Physician Burn Out Rising, Adding to MD Shortage

A recent study published in the Archives of Internal Medicine raises alarms about stresses being  placed on physicians in the current health delivery system.  Symptoms of burnout are far more common among physicians than other workers. Physicians who specialize in front line and primary care services are at the greatest risk.

The findings of the study raise many concerns.  Levels of burnout in US physicians are extremely high; primary care providers and emergency providers seem at the highest risk; physicians work longer hours than other workers; physician have greater struggles with integration of work and life issues than other workers; in fields outside of medicine, high levels of educational attainment seem to be protective against burnout, but this is not the case in medicine. Burnout among physicians is a unique entity and does not reflect societal trends.

Serious personal consequences can result from physician burnout. These can include problematic alcohol use, broken relationships, and suicidal ideation.  Increasingly there is a consensus that burnout can effect quality of care. These findings suggest an alarming problem of systemic proportion for the health delivery system as a whole.

With an almost 50% rate of burnout symptoms reported in US physicians it is clear that the etiology of this problem is within the care delivery system itself.

This fact has important implications for policy makers and health delivery systems which must address this issue head on, for the sake of physicians, patients and the delivery system as a whole.

Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population

COMMENTARY: Taken on face value, one could argue that this is nothing new.  The practice of medicine has always required intense training, dedication and neglect of many of the things in life that others take for granted.  Having said that, the environment today has never been more challenging.

Physicians are subject to an endless barrage of demands which include: certification and repetitive re-certification, medical-legal exposure with every patient encounter, ever growing demands for documentation of ALL aspects of the interaction with patients, ever growing demands for translation of clinical interaction into complex coding language in order to bill and “hope” for payment, skewed and arbitrary fee schedules and payment policies which vary widely between state, federal and private payer entities.

The ability to order lab work or imaging studies for what may seem a straightforward clinical case, can turn into hours of added work via the telephone, fax or email with payers insistent on limiting the amount of care delivered.  These added services are NOT compensated financially and place excessive demands on physician time.

Added to this are the long hours, natural human stresses associated with dealing with ill or injured patients and their families, as well as the emotional toll of having to make major decision, often in a split second, and then being second guessed endlessly by peer review, insurers, or legal review.

Sadly, there is essentially nothing in the recently passed Affordable Care Act (ACA) which will be of much assistance to physicians.  In fact the ACA will add multiple layers of additional burdens in terms of documentation, peer review, and patient volume expansion.  Of even greater concern, is the fact that many of our most seasoned and experienced physicians and surgeons are looking for early exit opportunities in order to leave what they view as a declining practice environment.

Burnout and career satisfaction among American surgeons

Why do surgeons consider leaving practice?

Lack of Sunlight and Temperature Extremes Predispose to Stroke

The effect of sunlight and temperature were explored during a recent presentation at the International Stoke Conference held in New Orleans, February 2012.

The authors noted that the incidence of stroke is higher in the winter.  This suggests that reduced exposure to sunlight may play a role in the increased incidence of stroke.  It is also noted that extreme temperatures, low or high, can increase the risk of stroke.

This study confirmed the finding of the effects of extremely high or low temperatures in leading to an increased incidence of stroke.  They also confirmed the correlation between reduced exposure to sunlight and an increased occurrence of strokes.

It is unclear what the biologic action is that causes strokes to occur more frequently in wintertime. However, we could speculate that it may have to do with an increase in sedentary lifestyle and lack of exercise with subsequent weight gain. Another factor to consider is possible altered sleep patterns brought on by changes in circadian rhythms.  While definitive causation cannot be determined at this time, it is good to be aware of the fact that extreme temperatures and lack of sunlight are factors to be considered in possible stroke prevention strategies.

Abstract 2591: Relationship Between Sunlight and Temperature Exposure to Stroke Incidence in the Reasons for Geographic and Racial Differences in Stroke (regards) Study [Session Title: Community/Risk Factors Posters I]

 

Danger! Hospital Privacy Curtains Germ Filled!

Dr. Michael Ohl, from the University of Iowa, Iowa City, in a presentation at the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago, identified privacy curtains, which are in use in almost every medical and surgical facility, as a significant source of germ contamination.  This fact adds to the growing list of concerns about bacterial contamination of everyday items used in hospitals.  This includes the famous white doctor’s coat, neck ties and of course, unwashed hands.

Privacy curtains, which generally separate patients in wards, emergency rooms and semi-private hospital rooms, have rarely been given much thought.  Most likely they are rarely laundered or often replaced. Thus, it is not  surprising that they should be found to be laden with germs.  This finding should prompt all facilities to move to a regular laundry schedule for these items, particularly since the findings of this study indicated that contamination of new curtains occurs within one to two weeks.

Additionally, all new facilities should be planned with a mind to private exam, observation and patient rooms to limit cross contamination from sick or infected patients.  Because these curtains are so frequently touched by doctors, nurses, patients and visitors they are an easy target for bacteria.  This study should refocus our attention on prevention of infection in all settings, but especially in the hospital setting.

Hospital privacy curtains laden with germs - http://is.gd/C8h7N8

Hospital privacy curtains laden with germs – http://is.gd/YuVuep

Sperm Counts Not Declining According To New Study

For over 20 years or longer, researchers and clinicians have had concerns over supposed falling sperm counts among males worldwide.  Most of this worry was based on studies published in the early 1990′s based on retrospective data from earlier decades.  The implications of this were alarming, in that, followed to conclusion, widespread male infertility and sub-fertility could lead to depopulation and even human species extinction over time.

