Image of the day: Syphilitic Chancres of the Lips

A 25-year-old man with no major medical conditions presented with a 2-month history of two painless ulcerated lesions in the midline of the lower and upper lips (Panel A). The round ulcers measured 0.8 cm to 2.4 cm in diameter with clean, smooth bases and slightly elevated, indurated borders. The patient also reported a 1-week history of symmetrically distributed nonpruritic macules on his trunk and limbs. Testing for the human immunodeficiency virus was negative. The patient reported having had unprotected orogenital sex with his girlfriend about 2 weeks before the onset of the ulcers. The physical examination revealed nontender, bilateral submandibular lymphadenopathy. Rapid plasma reagin testing was positive with a titer of at least 1:32. In addition, a Treponema pallidum particle agglutination assay was strongly positive, and a fluorescent treponemal antibody absorption test was positive for both IgG and IgM antibodies. The patient's girlfriend also had positive results on serologic analyses for syphilis, and both were treated with intramuscular penicillin. The lesions completely resolved during a 4-week period (Panel B).

sources:

Dong-Lai Ma, M.D.
Peking Union Medical College Hospital, Beijing, China
mdonglai@sohu.com

Sergio Vano-Galvan, M.D., Ph.D.
Ramon y Cajal Hospital, Madrid, Spain

Clinical Pearls: Paget's Disease

Paget’s disease of bone may present with bone pain but is often asymptomatic. Treatment (typically with bisphosphonates) is indicated in patients with pain that is localized to an affected site but not in asymptomatic patients.

Paget’s disease of bone is a common disorder characterized by focal areas of increased and disorganized bone remodeling affecting one or more bones throughout the skeleton.

Clinical Pearls

•  What is the epidemiology of Paget’s disease and what bones does it preferentially target?
Paget’s disease is rare before the age of 55 years, but increases in prevalence thereafter, in some countries affecting about 5% of women and 8% of men by the eighth decade of life. The disease predominantly affects people of European descent and is rare in Africans, people from the Indian subcontinent, and Asians. It preferentially targets the axial skeleton, most frequently affecting the pelvis (70% of cases), femur (55%), lumbar spine (53%), skull (42%), and tibia (32%).
•  What are the signs and symptoms of Paget’s disease?
The first indication of Paget’s disease of bone is typically an elevated serum alkaline phosphatase level or an abnormal radiograph in a patient whose health is being investigated for other reasons. Between 30 and 40% of patients have symptoms at the time of diagnosis, although the overall proportion of patients with symptoms is believed to be substantially lower (5 to 10%), since many cases never come to medical attention. The most common symptom is bone pain, which may be due to increased bone turnover or a complication such as osteoarthritis, spinal stenosis, or pseudofracture. Deafness may occur in patients with skull involvement. Osteosarcoma is a rare complication (present in less than 0.5% of cases) but should be suspected in patients who have a sudden increase in bone pain or swelling.

Morning Report Questions

Q: How is the diagnosis of Paget’s disease made?    
A: The diagnosis can usually be made on the basis of a radiograph showing the typical features of focal osteolysis with coarsening of the trabecular pattern, bone expansion, and cortical thickening. The extent of disease is best determined on radionuclide bone scans, which can be helpful in assessing symptoms that develop at sites distant from the site of pain at presentation. The use of magnetic resonance imaging or computed tomography is not routinely indicated, although it does have a role in selected patients in whom complications such as spinal stenosis or osteosarcoma are suspected. Typically, patients with Paget’s disease of bone present with an isolated elevation in the alkaline phosphatase level, with otherwise normal results of biochemical testing. However, normal levels of alkaline phosphatase do not rule out the diagnosis.

Q: How is Paget’s disease treated?
A: The drugs of first choice in the treatment of Paget’s disease of bone are nitrogen-containing bisphosphonates (aminobisphosphonates) such as alendronate, pamidronate, risedronate, and zoledronic acid, which preferentially target affected sites and are highly effective at suppressing the increased bone turnover that is characteristic of active Paget’s disease. Randomized trials have shown aminobisphosphonates to be superior to simple bisphosphonates such as etidronate and tiludronate in suppressing bone turnover in Paget’s disease, but not in improving symptoms. Levels of alkaline phosphatase start to fall within about 10 days after the commencement of bisphosphonate treatment and reach a nadir between 3 and 6 months. There is no evidence that asymptomatic patients benefit from antiresorptive therapy.

