Mammography Debate - When to Start Screening

At what age is it recommended for a woman to start routine mammograms:

A. 40 years old

B. 50 years old

C. Neither A or B

D. Both A and B.

Until last year, there was a uniform recommendation in the United States for women to start routine mammography for breast cancer screening at the age of 40 and then repeat every 1-2 years. However recently the US Preventive services Task Force (USPSTF) has issued new recommendations to start routine mammography screening at age 50, to repeat mammograms every 2 years between ages 50 - 74, and to end screening at age 74.

This recommendation is controversial. As a result there has been some confusion for both patients and physicians as to when a woman should consider getting her mammograms.

The USPSTF made their recommendation based on a review of published evidence of the efficacy of screening in lowering breast cancer mortality rates. These studies were identified through Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, MEDLINE January 2001 to December 2008. The reviewers found that film mammography is associated with reduced breast cancer mortality rates, especially in women 50 to 74 years old. Women aged 60 - 69 may have the greatest benefit. For women aged 40 to 49 years there was a 15% decrease in mortality.

However a new study from Sweden reports that mammography screening in women aged 40-49 years old showed a much greater reduction in mortality from breast cancer than has been previously reported. This data showed a 29% reduction in breast cancer mortality in this age group when screening was done. In this large study, more than 1 million women were involved, and they were monitored for 16 years. This study was done because of differences in counties in Sweden. Initially in 1986 Sweden targeted women aged 50 - 69 years but left it up to individual counties to determine if women 40 - 49 years old should be screened. About half of the counties invited women aged 40 - 49 years old to undergo screening and half did not. During the follow up period between 1986 - 2005, there were 619 deaths from breast cancer in women ho had been invited for screening, and 1205 deaths in women who had not undergone screening.

Currently in the U.S., most organizations recommend yearly mammograms beginning at age 40, including the American Cancer Society, the National Comprehensive Cancer Network, the American Medical Association, and the American College of Obstetricians and Gynecologists. It is only the USSPTF that does not recommend regular mammography in the 40 - 49 year age group.

For women between 40 - 49, it is best to speak with your physician. The decision may need to be made on an individualized basis. If a woman is considered to be at higher risk for breast cancer then an earlier mammography screening should be considered.

Answer - D.

Other related topics:

Who should be tested for breast cancer gene.

Top ten recommendations for reducing risk of cancer.

Bedbugs Among Us

Bedbugs are small insects (family Cimicidae) which are found around the world. Recently they have become particularly fond of New York.

Where do they hide?

These bugs can infest any location where people reside such as apartment buildings, offices, and public transportation systems. These reddish brown bugs which are similar in size to a dog tick can hide in multiple areas such as in cracks in walls or in electrical outlets, in crevices of mattresses, cushions and curtains, or in bottom of desk drawers and other pieces of furniture. The females may lay eggs daily in these same areas. It's hard to see the bugs unless one is looking for them. Often the first clue to their infestation appears on the skin as bite marks.

What do the bites look like?

The bites can be difficult to distinguish from other insect bites. They are usually a series of red, round, swollen, itchy, painless spots which are in a linear distribution (breakfast, lunch, and dinner) which may occur 1 - 2 days after being bitten. The reactions vary in severity depending on the sensitivity of the individual. The bugs find an exposed surface of skin such as on the arms, legs, neck or face, and then they proceed to inject an anesthetic and an anticoagulant through one tube while they suck up the blood through the other tube. Feeding time takes 5 - 10 minutes to be completed so it usually occurs while one is still for a period of time such as while sitting or sleeping. The satiated bugs then return to their hiding place.

How can the bites be treated?

It can take 3 - 6 weeks for the bites to heal. If the infestation is not cleared new bites may accumulate as the old ones heal. Steroid creams or lotions that contain pramoxine (such as Sarna, Aveeno Anti-itch, Neutrogena Skin-Aid) can help reduce the itching. Antihistamines (such as Zyrtec, Claritin/loratidine, Benadryl/diphenhydamine) may help reduce the severity of the reaction and also reduce itching. It is important to avoid scratching the area as this may lead to infection. If there are signs of infection such as pus-like drainage, pain or increased redness then a doctor should be consulted.

Do bedbugs carry any diseases?

This topic is currently under research. Hepatits B virus has been found in the droppings of bedbugs, but a higher incidence of the disease has not been associated with a bedbug infestation in the areas studied so far. In South and Central America, the bugs have transmitted the parasite Trypanosoma cruzi which causes Chaga's disease. There has also been some speculation about an association with these bugs and asthma in some countries. In general however bedbugs are not known for transmitting any widespread disease.

How to manage an infestation?

It is important to identify and eliminate the infestation. For effective eradication, it is recommended that a licensed pest control service be contacted to inspect and treat the area. There is no need to dispose of furniture once treatment has occurred. Clothing and linens can be adequately treated by washing and drying them in the hottest setting that the fabric can withstand.

If you would like to see these critters in action, here are some videos for you.

National Geographic Video on Bedbugs.

BedBugs! Attack!

Jon Stewart's piece on bedbugs.

For more details, see this bedbug fact sheet.

Who Needs the Flu Vaccine?

Based on global surveillance of influenza strains, all 3 strains in the 2008 to 2009 influenza vaccines are different from the 2007 to 2008 vaccine strains. Let's hope that we haven't missed any significant ones this year.

In general anyone who would like to avoid the flu syndrome should get the flu shot. Certain groups of people are especially recommended to receive the vaccine yearly according the Advisory Committee on Immunization Practices (ACIP).

• Children aged 6 months to 18 years.
• Household contacts and out of home caregivers of children less than 6 months old.
• Pregnant women.
• People who are 50 years or older.
• People of any age who have other underlying medical conditions such as asthma, diabetes, or malignancies.
• Nursing home residents and anyone who cares for them.
• Health care workers.