There were many theories offered for these findings, most related to environmental issues, such as pesticide use.  However, a new study from Denmark, which followed men for some 15  years suggests that there has been no substantive change in sperm counts in males over that time frame.  This data would suggest that if anything, earlier data may not only have been wrong, but that researchers postulated conclusions that were alarming based not on real data, but speculative extrapolation of the data they had available.

While the new study is good news on the whole, it by no means definitively answers the question of male fertility rates or changes.  Nor does this study conclusively eliminate environmental factors from a role in effecting sperm counts and male fertility.  Indeed, female fertility is also an issue and the myriad of factors that can affect selective couple fertility are such that specific studies regarding this are difficult and of limited scope.  Longitudinal studies, such as the new Danish study, following individuals in real time, is perhaps the best way, over time, to extract meaningful epidemiological data on events occurring in humans.

In Update on Sperm, Data Show No Decline - http://is.gd/URx2P7

Editorial: On Sperm Counts and Data Responsibility – http://is.gd/NP6PY9

Commentary: Trends in Sperm Counts: The Saga Continues – http://is.gd/xlOTqP

Commentary: Sperm Counts, Data Responsibility, and Good Scientific Practice – http://is.gd/LS33Ve

Evidence for decreasing quality of semen during past 50 years – http://is.gd/NDA7zg

CDC study suggests 1 in 10 children have ADHD

ADHD Diagnosis on the Rise

A recently released study from the Centers for Disease Control (CDC) indicates a dramatic increase in the number of children labeled as having Attention Deficit Hyperactivity Disorder (ADHD).  The new report has been the focus of commentary across the media.  The last study of this type indicated that as many as 7.8% of children (age 4-17) had, at one time or another, been diagnosed with ADHD (2003).  This most recent study, which focused on parental reporting of the diagnosis of ADHD, indicated that this rate had increased by a surprising large amount, 22%, to 9.5% of children ages 4-17 (2007).  1,2,3,4

It is now estimated that about one in ten school age children are currently diagnosed as having ADHD (5.4 million).  This is some one million more than was identified during the last study.  Also, about half of the children currently diagnosed as having ADHD were said to be on medication (some 2.7 million). 1

Also alarming was a reported increase in the diagnosis of ADHD among older teens (42%) and among Hispanic children (53%).  Clearly, these findings suggest some alteration in the pattern of the illness or in the manner of diagnosis. 1

Twelve states had marked increases in numbers of children diagnosed. However, they were geographically separated (such as New York, Louisiana, Virginia, Alabama).  Interestingly, these states with the highest increases were all in the east and south. 1

The new study, while indicating differences in rates of increase between various sub-groups, showed an increase in parent reported ADHD across all demographics.  Multiracial children and children on Medicaid were the groups with the highest reported rates of having been diagnosed with ADHD. 1

Clearly, there is much about ADHD we do not know or understand.  It is defined as a neurobehavioral developmental disorder.  ADHD children demonstrate attention problems and hyperactivity, with both key symptoms almost always occurring together.  What we do know is that the condition is more frequently diagnosed in boys (four times more commonly than girls), is the most common psychological/psychiatric diagnosis in children, effects as many as 5% of all children, up to 16% of school aged children, and persists in perhaps as many as 50% of adults who have the disorder.  We also know that low birth weight infants are at a much greater risk. 5

This most recent data points to confusion in explaining the reported increase.  Is it due to better diagnostic criteria being used? Is it due to greater parental and teacher awareness? Is it due to better overall pubic education and media exposure?  Are there environmental factors?  Some have pointed to a lack of certain fatty acids as a cause. An array of behavioral disorders from autism to ADHD has been blamed on various chemicals, pesticides, and vaccines. To date, a clear-cut cause based on genetics, environment, dietary factors or chemical exposure remains elusive. Lacking a clear-cut cause, treatment remains focused on symptomatic control.  1,5,6,7,8

Treatment is, of course, controversial with many opting for medications and others opting for combination of behavior modification and enhanced coping mechanism development. The use of medications while effective in up to 70% of children can be associated with dependence, drug tolerance, and side effects.  Both stimulants (such at the widely used Ritalin) and anti-psychotics have been used with success.  Interestingly, the mechanism of action of these drugs is directly opposite, which raises major questions as to the exact mode of action of these drugs in mitigating the symptoms of ADHD. 1,9,10

At this time, the key to treatment of this frustrating condition is parental awareness.  Early detection and diagnosis can lead to effective treatment for many, whether by means of behavioral therapy or medications.10

1. Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children — United States, 2003 and 2007 – November 12, 2010 / 59(44);1439-1443 – http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w

2. 1 in 10 US kids have ADHD; more awareness cited - http://www.google.com/hostednews/ap/article/ALeqM5jtE0v_PbmXXtyOzSXxORUAhDVyGQ?docId=4bde4aa13dfd4ace87df1d0a880cfc2b

3. One Million More U.S. Kids Are Diagnosed With Attention Deficit – http://www.bloomberg.com/news/2010-11-10/one-million-more-u-s-kids-are-diagnosed-with-attention-deficit.html

4. CDC: Childhood ADHD rate rises 22 percent – http://pagingdrgupta.blogs.cnn.com/2010/11/10/cdc-childhood-adhd-rate-rises-22-percent/

5. Attention deficit hyperactivity disorder – http://en.wikipedia.org/wiki/Attention_deficit_hyperactivity_disorder

6. Very Low Birthweight Children Have Long-Term Behavioral And Psychiatric Consequences – http://www.sciencedaily.com/releases/1997/06/970606122249.htm