Weight training: Exercises for a sculpted back

Perhaps because the back muscles aren’t readily visible in the mirror they are often more neglected than other muscle groups that gym-goers love to work out like the chest, biceps or abs. If you lift weights and don’t exercise your back, it’s one of the biggest mistakes you can make. The back muscles support your spine, your head and they also help with your basic movements. Weak back muscles can lead to improper posture, muscle stiffness, backaches (which are becoming very common due to our sedentary habits), spinal injuries and also lack of core strength. Generally speaking, the back muscles can be divided into three categories:

• Upper back also known as the Trapezius (Traps)
• Middle back also known as the Latissimus Dorsi (Lats)
• Lower back which consists of many smaller muscles

Pull-up
No exercise can match the efficacy of the good old-fashioned pull-up. It’s the ultimate test of upper body strength and one of the standard military fitness tests across the world.
How to do it: Hang yourself using your arms from a bar, keep your knees bent and pull yourself up to the point where your chin clears the bar and then go back to your original position. Try to do three sets of 10 to begin with.
Muscles targeted: Entire back – upper, middle and lower – along with arms, abs and shoulders
Expert tip: Don’t try the pull if you are overweight. There are three different grips for this – standard (palms facing out), reverse (palms facing in) and neutral (both palms face towards one another).  If you can’t do a pull-up, try doing a chin-up first. A chin-up has a closer hand grip and you use your biceps more to pull yourself towards the bar. Try doing some chin-ups for a few days and then go back and try the pull-ups again.
Deadlift
The deadlift is a classic weight training exercise and like the pull-up, targets the entire back. It’s however notorious for causing injuries when done improperly. Putting that aside there’s no better exercise to stabilise your back and gain some muscle.
How to do it: If this is the first time you’re attempting it, don’t put too much weight. Your starting position will be feet, shoulder width apart. Bend your knees to reach down and grab the bar without bending over. Lift the bar with your hands slightly lesser than shoulder width (markings on the bar will indicate where you should hold). Now raise the bar slowly till the hip level and then bring it back to your shin. Remember you are supposed to lift the bar using your legs, hips and other muscles and not your arms.
Muscles targeted: Entire back, chest, hips, hamstrings, quadriceps, abs, biceps, legs, hips and abs
Expert tip: This is one exercise that has to be done properly to avoid injuries. While lifting, you must remember not to use your arms so it becomes a push-pull exercise. You’re supposed to lift the bar with your back and leg muscles. Always keep your back straight while doing the exercise and also while lifting, keep in mind that you have complete control while lifting and lowering the weight.  Stop immediately if the movement feels unnatural.
Two seated row/ Cable row
This is a popular back exercise with beginners and is usually done on a pulley or cable machine which is available at most gyms. It’s a basic beginner exercise that targets all the back muscles and helps you acclimatise to the movements required for more complex back exercises.
How to do it: Sit bent slightly forward on a seat or a bench and grasp the cable attachment and place your feet on the vertical platform while you keep your hips, back and knees slightly bent. Pull the cable attachment to your waist while you push your chest forward while arching your back. Return to the original position until arms are extended and shoulders and lower back flexed forward. Repeat it.
Muscles targeted: Entire back, biceps and triceps
Expert tip: If this is your first time to the gym, start with a light weight to allow you lower back to get adapted to the motion. Try and keep control over the motion so that there is no jerk during the movement and you don’t pause or bounce during the lift.
Lat pull-down
A classic cable exercise, the lat pull-down’s great for beginners. It’s usually done on a pulley or cable-machine available at most gyms.
How to do it:  This exercise is usually done with a wide-grip but no too wide so that it restricts your movement. Sit on a stool and use a wide-bar or a lat bar. Make sure that you can grip the bar while sitting so that you don’t over-extend. Keep the back slightly arched and chest puffed while doing this exercise. Bring the bar down to your chest level and then extend your arms completely and bring it back.
Muscles targeted: Lats, shoulders and arms
Expert tip: A common beginner mistake is locking your head and neck which can lead to stiffness. Also make sure that you’re not straining your spine while doing this exercise.
Hyperextension
This is a back exercise which is usually done with a piece of equipment called the Roman Chair also called a hyperextension bench. Most gyms have this equipment; it’s basically an inclined gym bench with platforms to lock your legs – in some gyms it’s also called the hyperextension bench.
How to do it: Just lie down face forward on the bench and lock your ankles properly. You can either cross your hands around your chest or keep them behind your head. Bend over as far as you can while keeping your back straight and then come back to the original position.
Muscles targeted: The major muscle targeted is your lower back and it also works your glutes (buttocks) and hamstrings.
Expert tip: When coming up make sure you don’t go beyond the point where your back is straight. Try to keep as smooth a motion without any jerks whatsoever and don’t swing your back.
T-bar row
The T-bar is a machine that’s present in most gyms. It usually has two platforms for your legs and a long bar with two small handles. It will be easy to spot.
How to do it: Keep your feet firmly on the ground and using a narrow grip, hold the bar slightly off the ground while keeping your back straight and knees bent. Lift the bar towards your body with your back while squeezing the shoulder blades together. Lift the bar until it almost touches your lower chest and repeat the exercise.
Muscles targeted: Middle back, biceps and shoulders
Expert tip: Make sure your back is not arched while doing this exercise. Try and stay in the bent knees position throughout the exercise and don’t move your lower body.
One arm dumbbell rows
This exercise is usually done on a bench with one knee and arm on the bench and the other foot on the floor. This is an alternative exercise and targets only one side of the back and you’ve to repeat for both sides.
How to do it: Say you start with your right arm. Keep your left knee and left hand on the bar and the right on the ground. Keep your face straight and back arched. Pull your shoulder blade back while keeping your arm straight and pull the dumbbell as far up as possible and then slowly lower the dumbbell. After you’ve done the desired numbers of reps, switch sides.
Muscles targeted: Middle back/lats, traps and biceps
Expert tip: Always look straight while performing this exercise as this will help keep the back straight. Keep the upper half of your body completely fixed while doing this and don’t let your shoulder drop. Make sure you’re pulling using your back muscles and not your forearm.
 The aforementioned exercises are in no way an exhaustive list of back exercises but they should be enough to get you started and build a back that’ll be strong enough to stabilise your spine, give you a better posture and not feel embarrassed if you need to take your shirt off!