People who should not get the vaccine are the following:

• Anyone who is severely allergic to eggs.
• Anyone who has had an allergic reaction to a previous flu shot.
• Anyone who has had a recent febrile illness (should wait until the fever resolves before getting the vaccine.
• Anyone with a history of Guillan Barre within 6 weeks of having received the flu shot.
• Children less than 6 months old.

Biggest misconceptions about the flu shot is that it can give you the flu. The vaccine in the form of the shot does not give you the flu. Rarely, it can give you mild aches and possibly a low grade fever for 1-2 days. The nasal spray form of the flu vaccine, however, can give you a mild case of the flu. There are no supplements such as vitamin C or D which have been shown to prevent the flu. Other than the flu vaccine, the most effective means of prevention and spread of the flu is washing your hands and staying home when you are sick.

So what did you learn? Which of the following statements is correct?

A. Flu shot is not necessary if you take plenty of vitamin D supplement

B. The flu shot can give you mild flu-like symptoms

C. The flu shot is recommended for all children 6 months and older.

D. Pregnant women should avoid the flu shot.

E. If you miss the shot and get the flu, you should still show up at your job and work your buns off.

The correct answer is C.

Blood Pressure Control - People or Technology for Better Outcome?

Countries may vary widely in their capacity for management of hypertension, but in all cases the majority of hypertensive patients are inadequately controlled to a blood pressure (BP) goal of less than 140/90 mmHg.

In the U.S. only 35 percent of hypertensives are treated to goal. Although this is an improvement from a previous rate of 23% 10 years ago, it is still suboptimal. The goal for the Healthy People 2010 objective is 50%. Other countries are not doing much better. Europe has slightly higher rates of control but they also have a higher prevalence of high blood pressure (especially the Germans when compared to five other European Countries). China by last report had 8%, Taiwan 5%, and South Africa 14% of their hypertensives under optimal control. (uptodate)

The reasons for this level of poor control are multifactorial. There certainly is no shortage of pharmacological treatments nor is there a lack of published guidelines. However, the distribution of data alone does not lead to different outcomes. Hypertension is a chronic disease that does not have symptoms. It often requires significant lifestyle changes in addition to medications. Lifestyle changes are difficult to make and they are not a priority for many people. When lifestyle changes are made, then there may be non-compliance to medications. The physicians may not be aggressive enough or simply may not have enough time in their busy offices to advise or motivate patients regularly.

The burden of high blood pressure worldwide is high. "In 2004 the death rates per 100,000 population in U.S. from high blood pressure were 15.7 for white males, 51.0 for black males, 14.5 for white females and 40.9 for black females. From 1994 to 2004 the death rate from high blood pressure increased 26.6 percent, and the actual number of deaths rose 56.1 percent" according to the American Heart Association. It is estimated that the prevalence will increase with an aging population in the west and the adaptation of lifestyle choices such as fast food and increasing obesity in the developing countries.

Different strategies for improved management of hypertension are being evaluated. It is not surprising that a multidisciplinary intervention is most effective. In a recent study presented in JAMA , 778 participants with uncontrolled high blood were randomly assigned to three groups - usual care in clinic, home BP monitoring (with Omron Hem-705-CP bp cuff) and secure patient Web site training, or home BP monitoring, Web site training, and pharmacist care management through Web communications. These groups were studied from June 2005 to December 2007.

The patients in the latter 2 groups received training on how to use the web site (secure e-mail, refilling medications, viewing portions of their health records, use of the health library, and links to resources for lifestyle changes). The pharmacist group received a secure welcome message from the pharmacist which was also communicated to the patient's physician. The pharmacist had a telephone visit ( 1 hour) with the patient to review medications and risk factors. An action plan template designed for Web communication was then given to the patient. All feedback on the action plan was then done over the Web every 2 weeks. The pharmacist with the assistance of the physician would make specific recommendations.

Based on patient results, the data showed that compared to the usual clinic care group, the home BP monitoring plus the Web based service only group did not show a significant improvement in blood pressure control. However, the group with the Web-based pharmacist had a significant improvement over the other 2 groups with 25% more patients with optimal control. So neither people or technology but rather the intervention of both seemed to work best for this group of patients. It will be interesting to use this model in other chronic illnesses to assess the effectiveness of the model.

Finally it is important for the physicians to note that " the most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with and trust in the clinician. Empathy builds trust and is a potent motivator."

References: please see above links.

What did you learn?

1. What percentage of patients with high blood pressure who are under medical care in the U.S. are treated to a goal bp of less than 140/90 mmHg?

a. 23%
b. 35%
c. 50%
d. 8%

2. Web based services have been shown to be most effective for treatment of blood pressure when used in which of the following strategies?

a. Web services alone
b. Web services + home bp monitoring + ancillary health care provider
c. Web services + home blood pressure monitoring

Correct answers:
1. B
2. B.

Brain Stimulation Better Than Best Medical Therapy For Parkinson's

Preliminary data from ongoing trials suggest that deep brain stimulation (DBS) may be superior to the best medical therapy (BMT) for Parkinson's. In one trial of more than 300 patients, ages 22 and older, who were randomized to DBS vs BMT, the data showed that motor functioning at 6 months improved by 35% with deep brain stimulation as opposed to 5% with best medical therapy. However adverse effects were more common in the DBS group - 40% in comparison to 11% in BMT patients.

The best medical therapy arm of the trial was discontinued since there was enough data to evaluate the primary outcome. The deep brain stimulation patients were then randomized to 2 groups to compare bilateral stimulation of the subthalamic nucleus (STN) and globus pallidus interna (GPI) which comprise part of the basal ganglia - the part of the brain which is integral in the control of movement, motivation and addiction. Stimulation of these specific areas may cause different outcomes in mood, cognition, and movement. More specific targeting of these areas eventually may help decrease the adverse effects. The results of this part of the trial will not be available until 2009.