7. ADDers Are More Likely to Have Fatty Acid Deficiencies -http://borntoexplore.org/omega.htm

8. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder – http://www.ajcn.org/cgi/content/abstract/62/4/761

9. Treatment of Attention-Deficit–Hyperactivity Disorder – http://www.nejm.org/doi/full/10.1056/NEJM199903113401007

10. ADHD Diagnosis on the Rise – http://www.associatedcontent.com/article/6001472/adhd_diagnosis_on_the_rise.html?cat=25

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High Fructose Intake Increases Risk of High Blood Pressure

Diets which are high in fructose increase the risk of persons developing hypertension (high blood pressure).  This data was first presented at the American Society of Nephrology Annual Meeting (42nd Annual Meeting and Scientific Exposition in San Diego, California) and has been subsequently publish online in last weeks. These findings point to a need for reductions in intake of foods and beverages that have the additive high fructose corn syrup (HFCS).  The view is that this may well help prevent the onset of hypertension in many persons.

High fructose corn syrup (HFCS) is a sweeter form of corn syrup and in terms of nutritional intake is a newer food. Just as in the case of basic corn syrup, HFCS is made from corn by using enzymes to alter it.

Some researchers have also reported that HFCS intake is linked to obesity.  The past two centuries  have seen a major rise in obesity rates.  These rises parallel the increased consumption of fructose in the diet.  This has been particularly true over the past two decades with the major increased use of HFCS.  Americans now consume 30% more fructose than they did 20 years ago.  They consume four times as much fructose as was the case 100 years ago when obesity rates were below 5%.  Historically, these facts have coincided with the rise in occurrence of hypertension.  Previous studies, while suggestive, were inconsitent in linking excess fructose in the diet to high blood pressure development.

Patel and associates report in the recent online early publication in the Journal of the American Society of Nephrology their findings.  They note, “the recent increase in fructose consumption in industrialized nations mirrors the rise in the prevalence of hypertension, but epidemiologic studies have inconsistently linked these observations. We investigated whether increased fructose intake from added sugars associates with an increased risk for higher BP levels in US adults without a history of hypertension. We conducted a cross-sectional analysis using the data collected from the National Health and Nutrition Examination Survey (NHANES 2003 to 2006) involving 4528 adults without a history of hypertension. Median fructose intake was 74 g/d, corresponding to 2.5 sugary soft drinks each day. After adjustment for demographics; comorbidities; physical activity; total kilocalorie intake; and dietary confounders such as total carbohydrate, alcohol, salt, and vitamin C intake, an increased fructose intake of ≥74 g/d independently and significantly associated with higher odds of elevated BP levels: It led to a 26, 30, and 77% higher risk for BP cutoffs of ≥135/85, ≥140/90, and ≥160/100 mmHg, respectively. These results suggest that high fructose intake, in the form of added sugar, independently associates with higher BP levels among US adults without a history of hypertension.”

This article supports the widespread belief that HFCS is not a healthy alternative to natural cane sugar in beverages or foods.  Perhaps the most alarming finding is that the simple equivalent of 2.5 sugary soft drinks per day (which usually contain HFCS) is the all that is required to push one over the edge as it were in terms of a significant increase in risk of developing high blood pressure.  It would behoove us all to cut our intake of sugar overall.  Most particularly, we should attempt to limit our intake of HFCS as much as possible.  To this end, many soft drink manufacturers are offering alternatives which are sweetened with cane sugar as opposed to HFCS.  Diet and dietary intake it seems we learn more and more each day, play a crucial role in our health and wellness, as well as our development of chronic disease . . . ben kazie md

Increased Fructose Associates with Elevated Blood Pressure – http://jasn.asnjournals.org/cgi/content/abstract/ASN.2009111111v1

High Fructose Intake from Added Sugars: An Independent Association With Hypertension – http://www.sciencedaily.com/releases/2009/10/091029211521.htm

High fructose corn syrup – http://www.sciencedaily.com/releases/2009/10/091029211521.htm

Increased fructose intake is associated with elevated blood pressure – http://www.news-medical.net/news/20091030/Increased-fructose-intake-is-associated-with-elevated-blood-pressure.aspx

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Vitamin D Critical Nutrient – Who Knew?

The Centers for Disease Control (CDC) estimates that this year the number of deaths from cancer related causes will be over 560,000, with heart disease leading at just over 616,000.  These two causes of death together surpass the next 8 causes (stroke, respiratory disease, accidents, Alzheimer’s, diabetes, influenza and pneumonia, kidney disease and sepsis) combined.  So by far, cancer and cardiac disease are our leading killers. [1]

Recently, the medical, nutrition and research literature has seen an influx of new information regarding the role of various factors in the development of cancer and other major illnesses.  Of particular interest has been the role of vitamin D in disease prevention and causation.