Mammogram Every 2 Years May Be OK for Older Women

The society's current guidelines recommend annual mammograms for women age 40 and over, as long as they are in good health. Age alone should not be a reason to stop having the screening, according to the guidelines, but women with short life expectancies or serious health problems should discuss the pros and cons of screening with their doctor, the society suggests.

Decisions about guidelines are constantly evolving, Lichtenfeld said, as more research is published.

Judith Malmgren, an affiliate assistant professor of epidemiology at the University of Washington, in Seattle, said the new study "confirms earlier studies that biennial screening is fine for older women with fewer false-positives."
However, she said, women with a family history or those who feel uncomfortable with the longer interval should opt for annual exams.
The study was funded by a variety of grants from the U.S. National Cancer Institute and others. Braithwaite was partially funded by the Mentored Research Scholar Award from the American Cancer Society.
For older women ages 66 to 74, getting a mammogram every two years appears as good as getting one every year, according to a new study. "Your risk of having breast cancer detected at a later stage is no greater if you screen every two years compared to every year," said Dejana Braithwaite, an assistant professor of cancer epidemiology at the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco.
Braithwaite compared annual with every-other-year screenings and the effect on whether the cancer was diagnosed at a late stage. She also compared how the two intervals affected the number of "false-positive" test results, in which mammograms interpreted as possibly showing cancer actually did not do so after further testing.
Women screened every year were more likely to have false-positive results than women screened every two years, she said.
The study is published online Feb. 5 in the Journal of the National Cancer Institute.
The debate about the frequency of mammograms and how long to continue them is ongoing. In 2009, the U.S. Preventive Services Task Force, an independent panel of experts, issued recommendations that women 50 to 74 have mammograms every two years. It recommends women under 50 discuss with their doctor the pros and cons of regular screening.
Other organizations continue to recommend annual mammograms beginning at age 40.
For the new study, Braithwaite looked at data on more than 140,000 women, ages 66 to 89, collected from 1999 to 2006. The women all had mammograms at facilities that participated in a data linkage between the Breast Cancer Surveillance Consortium and Medicare claims.
Nearly 3,000 of the women were diagnosed with breast cancer.
Braithwaite also had data on those who ended up with false-positive results. If cancer is suspected on a mammogram, more tests are ordered. If no cancer is found, this false-positive result can mean unnecessary procedures, added expense, time lost from work and anxiety, experts say.
The researchers estimated the probability of false-positives over a decade for the women 66 to 74.
"After 10 years of screening, almost half, or 48 percent, of the women who were screened every year had at least one false-positive," Braithwaite said. "Among those screened every two years, 29 percent had at least one false-positive after 10 years."
Results were similar in the upper age group, 75 to 89, she said.
The finding that late-stage cancers were no more likely in the women screened every other year is not a surprise, said Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, who was not involved in the study.
"We've known that breast cancers in older women tends to be slower growing," he said.