Treatments for Snoring

Treatment of snoring does not include which of the following

a. weight reduction
b. avoidance of alcohol at night
c. injection of botulin toxin into soft palate ( the back of the roof of the mouth)
d. placement of implants into the soft palate palate
e. peppermint oil inhalation

Snoring is a common condition. In the Wisconsin Sleep Cohort Study, habitual snoring was present in 44 percent of males and 28 percent of females between 30 and 60 years of age. Snoring may be associated with obstructive sleep apnea or it may be primary and not associated with any underlying conditions. It is caused by partial airway collapse with vibration of the upper airway. Most vibration of the soft tissues occurs at the level of the soft palate.

There are several treatments for primary snoring which are mainly for the benefit of the snorer's partner. Some of these treatments include the following.

1. Weight Loss - Obesity is thought to contribute to snoring by reducing the airway dimension.

2. Alcohol and Tobacco Avoidance - Alcohol worsens the condition by decreasing the tone in the pharyngeal muscles. The same is true of sleeping pills. Alcohol should be avoided for several hours before sleep. it is not clear how smoking contributes to sleep-disordered breathing - nightly nicotine withdrawal or increased nasal congestion may contribute.

3. Positional Therapy - Some individuals snore more when they are lying flat on their back.
Turning to a lateral position has been shown to decrease snoring in these snorers. A foam wedge can be used to maintain the position.

4. Medication - Nasal steroids can be used to decrease congestion. Protriptyline has been used but it may have side effects such as impotence.

5. Reducing Nasal Resistance - Mechanical devices may be used to dilate the anterior nasal valve. One that works well is a stiff adhesive strip that is applied externally across the nasal alae where it serves to retract and stabilize them.

6. Surgical Procedures - The newest technique which has been recently approved by the FDA is the placement of polyethylene terephthalate (PET) implants into the center of the soft palate to stiffen the area and to reduce fluttering. This procedure is less invasive and less painful than the traditional surgeries which include uvulopalatopharyngoplasty (shortening of the uvula and removing part of the soft palate) by scalpel or laser and radiofrequency treatment (which induces scar formation of the palate).

The correct answer is e.

Vitamin D in the Spotlight

Vitamin D supplementation (finish the sentence correctly)

a. is usually not necessary as it is found in most foods
b. causes rickets, a bone disease
c. may protect against cancer
d. all of the above
e. none of the above.



The correct answer is C. Vitamin D has has received much attention recently. Several studies have reported an array of health benefits associated with vitamin D in children and in adults, possibly protecting against cardiovascular disease, certain cancers, and immune system disorders such as rheumatoid arthritis. These data have generated debate over the daily amount of vitamin D that should be recommended.

The current recommendation is 200 to 600 international units (IU) daily, depending on age. New data has emerged to question this guideline. There are very few food sources of vitamin D, namely fatty fish and eggs. Most of our vitamin D is synthesized in our skin through a process that requires sunlight. However, due to more sedentary lifestyles such as long working hours, web surfing, and playing video games, and heeding advice to avoid the sun to prevent skin cancer the level of vitamin D may be lower than our body requires. Some even suggest a worldwide pandemic of vitamin D deficiency.

It is well established that vitamin D deficiency causes rickets, a bone disease which usually affects children, in which the bones become very soft. See Dr. Janesta Noland's post on this blog regarding new vitamin D recommendations for children.

Additional benefits have been suggested for adults. In one study, vitamin D supplementation of 800 IU daily was associated with a decreased risk of colon cancer. This was shown to occur as a result of the expression of Bax - a protein that promotes the killing of damaged cells. In three meta-analysis observational studies, a serum 25-hydroxyvitamin D level of 30 ng/ml (75 nmol/L) or higher was associated with at least a 50% lower risk of breast cancer. As a result it has been suggested that women should be checked annually for vitamin D level to better identify their risk of breast cancer. A study funded by the National Institute of Health showed that women who took 1100 IU per day of vitamin D for 4 years reduced their risk of breast cancer by 60 percent.

Bottom line is that although it is not yet an official recommendation, based on recent studies, there may be a benefit to taking between 1000-2000 IU per day of vitamin D.

References: see above links. Am. J. Clinical Nutrition, 2007; 85:1586-91

New Vitamin D Recommendation for Children

Dr. Janesta Noland, our guest pediatrician blogger, has provided a summary of the new recommendation for vitamin D supplementation in children.

New data reveal many ways in which vitamin D is important in overall health and prevention of disease requiring higher levels than those which cause clinically evident rickets. Additionally, data show that the previously recommended 200 IU daily will not maintain levels above 11ng/ml in a significant proportion of children. As a result of these findings on dose and medical importance of vitamin D, the American Academy of Pediatrics (AAP) is changing its recommendation to a higher dose of 400 IU daily in all infants, children and adolescents not taking 1000mL (33oz.) daily of fortified formula or milk.

For lots (and I mean lots) more detail on vitamin D read on....

The American Academy of Pediatrics has recommended since 2003 that all breastfeeding infants be supplemented with 200 IU of vitamin D daily1. Vitamin D is essential in calcium absorption in the gut and in bone metabolism including growth and remodeling. Vitamin D production occurs in the skin after exposure to UVB radiation and is affected by latitude, air pollution, time in the sun, season, cloud cover, body mass and amount of body exposure. Dietary sources of vitamin D are not generally significant: the only foods that contain meaningful amounts are fatty fish, fish oils, liver, fat from marine mammals and eggs from chicken fed vitamin D.