Vitamin D is one of the fat-soluble vitamins (like vitamin E).  In nature it is found in only a few food items. Most commonly one sees it as a food additive or as a dietary supplement. Vitamin D is produced naturally when sunlight (ultraviolet rays) strike the skin.  These UV rays trigger vitamin D synthesis in the skin.  Regardless of how it is obtained, from sun exposure, food, or supplements vitamin D is biologically inactive.  In order to be of use, it must be activated via chemical reactions in our bodies. The first reaction occurs in the liver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol. The second reactions occurs primarily in the kidney and forms the active 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol. [2]

The major role played by vitamin D is maintenance of normal blood levels of calcium and phosphorus. Vitamin D aids in calcium absorption from our stomach via digestion, which helps form and maintain strong bones. New research points to a role for vitamin D in prevention of osteoporosis, hypertension (high blood pressure), cancer, and several autoimmune diseases. [3, 4]

Dr. John Cannell, Executive Director of the Vitamin D Council has commented that “humans make thousands of units of vitamin D within minutes of whole body exposure to sunlight; from what we know of nature, it is unlikely such a system evolved by chance.” Dr. Frank Lipman, an internationally recognized expert in the fields of Integrative and Functional Medicine and practicing physician has commented that, “for hundreds of thousands of years, man has lived with the sun: our ancestors were outdoors far more often than indoors and we developed a dependence on sunshine for health and life, so the idea that sunlight is dangerous does not make sense. How could we have evolved and survived as a species, if we were that vulnerable to something humans have been constantly exposed to for their entire existence?” Dr. Frank Apperly, in whose concluding remark of his 1941 study on cancer rates vs. latitude stated: “A closer study of the action of solar radiation on the body might well reveal the nature of cancer immunity.”[5]

Ramagopalan and associates recently reported in Genome Research on their findings that vitamin D is involved in actions on some 229 genes with almost 2800 genomic positions affected on those genes.  The summary of their abstract findings states: Initially thought to play a restricted role in calcium homeostasis, the pleiotropic actions of vitamin D in biology and their clinical significance are only now becoming apparent. However, the mode of action of vitamin D, through its cognate nuclear vitamin D receptor (VDR), and its contribution to diverse disorders, remain poorly understood. We determined VDR binding throughout the human genome using chromatin immunoprecipitation followed by massively parallel DNA sequencing (ChIP-seq). After calcitriol stimulation, we identified 2776 genomic positions occupied by the VDR and 229 genes with significant changes in expression in response to vitamin D. VDR binding sites were significantly enriched near autoimmune and cancer associated genes identified from genome-wide association (GWA) studies. Notable genes with VDR binding included IRF8, associated with MS, and PTPN2 associated with Crohn’s disease and T1D.” [11] Reports on this study have popped up in multiple media sources as well [6,7,8,9,10]

It is true that sunlight can cause basal cell and squamous cell cancers in susceptible persons.  However, a good correlation between sunlight exposure and lowered incidence of internal cancers exists. It has been shown that  cancer mortality increases with distance from the equator.  This finding was clearly demonstrated in a 1941 study by Dr. Frank Apperly and confirmed in other studies.[17]  He examined cancer deaths across North America and found that more northern latitudes had higher cancer death rates.  In his review he found that cities between 30-40 degrees latitude had an 85% higher overall cancer death rates than cities located between 10-30 degrees latitude.  Cities between 40-50 degrees latitude averaged 118% higher death rates from cancer and those between 50-60 degrees latitude had a 150% higher cancer mortality. Dr. Apperly also studied the relationship of sunlight and skin cancer.  Surprisingly, he found that sunlight produces an immunity to cancer in general. In locales with a mean temperature less than 42 degrees F this was even true with skin cancer.  At mean temperatures higher than 42 degrees F solar radiation appears to increase the incidence of skin cancer.  Upon reviewing the data, he postulated that the closer one is to the equator, the lesser the risk of developing internal cancers, but the higher the risk of developing. It appears that Dr. Apperly was among the first to investigate the relationship between temperature and skin cancer as well as how sunlight might reduce the risk of death from internal cancers.  He concluded his review by saying that “a closer study of the action of solar radiation on the body might well reveal the nature of cancer immunity.” [5,6,12,19]

Cancer has in some regions of the country, surpassed heart disease as the leading cause of death. The mortality rate for cancer is high (roughly 42%) and increases with increasing age.  This is particularly true for those aged 40 to 60 years. Despite discussion of cancer prevention, true efforts in this regard have been minimal. Drugs developed so far have been expensive and many have serious side effects. Most focus has been on early detection rather than prevention of cancer.  There are some 18 vitamin D-sensitive cancers. Ultraviolet light, and specifically ultraviolet B (UVB), could possibly reduce cancer by limited exposure of suitable skin areas to UVB of an intensity and duration insufficient to produce skin cancer. To date, the medical literature sites a great fear of development of skin cancer from overexposure to sunlight and UV rays.  To be sure, this is based on some degree of truth.  Though skin cancer incidence is significant, mortality from skin cancer is rare. Roughly 1,000,000 Americans will be affected by skin cancer but only 10,000 deaths were expected in 2005 (a 1% mortality rate). Skin cancer is easily detected and often cured by excisional biopsy alone. [6,12,13,14]

All of this points to the real issue which is the role of vitamin D in prevention of cancer and disease. [2,3,4,6,7,8,9,10,11]

Some have postulated that vitamin D deficiency is a major factor in the development and progression of autism. While still a theory, the idea of a significant role for vitamin D in the causation of autism is gaining momentum. More and more scientists are examining this possible link in the hopes that this theory will hold up against scientific scrutiny.  If true, it would be mean a relatively simple solution might exist for what has become a too frequent and often tragic condition. [15]

