very active in the summer," Collins says. "They're always outdoors, they're always at the pool or whatever, so they will decide to get their bunion fixed in the winter, because in their mind, they're not missing anything fun."

Powers has suffered with bunion pain for nearly 25 years. However, many women never experience pain from their bunions, even when the deformity looks severe. Shoes do not cause bunions, but they may cause bunion pain. That's why foot and ankle surgeons recommend shoe modifications to new patients. Avoiding high heeled shoes and styles that crowd the toes together can help. Collins says proper shoe selection and adjustment can go a long way.

"If they have a shoe that fits well everywhere else, but there's just a little bit of irritation at just that one spot, we may recommend that they have the shoe modified (by a shoe repair shop)," he says.

South Carolina foot and ankle surgeon Michelle L. Butterworth, DPM, FACFAS, treats a lot of teachers with back to school bunion pain. She says many women don’t understand what doctors mean about shoe width: It's the front of the shoe that needs to be wide.

"Anything that's real pointy is going to put more pressure on that (bunion) bump," she explains.

In addition to recommending shoe changes, foot and ankle surgeons may also prescribe foam- or gel-filled padding, orthotics, anti-inflammatory medications, and injections for bursitis, nerve irritation and joint irritation. While these techniques address pain, they do not stop the bunion from getting worse. Only surgery can correct the deformity.

Bunion surgery boasts a high success rate. But surgeons agree that patients need to understand what their procedure and recovery will involve.

"Probably the biggest thing is, they think surgery's not going to work and (the bunion is) going to come back," says Butterworth. "It's probably the biggest myth I dispel."

Powers is one of her patients.

"That's one of the reasons why I haven't had this surgery before now," Powers says. "A lot of people tell me once you have (bunions), you are always prone to have them, they'll come back."

Following the surgeon's instructions for recovery can significantly reduce the chances of a bunion returning.

"If wearing four-inch heels and working on your feet all day wasn't good for you before the surgery, it's certainly not going to be good for you after the surgery," notes Michael Loshigian, DPM, FACFAS, a New York City foot and ankle surgeon.

Powers hasn't made up her mind about bunion surgery. She's already tried prescription pain medication, and struggles to find comfortable shoes. This fall, Butterworth will perform bunion surgery on Powers' 19-year-old daughter, who inherited her mother's feet. Powers wants to see how that turns out. She also has to worry about finding someone to cover her 12-hour work shifts for several weeks.

But if she does choose surgery, she already knows how she'll celebrate after her recovery.

"I'm buying a pair of stiletto heels and I'm wearing them everywhere I go," she jokes.

The ACFAS provides a list of answers to frequently asked questions about bunion surgery on http://FootPhysicians.com.