For current typical lifestyles, and given recommendations by the AAP and American Cancer Society to avoid sun exposure because of the risk of skin cancer, children may not have adequate levels of vitamin D. Profound deficiency of vitamin D can cause rickets and continues to be reported in the US despite the current recommendations. The peak incidence is between 3 and 18 months of age. The risk is higher in infants who are exclusively breastfed and infants with darker skin pigmentation.2,3,4,5,6,7

Long before vitamin D deficiency rickets is evident, insufficiency may occur and may appear as growth failure, lethargy, irritability, and hypocalcemic seizures8,9,10. New evidence in adults suggests that vitamin D also plays a role in preventing autoimmune disease such as rheumatoid arthritis11 and multiple sclerosis12, some forms of cancer13,14,15,16,17,18,19,20,21 (breast, ovary, prostate and colorectal) and may diminish the incidence of Type 2 diabetes22,23,24. Some evidence in children suggests vitamin D supplements in infancy may decrease type 1 diabetes25,26,27.

Vitamin D must by hydroxylated in the body to be active. Serum levels of 25[OH]vitamin D are the best indicator of vitamin D status. The level of vitamin D in the blood that constitutes deficiency has only recently been defined for adults (12-15 ng/ml and insufficiency at <20>

Given the now better-understood risks of vitamin D insufficiency in children that precedes the development of clinically evident rickets, supplementation with vitamin D is important. 400 IU daily is known to be safe, and both prevent and treat rickets. An AAP clinical report is in press32 which will establish this new recommended dose which should be initiated as soon as breastfeeding is well established.

All infant formula in the US is fortified to 400 IU per liter (about 33 ounces). Exclusively formula-fed infants who take this amount of formula do not need supplementation. However, infants who are breastfed or who are taking both formula and breast milk require supplementation.

Vitamin D can be taken in two forms: ergocalciferol (D2 – plant-based) or cholecalciferol (D3 – fish-based). D3 has greater efficacy in raising serum levels33 and thus is the recommended and most commonly used form. It is available both in multivitamin form and alone in liquid or drops. (Because of the potential for overdose with the concentrated drop form, liquid is recommended.)

The vitamin D status of pregnant and lactating mothers greatly impacts vitamin D levels in their infants. Fetal vitamin D levels appear to have both short and long-term consequences – one study showed an increase in birth weight when mothers have levels above 20 ng/ml34, and another showed increased bone density in 9 year old children whose mothers were supplemented during pregnancy35. No consensus exists on the dose of vitamin D supplementation in these women, despite the fact that studies show that on average pregnant women are deficient without supplementation (13 ng/ml in one study and <10>

The Canadian Paediatric Society recommends 2000 IU daily for pregnant and breastfeeding women31. Two pilot studies of high-dose vitamin D supplementation in lactating mothers (6400 IU) showed serum levels in their infants equivalent to levels in infants taking 300-400 IU supplements41,42. Safety of the long-term use of such high levels of supplementation in women has not been studied, however, and cannot be recommended. Since vitamin D deficiency is not limited to infancy but persists throughout the lifespan, particularly during phases of rapid growth, supplementation is important in children and adolescents as well. Consumption of 32oz/day of vitamin D fortified milk would provide the required 400 IU, but dietary practices make that difficult to achieve. Thus a multivitamin with 400 IU of vitamin D is appropriate.

Excellent links:

http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/908(This is the old policy – new is in press)

http://www.nih.gov/news/pr/aug2007/od-17.htmhttp://ods.od.nih.gov/factsheets/vitamind.asp