Determining vitamin D deficiency requires testing since there is no way to know for certain until a 25-hydroxyvitamin D test, also called a 25(OH)D, level is determined. It is felt that levels should be above 50 ng/ml (125 nmol/L) year-round, in both children and adults. Recent studies suggest that the minimal acceptable level is 50 ng/ml (125 nmol/L). A recent study analyzed five studies in which both the parent compound (cholecalciferol) and 25(OH)D levels were measured. Findings show that the body does not reliably begin storing cholecalciferol in fat and muscle tissue until 25(OH)D levels get above 50 ng/ml (125 nmol/L). The average person starts storing cholecalciferol at 40 ng/ml (100 nmol/L), but at 50 ng/ml (125 nmol/L) virtually everyone begins to store it for future use. Therefore, at levels below 50 ng/ml (125 nmol/L), the body uses up vitamin D as fast as you can make it, or take it, indicating chronic “starvation”  in regard to vitamin D which is clearly not a good thing. 25(OH)D levels should be between 50–80 ng/ml (125–200 nmol/L), year-round. [3,12,13,14,15,16]

There is some variation in the recommended dose of vitamin D on a daily basis. Recommendations from the National Institutes of Health are far lower than those advocated by many disease prevention groups. To be sure, one must account for the amount of vitamin D estimated to be obtained from one’s diet as well as exposure to sunlight overall.  Then, additional supplementation may be needed.  This is especially true if one has proven low levels on blood chemistry. [3,14]

The risk of vitamin D overdose, or toxicity, seems to be minimal and to date, very rare.  It is estimated that one would have to have an intake of between 600,000 and 1,680,000 IUs (International Units) per day for several days or months to develop this condition.  Most over the counter supplements come in dosages of 1000, 2000 or 5000 IU. Given this fact, reasonable supplementation, especially in light of confirmed deficiency makes perfect medical sense. [3,14,18]

Patients should consult their physician and may wish to suggest that 25(OH)D levels be measured on a routine basis in conjunction with their annual physical exam and laboratory testing . . . ben kazie md

  1. Deaths and Mortality – http://www.cdc.gov/nchs/fastats/deaths.htm
  2. Vitamin D – http://en.wikipedia.org/wiki/Vitamin_D
  3. Dietary Supplement Fact Sheet: Vitamin D – http://ods.od.nih.gov/factsheets/vitamind.asp
  4. Vitamin D – http://www.mayoclinic.com/health/vitamin-d/NS_patient-vitamind
  5. Vitamin D Quotes – http://www.vitamindcouncil.org/vitamin-d-quotes.shtml
  6. Shedding Light on Vitamin D & Cancer – http://issuu.com/iwishart/docs/investigate_apr09_100dpi
  7. Vitamin D linked to autoimmune and cancer disease genes, underscoring risks of deficiency – http://www.bionity.com/news/e/121670/?WT.mc_id=ca0068
  8. Vitamin D linked to autoimmune and cancer disease genes, underscoring risks of deficiency – http://www.eurekalert.org/pub_releases/2010-08/cshl-vdl081710.php
  9. Vitamin D Found to Influence Over 200 Genes, Highlighting Links to Disease – http://www.sciencedaily.com/releases/2010/08/100823172327.htm
  10. Vitamin D found to influence over 200 genes, highlighting links to disease – http://www.physorg.com/news201791554.html
  11. A ChIP-seq defined genome-wide map of vitamin D receptor binding: Associations with disease and evolution – (Ramagopalan SV, Heger A, Berlanga AJ, Maugeri NJ, Lincoln MR, Burrell A, Handunnetthi L, Handel AE, Disanto G, Orton S, Watson CT, Morahan JM, Giovannoni G, Ponting CP, Ebers GC, Knight JC.; Genome Res 2010 – http://genome.cshlp.org/content/early/2010/08/20/gr.107920.110.abstract?sid=7cd67983-f82c-469f-88df-d7a2e99a5fdf
  12. Vitamin D and Your Health Deficiency – http://www.vitamindcouncil.org/health/deficiency/am-i-vitamin-d-deficient.shtml?gclid=CPWii7P61KMCFZNg2godBH87ug
  13. Vitamin D Deficiency Syndrome – http://www.vitamindcouncil.org/vdds.shtml
  14. Treating Disease With Vitamin D – http://www.vitamindcouncil.org/treatment.shtml
  15. Vitamin D Theory of Autism – http://www.vitamindcouncil.org/health/autism/vit-D-theory-autism.shtml
  16. Am I Vitamin D Deficient? – http://www.vitamindcouncil.org/health/deficiency/am-i-vitamin-d-deficient.shtml
  17. An adjunctive preventive treatment for cancer: Ultraviolet light and ginkgo biloba, together with other antioxidants, are a safe and powerful, but largely ignored, treatment option for the prevention of cancer – http://www.medical-hypotheses.com/article/S0306-9877%2806%2900005-3/abstract
  18. Hypervitaminosis D – http://en.wikipedia.org/wiki/Hypervitaminosis_D
  19. Apperly FL; The relation of solar radiation to cancer mortality in North America. Cancer Research. 1941:1:191-195 – http://cancerres.aacrjournals.org/content/1/3.toc

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Salmonella Infection Outbreak

EGGS FOCUS OF OUTBREAK

What is Salmonella?

Salmonellosis is an infection caused by the bacteria Salmonella. Those infected with Salmonella develop diarrhea, fever, and abdominal cramps 12 to 72 hours after infection. The illness usually lasts 4 to 7 days.  Most recover without treatment. However, in some the diarrhea may be so severe that hospitalization is required. Sometimes fatal infections occur in young children, frail or elderly people, and others with weakened immune systems. In these patients, the Salmonella infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics. The elderly, infants, and those with impaired immune systems are more likely to have a severe illness.