Bibliography
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2. Thacher T, Fischer P, Strand M, Pettifor J. Nutritional rickets around the world: causes and future directions. Ann Tropical Paediatrics 2006;26(1):1-16.
3. Pettifor J. Nutritional rickets: deficiency of vitamin D, calcium, or both? Am J Clin Nutr 2004;80(suppl):1725S-1729S
4. Kreiter SR, Schwartz RP, Kirkman HN, Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breast-fed infants. J Pediatr 2000;137:153-157
5. Weisberg P, Scanlon K, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr 2004;80(suppl):1697S-1705S.
6. Pettifor J. Rickets and vitamin D deficiency in children and adolescents. Endocrin Metabol Clin NA 2005;34(3):537-553.
7. Ward L. Vitamin D deficiency in the 21st century: a persistent problem among Canadian infants and mothers. CMAJ 2005;172(6):769-770.
8. Hatun S, Ozkan B, Orbak Z, Doneray H, Cizmecioglu F, Toprak D, et al. Vitamin D Deficiency in Early Infancy. J. Nutr. 2005;135(2):279-282.
9. Stearns G, Jeans P. The effect of vitamin D on linear growth in infancy. J Pediatr 1936;9:1-10. 10. Pawley N, Bishop N. Prenatal and infant predictors of bone health: the influence of vitamin D. Am J Clin Nutr 2004;80(suppl):1748S-1751S.
11. Merlino LA, Curtis J, Mikuls TR, Cerhan JR, Criswell LA, Saag KG. Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women's Health Study. Arthritis Rheum 2004;50(1):72-7.
12. Munger KL. , Levin, LI,Hollis BW , Howard, NS , Ascherio A (2006). "Serum 25-hydroxyvitamin D levels and risk of multiple sclerosis.". Journal of the American Medical Association 296 (23): 2832–2838.
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15. "Vitamin D 'can lower cancer risk'", BBC News 28 December 2005
16. Beer T, Myrthue A (2006). "Calcitriol in the treatment of prostate cancer". Anticancer Res 26 (4A): 2647–51.
17. Martin Mittelstaedt (28 April 2007). "Vitamin D casts cancer prevention in new light", Global and Mail.
18. Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. (2007). "Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial.". Am J Clin Nutr. 85 (6): 1586–91.
19. Skinner HG, Michaud DS, Giovannucci E, Willett WC, Colditz GA, Fuchs CS (2006). "Vitamin D intake and the risk for pancreatic cancer in two cohort studies". Cancer Epidemiol. Biomarkers Prev. 15 (9): 1688–95
20. Tuohimaa P, Pukkala E, Scélo G, et al (2007). "Does solar exposure, as indicated by the non-melanoma skin cancers, protect from solid cancers: vitamin D as a possible explanation". Eur. J. Cancer 43 (11): 1701–12.
21. Freedman DM, Looker AC, Chang SC, Graubard BI (2007). "Prospective study of serum vitamin D and cancer mortality in the United States". J. Natl. Cancer Inst. 99 (21): 1594–602.
22. Chiu K, Chu A, Go V, Soad M. Hypovitaminosis D is associated with insulin resistance and beta cell dysfunction. Amer J Clin Nutr 2004;79:820-825.
23. Pittas AG, Dawson-Hughes B, Li T, Van Dam RM, Willett WC, Manson JE, et al. Vitamin D and calcium intake in relation to type 2 diabetes in women. Diabetes Care 2006;29(3):650-6.
24. Ford ES, Ajani UA, McGuire LC, Liu S. Concentrations of serum vitamin D and the metabolic syndrome among U.S. adults. Diabetes Care 2005;28(5):1228-30.
25. The EURODIAB Substudy 2 Study Group. Vitamin D supplement in early childhood and risk for Type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1999;42:51-54.
26. Hypponen E, Laara E, Reunanen A, Jarvelin MR, Virtanen SM. Intake of vitamin D and risk of type 1 diabetes: A birth-cohort study. Lancet 2001;358:1500-03.
27. Harris SS. Vitamin D in type 1 diabetes prevention. J Nutr 2005;135(2):323-5.
28. Greer FR, Marshall S. Bone mineral content, serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements. J Pediatrics 1989;114:204-212.
29. Gessner BD, Plotnik J, Muth PT. 25-hydroxyvitamin D levels among healthy children in Alaska. J Pediatr 2003;143(4):434-7.
30. Ziegler E, Hollis BW, Nelson S, Jeter J. Vitamin D deficiency in breastfed infants in Iowa. Pediatrics. 2006 Aug;118(2):603-10.
31. Canadian mothers and babies don't get enough vitamin D 2007 Canadian Paediatric Society Recommendation
32. Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children and adolescents. In Press.
33. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89(11):5387-5391.
34. Mannion C, Gray-Donald K, Koski K. Milk restriction and low maternal vitamin D intake during pregnancy are associated with decreased birth weight. CMAJ 2006 Apr 25;174(9):1273-7.
35. Wagner C, Hulsey T, Fanning D, Ebeling M, Hollis B. High dose vitamin D3 Supplementation in a cohort of breastfeeding mothers and their infants: A six-month follow-up pilot study. Breastfeeding Medicine 2006;2(59-70).
36. Cockburn F, Belton NR, Purvis RJ, Giles MM, Brown JK, Turner TL, et al. Maternal vitamin D intake and mineral metabolism in mothers and their newborn infants. Brit Med J 1980;5:11-14.
37. van der Meer I, Karamali N, Boeke A. High prevalence of vitamin D deficiency in pregnant non-Western women the The Hague, Netherlands. Am J Clin Nutr 2006;84:350-353.
38. Delvin EE, Salle L, Glorieux FH, Adeleine P, David LS. Vitamin D supplementation during pregnancy: Effect on neonatal calcium homeostasis. J Pediatr 1986;109:328-334.
39. Vieth R, Chan PCR, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level (LOAEL). Amer J Clin Nutr 2001;73(2):288-294.
40. Brooke OG, Brown IRF, Bone CDM, Carter ND, Cleeve HJW, Maxwell JD, et al. Vitamin D supplements in pregnant Asian women: Effects on calcium status and fetal growth. Brit Med J 1980;1:751-754.
41. Wagner C, Hulsey T, Fanning D, Ebeling M, Hollis B. High dose vitamin D3 Supplementation in a cohort of breastfeeding mothers and their infants: A six-month follow-up pilot study. Breastfeeding Medicine 2006;2(59-70).
42. Hollis BW, Wagner CL. Vitamin D requirements during lactation: High-dose maternal supplementation as therapy to prevent hypovitaminosis D in both mother and nursing infant. Amer J Clin Nutr 2004;80S:1752S-1758S.

Chronic Fatigue Syndrome

According to the CDC, chronic fatigue syndrome (CFS) is defined by the presence of:
unexplained, persistent fatigue that is of new onset; is not the result of ongoing exertion; is not alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities AND

a. impairment in short term memory or concentration
b. sore throat or tender lymph nodes in the neck or under the arms
c. muscle pain or multijoint pain without redness or swelling
d. headache of a new pattern or severity
e. 2 of the above
f. 4 of the above

Correct answer is F - chronic fatigue syndrome is diagnosed by persistent fatigue and the presence of four or more of the above symptoms that persist during six or more consecutive months and that have not been present prior to the onset of the CFS. Other symptoms which are also included in making the diagnosis are unrefreshing sleep, low grade fever or post-exertional malaise lasting more than 24 hours.

Patients who have chronic fatigue but who do not have these criteria are defined as having idiopathic chronic fatigue. Less than 10 percent of patients who complain of fatigue meet the criteria for CFS. It is twice as more likely to occur in women.


CFS is a difficult diagnosis to make due to the lack of physical or laboratory findings. The history is the most important part of the evaluation. Simple blood tests for blood count, thyroid, sugar, kidney and liver function and HIV and tuberculosis may be done to rule out other causes, but in general more extensive testing for conditions such as Lyme disease or EBV (Epstein Bar Virus) is not recommended.

The cause remains unclear. From the 1930's to the 1950's, the cause was assumed to be due to chronic brucellosis infection, and from 1950's to 1970's it was hypoglycemia. More recently research has focused on chronic Epstein Barr virus (EBV) infection, Lyme disease, allergies, candidiasis, and immune system disorders. However, scientific data does not support any of these hypotheses. Another controversial factor is the role of depression in this condition. Three studies verified that two-thirds or more of patients with CFS meet criteria for anxiety disorders or depression. However, it is debated if this is a primary cause or a secondary symptom as a result of chronic fatigue.