Salmonella is actually a group of bacteria that can cause diarrheal illness in humans. They are microscopic living creatures that pass from the feces of people or animals to other people or other animals. There are many different kinds of Salmonella bacteria. Salmonella serotype Typhimurium (typhoid fever) and Salmonella serotype Enteritidis are the most common in the United States. Salmonella germs have been known to cause illness for over 100 years. They were discovered by an American scientist named Salmon, for whom they are named.

Healthy persons infected with Salmonella often experience fever, diarrhea, nausea, vomiting and abdominal pain. In rare circumstances, infection with Salmonella can result in the organism getting into the bloodstream and producing more severe illnesses such as arterial infections, endocarditis, or arthritis.

What Eggs Are Affected?

Eggs affected by this recall were distributed to grocery distribution centers, retail grocery stores and food service companies which service or are located in fourteen states, including the following: Arkansas, California, Iowa, Illinois, Indiana, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Texas, and Wisconsin. Eggs are distributed under the following brand names: Hillandale Farms, Sunny Farms, and Sunny Meadow in 6-egg cartons, dozen-egg cartons, 18-egg cartons, 30-egg package, and 5-dozen cases. Loose eggs are packaged under the following brand names: Wholesome Farms and West Creek in 15 and 30-dozen tray packs. The loose eggs may also be repackaged by customers.

The only eggs effected by this recall have plant numbers P1860 or P1663 and Julian dates as follows:

  • P1860 – Julian dates ranging from 099 to 230
  • P1663 – Julian dates ranging from 137 to 230

Only eggs with these plant numbers are effected – even though the brand name may be the same

How Do Eggs Become Infected?

Unlike eggborne salmonellosis of past decades, the current epidemic is due to intact and disinfected grade A eggs. Salmonella enteritidis silently infects the ovaries of healthy appearing hens and contaminates the eggs before the shells are formed.

Most types of Salmonella live in the intestinal tracts of animals and birds and are transmitted to humans by contaminated foods of animal origin. Stringent procedures for cleaning and inspecting eggs were implemented in the 1970s and have made salmonellosis caused by external fecal contamination of egg shells extremely rare. However, unlike egg-borne salmonellosis of past decades, the current epidemic is due to intact and disinfected grade A eggs. The reason for this is that Salmonella enteritidis silently infects the ovaries of healthy appearing hens and contaminates the eggs before the shells are formed.

Although most infected hens have been found in the northeastern United States, the infection also occurs in hens in other areas of the country. In the Northeast, approximately one in 10,000 eggs may be internally contaminated. In other parts of the United States, contaminated eggs appear less common. Only a small number of hens seem to be infected at any given time, and an infected hen can lay many normal eggs while only occasionally laying an egg contaminated with the Salmonella bacterium.

How Does One Reduce Risk?

Eggs, like meat, poultry, milk, and other foods, are safe when handled properly. Shell eggs are safest when stored in the refrigerator, individually and thoroughly cooked, and promptly consumed. The larger the number of Salmonella present in the egg, the more likely it is to cause illness. Keeping eggs adequately refrigerated prevents any Salmonella present in the eggs from growing to higher numbers, so eggs should be held refrigerated until they are needed. Cooking reduces the number of bacteria present in an egg; however, an egg with a runny yolk still poses a greater risk than a completely cooked egg. Undercooked egg whites and yolks have been associated with outbreaks of Salmonella enteritidis infections. Both should be consumed promptly and not be held in the temperature range of 40 to 140 for more than 2 hours.

Is There Treatment If Infected?

Nontyphoid Salmonella infection is generally self-limited. Treatment for enteritis or food poisoning is controversial. Some doctors recommend no antibiotics since the disease is self-limited, while others suggest using antibiotics such as ciprofloxacin for 10-14 days. A review of 12 clinical trials showed no significant change in the overall length of the illness or the related symptoms in otherwise healthy children and adults treated with a course of antibiotics for nontyphoid Salmonella disease. Antibiotics tend to increase adverse effects and prolong Salmonella detection in stools. Patients identified as immunosuppressed (for example, patients with AIDS or undergoing cancer chemotherapy) should receive antibiotics. Some investigators believe antibiotics prolong the carrier state.  Antibiotics usually chosen to treat Salmonella infections are fluoroquinolones and third-generation cephalosporins (used in children because fluoroquinolones are not indicated for use in children). Resistance to these drugs is a potential problem for those individuals that become infected with Salmonella as drug treatment options become limited.

Clearly, common sense, attention to cleanliness, thorough cooking of eggs and general public health measures are the best protection from infection.  Once infection occurs, prompt treatment with supportive measures and medications as medically indicated is essential.  Careful attention to hand washing and personal hygiene is critical to reduce the risk of spreading infection to care givers and other family members . . . ben kazie md

No evidence that tainted eggs go beyond 2 farms – http://enews.earthlink.net/article/hea?guid=20100823/b67576dd-7b7d-4d05-a524-e98ac055c671

FDA: No evidence yet that millions of eggs tainted by salmonella extend beyond 2 Iowa farms – http://www.startribune.com/business/101287334.html?elr=KArks4OiP:DiiU1OiP:Dii_47cQiU47cQUU

Investigation Update: Multistate Outbreak of Human Salmonella Enteritidis Infections Associated with Shell Eggs – http://www.cdc.gov/salmonella/enteritidis/

CDC Investigation Announcement: Multistate Outbreaks of Human Salmonella Hartford and Salmonella Baildon Infections – http://www.cdc.gov/salmonella/baildon-hartford/index.html

Hillandale Farms of Iowa Conducts Nationwide Voluntary Recall of Shell Eggs Because of Possible Health Risk – http://www.fda.gov/Safety/Recalls/ucm223452.htm

Investigation Update: Multistate Outbreak of Human Typhoid Fever Infections Associated with Frozen Mamey Fruit Pulp – http://www.cdc.gov/salmonella/baildon-hartford/index.html

How can I tell if my eggs have been recalled? – http://www.fda.gov/Food/NewsEvents/WhatsNewinFood/ucm223536.htm

How are Salmonella infections treated? -http://www.medicinenet.com/salmonella/page3.htm#treated

Antibiotics for treating salmonella gut infections – http://www.ncbi.nlm.nih.gov/pubmed/10796610 (Sirinavin S, Garner P. Antibiotics for treating salmonella gut infections. Cochrane Database Syst Rev. 2000;CD001167)

Salmonellosis – http://www.cdc.gov/nczved/divisions/dfbmd/diseases/salmonellosis/

Salmonella enteritidis – http://www.cdc.gov/ncidod/dbmd/diseaseinfo/salment_g.htm

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New Test Predicts Onset of Alzheimer’s

Alzheimer’s disease (AD) is the most common form of dementia, affecting 5% of the population older than 65 years and 30% – 50% of those older than 80. Substantial progress has been made in identifying genes for rare forms of early onset AD and this early success significantly contributed to the  study of AD mechanisms and, more recently, multiple drug discovery approaches. Late-onset AD, the common form of the disease, has been more difficult to solve.  The combination of high-density genotyping methods, large well-characterized AD and control populations, and statistical methods to evaluate population stratification now provide the tools to identify additional genes contributing to AD risk.

Medical and clinical experts now agree that AD starts a decade or more before people have symptoms. By the time there are symptoms, it may already be far too late to save the brain. The goal then is to find ways to identify people who are getting the disease, and use those people as subjects in studies to see how long it takes for symptoms to occur and in studies of drugs that may slow or stop the disease.  Most recently, a paper just published in the Archives of Neurology, outlines a signature in spinal fluid, which very accurately predicts which patients will develop onset of AD within about 5  years. Researchers are finding a number of simple and accurate ways of detecting AD long before there are definite symptoms. In addition to work on genetic tests and spinal fluid tests they also have new PET scans of the brain that show the telltale amyloid plaques that are a unique feature of the disease. Hundreds of new drugs are undergoing testing and trials in the hope that one or more might change the course of the relentless brain cell death that robs people of their memories and abilities to think and reason. The latest PET scans for AD are not commercially available, but the spinal fluid tests are.

These new tests bring with them new questions and concerns.  Should patients and doctors use the commercially available spinal tap tests to find a disease that is yet untreatable? In research studies patients are often not told they may have the disease, but in the real world, many, if not most will be told. Many feel this should be left up to doctors and their patients. Others feel that doctors should not use the spinal fluid tests at all.  The concern is that the spinal fluid tests are not reliable enough and there can be variation in results between labs.  Finally, this type of testing has only been studied in the research settings where patients are carefully selected to have no other conditions, like strokes or depression, that could affect their memories. Some patients with severe memory loss do not have the AD. Doctors may choose to use the spinal tap test in cases where they want to be sure of the diagnosis. Also, they may wish to offer the test to people with milder symptoms who want to know whether they are developing AD.

One negative is that spinal fluid can only be obtained with a spinal tap, and that procedure, with its reputation for pain and headaches, makes some doctors and many patients nervous. The procedure involves putting a needle in the spinal space and withdrawing a small amount of fluid.  It is well-known however that spinal taps are safe and not particularly painful for most people. Still, a program of education is needed to make people feel more comfortable about having them. Since most family doctors and internists are not experienced in performing the test, there could be special spinal tap centers where they could send patients.

The new study included more than 300 patients in their 70s, 114 with normal memories, 200 with memory problems and 102 with Alzheimer’s disease. Their spinal fluid was analyzed for amyloid beta, a protein fragment that forms plaques in the brain, and for tau, a protein that accumulates in dead and dying nerve cells in the brain. To avoid bias, the researchers analyzing the data did not know anything about the clinical status of the subjects. Also, the subjects were not told what the tests showed. Nearly every person with Alzheimer’s had the characteristic spinal fluid protein levels. Nearly three-quarters of people with mild cognitive impairment, a memory impediment that can precede Alzheimer’s, had Alzheimer’s-like spinal fluid proteins. All of those with the proteins developed Alzheimer’s within five years. Nearly one-third of people with normal memories had spinal fluid indicating Alzheimer’s. Researchers suspect that those people will develop memory problems.

The prevailing hypothesis about Alzheimer’s says that amyloid and tau accumulation are necessary for the disease and that stopping the proteins could stop the disease. It is not yet known what happens when these proteins accumulate in the brains of people with normal memories. They might be a risk factor like high cholesterol levels, yet as we know, many people with high cholesterol levels never have heart attacks. Alternatively, it could mean that AD has already started and if the person lives long enough he or she will with absolute certainty get symptoms like memory loss. Many believe that when PET scans for amyloid become available, they will be used instead of spinal taps, in part because doctors and patients are more comfortable with brain scans.