Several treatment strategies including multiple medications have been tried, but the only regimens which have been shown to have a positive impact are cognitive behavior therapy (CBT) and graded exercise therapy. The behavior therapy consists of a series of one hour sessions designed to modify behavior that may delay recovery. Support groups were not as beneficial as individual sessions. Ideally this is done in combination with exercise therapy. Although exercise can initially worsen the symptoms, it is not advised to increase rest. Patients are encouraged to gradually push themselves by doing cardiopulmonary exercises such as walking on a treadmill. Finally another important factor in long term treatment management is the rapport that exists between the physician and patient.

Patient resources: Center for Disease Control, National CFS and Fibromyalgia Association, Up To Date Patient Information.

References:
The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group.
Psychiatric diagnoses in patients who have chronic fatigue syndrome.
Interventions for the treatment and management of chronic fatigue syndrome: a systematic review.
Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial.

New Blood Pressure Guidelines

Normal blood pressure reading in an adult is

a. systolic less than 110 / diastolic less than 80 millimeters of mercury (mmHg)
b. systolic less than 120 / diastolic less than 80 mmHg
c. systolic 120-139 or diastolic 80-89 mmHg
d. systolic 140-159 or diastolic 90-99 mmHg


The correct answer is b. The seventh report of the Joint National Committee(JNC 7) proposed a new range for normal blood pressure (less than 120/80) and a new category of prehypertension. This recommendation was based on several studies, completed since the 6th JNC report in 1997, which showed a strong correlation between increasing blood pressure and an increase in heart attacks, cardiovascular disease, stroke, and kidney disease.

An analysis of data from the Framingham Heart Study demonstrated that relative to blood pressure less than 120/80 mmHg, prehypertension (120 to 129/80 to 84 mmHg) was associated with an increased risk of heart attacks (relative risk 3.5) and coronary artery disease (relative risk 1.7), but not stroke. In the Women's Health Initiative study involving over 60,785 postmenopausal women who were followed for 7.7 years, women with prehypertension, compared to normotensive individuals, had an increased risk of cardiovascular death, myocardial infarction and stroke. The risk of cardiovascular disease beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg.

Data from the 1999 and 2000 National Health and Nutrition Examination Survey (NHANES III) suggested that the prevalence of prehypertension among adults in the United States was approximately 30 percent. The prevalence was markedly higher among men than women (39 and 23 percent, respectively). Lifestyle modifications and a closer monitoring is recommended for these patients. Medications may be necessary if other risk factors are present. According to JNC7, a blood pressure of systolic 140-159 mmHg or diastolic 90-99 is classified as stage I hypertension, and a medication should be started for these patients. Stage II hypertension is categorized as systolic more than 160 mmHg or diastolic more 100 mmHg. These patients will usually require two medications for control of the blood pressure in addition to making the lifestyle modifications.

For more information on lifestyle modifications and medication management see JNC 7 report.
Note that the European Recommendations have chosen to continue the same guidelines as the JNC 6 report.

Is Your Sugar Level Normal

A normal fasting glucose (sugar) level is above 69 mg/dl (milligram per deciliter) or 3.9 mmol/L (millimoles/liter)and less than

a. 140 mg/dl (7.8mmol/L)
b. 125 mg/dl (7.0 mmol/L)
c. 110 mg/dl (6.1 mmol/L)
d. 100 mg/dl (5.6 mmol/L)


The correct answer is d. A normal fasting glucose level is between 70 - 100 mg/dl (3.9-5.6 mmol/l) . This level was established by the American Diabetes Association (ADA) in 2003. Previously a cut off point of 110 mg/dl was considered to be normal. Those of you who have had glucose levels in that range and were told that your level was normal should consider getting an updated glucose check.

Levels between 100-125 mg/dl (5.6-7.0 mmol/l) are termed as "impaired fasting glucose". These patients may have a three fold increase in risk of diabetes. Lifestyle changes such as weight loss, physical activity and a low sugar diet are recommended to improve these numbers.

Diabetes is defined as glucose level above 125 mg/dl (7.0 mmol/l). The level was reduced from 140 to 125 in 1997. The ADA recommends testing for glucose in all adults with BMI ≥25 kg/m2 and one or more additional risk factors for diabetes. There are several risk factors for diabetes. These include age of 45 years or older, body mass index of 25 kg/m2 or higher, family history of diabetes, physical inactivity, ethnicity of African-American, Hispanic, Native American, Asian-American, and Pacific Islanders, delivering a 9 lb or larger baby, high blood pressure (>140/90), abnormal cholesterol level (HDL <35,>250), and polycystic ovary syndrome. In individuals without risk factors, testing should begin at age 45 years.

Video tutorial on diabetes: Dr. Jerold Olefsky.

What are mg/dl and mmol/l? How to convert? Glucose? Cholesterol?

There are two main methods of describing concentrations: by weight, and
by molecular count. Weights are in grams, molecular counts in moles. (If you
really want to know, a mole is 6.023*10^23 molecules.) In both cases, the
unit is usually modified by milli- or micro- or other prefix, and is always
"per" some volume, often a liter.

This means that the conversion factor depends on the molecular weight of the
substance in question.
mmol/l is millimoles/liter, and is the world standard unit for measuring
glucose in blood. Specifically, it is the designated SI (Systeme
International) unit. "World standard", of course, means that mmol/L is used
everywhere in the world except in the US.

mg/dl (milligrams/deciliter) is the traditional unit for measuring bG (blood
glucose). Most discussions take place using mg/dl, and no one really
expects you to pull out your calculator to compose your article. However, if
you don't quote both units, it's inevitable that many readers will have to
pull out their calculators to read it. ( I learned this the hard way).

To convert mmol/l of glucose to mg/dl, multiply by 18.
To convert mg/dl of glucose to mmol/l, divide by 18 or multiply by 0.055.

mmol/l ---mg/dl--- interpretation
2.0 -------35 ------extremely low, danger of unconciousness
3.0 -------55 ------low, marginal insulin reaction
4.0 -------75 ------slightly low, first symptoms of lethargy etc.
5.5 -------100 -----mecca
5 - 6 ---90-110 ----normal preprandial in nondiabetics
8.0 ------150------ normal postprandial in nondiabetics
10.0 -----180------ maximum postprandial in nondiabetics
11.0 -----200
15.0------270------ a little high to very high depending on patient
16.5 ------300
20.0 -----360------ getting up there
22 -------400------ max mg/dl for some meters and strips
33 -------600 ------high danger of severe electrolyte imbalance

More conversions:
To convert mmol/l of HDL or LDL cholesterol to mg/dl, multiply by 39.
To convert mg/dl of HDL or LDL cholesterol to mmol/l, divide by 39.
To convert mmol/l of triglycerides to mg/dl, multiply by 89.
To convert mg/dl of triglycerides to mmol/l, divide by 89.
To convert umol (micromoles) /l of creatinine to mg/dl, divide by 88.
To convert mg/dl of creatinine to umol/l, multiply by 88.




post courtesy of FAQs.org

Got Sexually Transmitted Diseases?

The most common sexually transmitted disease in the United States is

a. Human papilloma virus (HPV)
b. Chlamydia
c. HIV
d. Gonorrhea
e. Trichomonas


The correct answer is B. Chlamydia is the most common sexually transmitted disease (STD) in the United States. Each year there are 19 million new cases of sexually transmitted diseases in the U.S. Chlamydia, HPV and trichomonas account for 88% of these infections.

The danger of chlamydia is that it may not cause any symptoms. It is asymptomatic in 80 percent of women and in 50 percent of men who have an active infection. If there are symptoms - burning, itching - they may go away on their own while the bacteria remains in the body. If left untreated Chlamydia may lead to several complications. In women it can cause pelvic inflammatory disease (PID). This is a condition in which the bacteria travel up the vagina to the uterus and to the fallopian tubes causing scarring, chronic pelvic pain and sterility. In men it can cause prostatitis (inflammation of the prostate), urethral scarring and infertility.

Chlamydia can be detected by a urine test in men and women or during a pap test in women. It is recommended for all sexually active women under 25 to be screened for chlamydia annually. If the patient is African-American then a screening for gonorrhea is also recommended.

Once detected chlamydia is easily treated with antibiotics - doxycycline 100 mg twice daily for 7 days or azithromycin 1 gram once. The partner of the patient must also be treated. In fact according to new guidelines it is advised for the doctor to give extra doses of antibiotics to the patient so that he or she could distribute it to the partner. This is one of the few exceptions in medicine when a doctor may prescribe a medication without seeing the patient. The rationale for this strategy is that it will increase cure rate.

All infected individuals should be re-screened in 3 months after treatment.

Ideally of course it would be best for each person to be have an STD screening before having sex with a new partner. If you are intimate enough to have sex then you should be comfortable enough to have the STD discussion. If you do not have a regular doctor, the test may be obtained at any planned parenthood or county facility.

If you have any STD related questions, you can email Dr. Jeffrey Klausner at Ask Dr. K. Another resource is SEXINFO, a texting service from the San Francisco Department of Health.

When Should Cholesterol Screening Start

At what age do you think that routine cholesterol testing should begin?
a. age 2
b. age 16
c. age 25
d. age 30

According to new recommendations by the American Academy of Pediatrics, the correct answer is A. Screening is advised to begin at age 2 and no later than age 10 for children who have a family history of high cholesterol or, or a family history of early heart disease (age 55 or younger in a male parent or grandparent, age 65 or younger for female first and second degree relatives.). Other children who should be screened regardless of family history are those who are overweight (at or above the 85th percentile), or who have risk factors such as, diabetes, or high blood pressure.

Children under age 2 should not be screened. If the fasting lipid profile is normal, a child should be screened again in three to five years. If the cholesterol level is high and the child cannot lower it by lifestyle changes in 6 to 12 months, then it is recommended to start medications such as statins to lower the cholesterol level. Normal cholesterol levels are different for children. Total cholesterol should be less than 170 and the LDL cholesterol should be less than 110.

The rationale for these guidelines is that atherosclerosis which leads to heart disease starts very early in life. With 30 percent of young Americans considered overweight or obese there is a rising concern that there will be an epidemic of heart attacks and strokes when these children reach adulthood. Although it will be controversial to start children as young as 8 on drug therapy, the Academy argues that research has shown that these medications are safe in children and that the benefit of starting the treatment earlier outweighs any potential risks.

Reference: "Lipid Screening and Cardiovascular Health in Childhood."Stephen R. Daniels, Frank R. Greer, and the Committee on Nutrition.PEDIATRICS Vol. 122 No. 1 July 2008, pp. 198-208

Fracture Risk Calculator

How likely is it for you to sustain a fracture in the next 10 years? A new algorithm tool has been developed by the World Health Organization (WHO) to help assess your risk of fractures and osteoporosis.

Osteoporosis is a deterioration of bone mass (porous bone) which leads to fractures of wrist, hip and spine. It is usually measured by a radiological test called the bone-mineral density test. Treatment may be indicated depending on the amount of bone loss detected.

The new tool called the "FRAX" calculator may be used with or without the results of a bone-mineral density test. The model incorporates other clinical criteria such as age, sex, body-mass index, and seven other risk factors to predict the 10 year risk of fractures. Investigators analyzed data from multiple large international population-based studies to develop this statistical model which should add to the accuracy of the bone-mineral density test and better guide the use of medications used for prevention of fractures.