It is clear that for a sensible treatment rationale to develop concerning AD, more knowledge is necessary. It may well be that drugs that are currently used to treat AD, almost always AFTER symptoms have developed, may be more useful if initiated at the first sign of development, just as statin drugs are used to lower cholesterol in patients with high levels, even if they have yet to have a stroke or heart attack.  In any event, early detection is ALWAYS a key to disease treatment and potential successful treatment outcome.  We hope that PET scans will become widely available and soon, so that more patients can be screened in a less invasive manner.  Hopefully, this and as yet to be discovered techniques and medications will finally put a halt to the expanding scourge of Alzheimer’s . . . ben kazie md

New Test Predicts Onset of Alzheimer’s by as Much as a Decade – http://www.associatedcontent.com/article/5674310/new_test_predicts_onset_of_alzheimers.html?cat=12

Spinal-Fluid Test Is Found to Predict Alzheimer’s – http://www.nytimes.com/2010/08/10/health/research/10spinal.html?_r=1&th&emc=th

Diagnosis-Independent Alzheimer Disease Biomarker Signature in Cognitively Normal Elderly People – http://archneur.ama-assn.org/cgi/content/abstract/67/8/949

Meta-analysis Confirms CR1, CLU, and PICALM as Alzheimer Disease Risk Loci and Reveals Interactions With APOE Genotypes – http://archneur.ama-assn.org/cgi/content/full/archneurol.2010.201

What is Alzheimer’s – http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp

Tau protein – http://en.wikipedia.org/wiki/Tau_protein

Beta amyloid – http://en.wikipedia.org/wiki/Amyloid_beta

10 Signs of Alzheimer’s – http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp

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Autism May Cluster Among Highly Educated

Surprising data from a recent study suggest that clusters of autism have been identified mostly in communities with highly educated, mostly white residents.  The most significant factor correlating with the diagnosis of autism was the parent’s educational attainment level.  This was distinct from almost all other factors.  The fact that the majority of these communities were European-American/White may or may not indicate a racial component as socio-economics may also be influencing the racial makeup of these groups.Researchers found that after adjusting for other variables, the majority of areas of autism clustering were characterized by high parental education (relative risks greater for college-graduate vs. non high-school graduate parents).  Other possible considerations related to these findings are that regional health centers do not actively conduct case finding and parents with lower education are, for various reasons, less likely to successfully seek services.  In other words, the relative preponderance of autism cases may be skewed by other factors related to detection and by health services seeking behavior among various groups and within diverse communities.

Autism is a developmental disorder that appears in the first 3 years of life, and affects the brain’s normal development of social and communication skills. Most parents suspect something is wrong by age 18 months and generally seek professional help by age 2. Children with autism typically have difficulties in pretend play, social interactions, verbal and nonverbal communication.  Some children with autism appear normal before age 1 or 2 and then suddenly “regress”, losing language or social skills previously gained. This is called regressive autism.

People with autism may be overly sensitive in sight, hearing, touch, smell, or taste (they may refuse to wear “itchy” clothes and become distressed if forced to wear the clothes); have unusual distress when routines are changed; perform repeated body movements; show unusual attachments to objects. Communication problems often cover a wide variety of presentations.  These may include such things as the inability to start or maintain a social conversation, the use of gestures instead of words, delayed or absent development of language, lack of visual focus in conversation, incorrect self referral, repeating of words and nonsense rhyming.

Social interactions are often abnormal.  Autistic children do not make friends easily, often will not play interactive games, behave in a withdrawn manner, avoid eye contact, prefer to be alone and seem to lack compassion or empathy for others. Responses to various environmental stimuli may appear abnormal.  They may not startle at loud noises, often display increased or decreased senses of sight, hearing, touch, small or taste, may find normal noises painful holding their hands over their ears, may withdraw from physical contact, may rub or lick objects, and may over or under react to pain.

At playtime these children often do not imitate the actions of others, tend to be solitary and demonstrate a lack of pretend or imaginative play. Other behaviors that can signal early warnings include intense tantrums, single topic focus, short attention span, narrow interests, overactive or passive, aggression toward others, poor response to change and repetitive body motions.

Basic research has implicated various areas of the brain as being effected.  These areas include the brain stem, cerebellum and corpus callosum.  These brain areas all have to do with basic motor function as well interconnection and communication between various parts of the brain itself.

Autism is a diagnosis and disorder that is the cause of great stress to parents and families.  They often search in vain for a diagnosis and proper treatment.  It is a fact that both diagnosis and treatment are often difficult and sometimes controversial. While this study does not pinpoint a preventive strategy, any new information is helpful as researchers try to understand the complex development of personality in young children and the myriad of factors that may contribute the development of this disorder . . . ben kazie md

Autism May Be Linked to Educational Level – http://www.associatedcontent.com/article/2892156/autism_may_be_linked_to_educational.html?cat=25

Geographic distribution of autism in California: A retrospective birth cohort analysis – http://www3.interscience.wiley.com/journal/123232153/abstract

Autism May Cluster Among Highly Educated – California study finds a higher rate in neighborhoods with lots of college grads – http://healthday.com/Article.asp?AID=634644

Autism cluster found in Santa Clara County linked to parent education, not neighborhood toxins – http://www.mercurynews.com/breaking-news/ci_14126944?nclick_check=1

UC Davis researchers find California autism clusters, but the cause is a bit of a surprise – http://latimesblogs.latimes.com/booster_shots/2010/01/uc-davis-researchers-find-california-autism-clusters-but-the-cause-is-a-bit-of-a-surprise.html

About Autism – http://www.autism-society.org/site/PageServer?pagename=about_home

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