Sudden Cardiac Death

Tim Russert’s unexpected passing from a heart attack served as a solemn reminder that heart disease is an important topic for everyone to know about. Sudden cardiac death accounts for 310,000 deaths a year in the United States. It occurs after a heart attack ( caused by a blockage in an artery that supplies the heart) or an enlarged heart (caused by infections or congenital diseases) results in a life-threatening, abnormal heart rhythm. When this happens, the heart is unable to effectively pump blood out to the body and maintain life. Defibrillators are used to convert the abnormal rhythm to a regular one. A quick response is essential for survival. As a result, defibrillators are now found in many locations such as schools, office buildings, and airplanes.

Certain risk factors contribute to heart disease. These include high cholesterol, high blood pressure (above 140/90), diabetes, being overweight (BMI greater than 25), smoking and not exercising. Other risk factors which we are unable to control include having a family history of heart disease or sudden cardiac death, male gender, increased age or being a postmenopausal female. Although risk factors exist, the condition can still not be fully prevented. Inform your physician about any feelings of discomfort which you may have in your chest, jaw or abdomen that is made worse with exertion and is relieved with rest.

Blog: courtesy of Dr. Roger Kapoor.
Refernces: please see links.

Reliable Medical Resource

Technology is a good thing. Information is more and more accessible - after all that is Google's mission - but reliability of the information is not easily determined. I appreciate patients educating themselves about their medical conditions. However, there are times when they would have been been better off without doing the online research. Not all information is good information and content out of context can be confusing.

So for your benefit and for your overworked doctor's reassurance, here's a link which is worth checking the next time you need to get information on an ailment. The link was recently made available by Up To Date - an evidence based information source normally provided for physicians only. Many physicians rely on this service which is available to them for a fee, however, the patient information section is free.

Tainted Tomatoes

Tomatoes have been identified as the source of salmonella poisoning in 145 people in several states in the US over the last 2 months. It is best to avoid Roma and round red tomatoes. Tomatoes that are considered safe to eat are cherry tomatoes, grape tomatoes, tomatoes that are still on the vine, and home grown tomatoes.

For updates see this Food and Drug Administration page.

You may recall this review from a previous contamination that involved spinach.
Salmonella is a bacteria that is transmitted to humans by eating foods that are contaminated by animal or human feces. It does not cause any change in the smell or taste of the food that it infects. It is the most frequently reported cause of food borne illnesses in the US - 1.4 million cases annually.


Symptoms of salmonella infection include diarrhea, cramps, fever, and vomiting. The symptoms may be much more severe in young children, the elderly, and in the immunocompromised patients. Although the illness may resolve spontaneously after 7 days, it may take several months before the bowels return to normal. A small percentage of the people may also develop joint pain, painful urination, and eye irritation that may last for months to years.

Seizures

Senator Ted Kennedy is undergoing surgery for a brain tumor today. The first indication that a pathology was involved was his recent episode of a seizure. The events that lead to his recent diagnosis are important to understand.

What exactly is a seizure and why does it happen? A seizure occurs when our brain has an abnormal electrical signal, similar to an unexpected, sudden burst of lightening. The particular area of the brain involved dictates what symptoms someone might experience from uncontrollable shaking (muscle spasms) to staring spells to a loss of consciousness. The term epilepsy describes someone who has many seizures. Much like a fever is our body’s way of telling us that something is not right, a seizure is our brain’s way of raising a red flag. An abnormal electrical signal can be sent as a result of any of the following reasons: injury to the head, brain infection, brain tumor or stroke. In addition, anything that disrupts the environment our brain cells live in can also cause them to become irritated and result in a seizure: low blood sugar, drug use (cocaine etc), alcohol withdrawal or very high fevers.

So, besides calling a health care professional, what do you do if someone is having a seizure? In general, not interfering with a seizure is often the right thing to do. Remember that a seizure is completely involuntary, so don’t try to stop a person from shaking or place anything in their mouth. However, if the person starts to show signs of vomiting, quickly turn them to their side so that they able to expel everything that comes out of their mouth (swallowing it might result in lung damage). You can also attempt to place a cushion under their head to prevent them from repeatedly hitting their head on the floor. Try to move all objects away from the person so that they can do less harm to themselves – create as much space around the individual as you can. After a seizure, the person will likely be in a deep sleep, disoriented or agitated. Whatever the situation, most seizures are self-limiting and you should refrain from giving the individual anything to eat or drink until the person is completely alert and oriented.

Blog: courtesy of Dr. Roger Kapoor.
References: please see links.

Promising Early Lung Cancer Detection

I went to a funeral of a dear patient today. I had taken care of her for 15 years. She was 72 years old, she was married for 54 years, and she had one son. She loved to play golf, to over-decorate the house for the holidays, and to spend time with her family. But she also loved to smoke her cigarettes despite our many discussions about the risks of smoking.

She had been fine until 3 months ago when she presented with abdominal pain. Shortly thereafter she was diagnosed with widespread lung cancer that was growing by the day. Six weeks is all that she had from the time of her lung biopsy to her death.

Lung cancer scares me because I know that no matter how complete a physical exam or how many tests that I perform, there is a chance that it may still be awaiting my patient. Lung cancer kills more people around the world than any other cancer. 10 million new lung cancer diagnoses are made each year. Most of these cases are diagnosed too late in the course for effective treatment. Over three quarters of all lung-cancer patients are/were long-term regular smokers. The only means of diagnosing lung cancer is by chest xray or chest CT scan. Neither of these tests is effective in detecting the cancer at an early stage.

A recent study in the Journal of Thoracic Oncology, however, has concluded that a blood test may be able to predict early non-small cell lung cancer with an accuracy rate of 87%. The cancer may be present 3-5 years before it is detected on the imaging tests. Although it is too late for this particular patient, there is promise that others may have a chance of earlier detection and therefore of cure of lung cancer by a simple blood test. More studies will be needed to better define the role of this technology in clinical context.