Which Cancer Tests Do You Really Need?

Not all cancer screening tests are helpful, and some are potentially harmful, according to a new Consumer Reports rating.

In the new report, Consumer Reports recommends only three of 11 common cancer screening tests, and then only for certain age groups.

Screenings for cervical, colon, and breast cancer are recommended.
Screenings for cancers affecting the bladder, lungs, skin, mouth, prostate, ovaries, pancreas, and testicles are not.
"The science of prevention and screening has changed," says John Santa, MD, MPH, director of the Consumer Reports Health Ratings Center. He oversaw the project.
"Consumers need to know that some screening tests are terrific, some are not good, and some can harm you," Santa says.
"We are not talking about people at high risk," he says. "And of course they are not symptomatic. We're not talking about what you should do if you have a mole that is changing or if you feel a breast lump."

To develop the ratings, Santa and his team looked at medical research, consulted medical experts, surveyed more than 10,000 readers, and talked with patients about screening tests.
They looked closely at recommendations of the U.S. Preventive Services Task Force. This independent panel provides guidelines on health care based on evidence. Much of Consumer Reports' recommendations follow the task force guidelines to the letter.  But, their recommendations sometimes differ from those of organizations such as the American Cancer Society (ACS). Here, details on the three recommended tests:

• Cervical cancer . Women 21 to 30 should have a Pap smear to test for cervical cancer every three years. Women 30 to 65 can wait five years if they have had testing for human papillomavirus (HPV), the virus that causes the cancer. Those 65-plus can skip screening if they were screened regularly earlier. Those under 21 can also skip the test, as experts know the cancer is not common at those ages. 

• Colon cancer. Those 50 to 75 should get screened regularly, and older people should discuss the pros and cons with their doctor and decide. Options include a colonoscopy, which examines the entire colon, every 10 years, or a sigmoidoscopy, which looks at the lower third, every five years plus a stool test every three years, or an annual stool test. As far as other guidelines, no groups suggest screening younger than 50 unless high risk. The ACS also doesn't say to specifically stop at age 75.

• Breast cancer. Women 50 to 75 need a mammogram every two years. Those 40 to 49 or 75 andolder should talk with their doctor about pros and cons. These guidelines do split with those of the ACS, though. The cancer society recommends yearly mammograms after age 40 and as long as healthy.

The other eight tests were not recommended for those not at high risk because the cancers are uncommon, the test's effectiveness is not proven, or the test can't detect the disease at a curable stage. And even though some of the tests aren't really recommended by anyone, this list is a valuable reminder for people who may feel they need to seek them out.

On the "avoid" list, screenings for:

• Bladder cancer. The test looks for blood or cancer cells in the urine.

• Lung cancer. The test is a low-dose CT scan. The ACS only recommends this for high-risk people (such as older individuals who've smoked for years).

• Skin cancer. The test is a visual exam of your skin to spot signs of the deadly skin cancer melanoma. The ACS says a skin exam by a doctor should be included as part of the routine check-up.

• Oral cancer. This visual exam of the mouth is done by a dentist or other health care professional. The ACS suggests this as part of your normal routine oral care.

• Prostate cancer. The blood test is known as the PSA (prostate-specific antigen) test. The ACS says to discuss PSA tests with your doctor, but doesn’t recommend widespread screening of everyone.

• Ovarian cancer. Tests include a blood test to look for a protein linked with the cancer, and a transvaginal ultrasound. This test is generally not recommended by anyone for the general public.

• Pancreatic cancer. Tests are abdominal images or genetic tests. This test is also generally not recommended by anyone for the general public.

• Testicular cancer. The test is a physical exam of the testicles. ACS does recommend this as part of routine care; the task force doesn't.

Cancer Tests: Perspectives

The new ratings drew mixed reactions.
Otis Brawley, MD, chief medical officer of the American Cancer Society, says the report helps to put screening into its proper perspective. "There has been a significant amount of over-promising and over-promoting," he says.
He frowns on aggressive campaigns that have included mammogram parties or group colonoscopies.
"A lot of screening is being done by organizations that can profit from it," he says.
"The truth is, certain tests do have some significant benefit, and every test has some limitations," he says. "In the spirit of informed decision-making, people need to understand both the potential for benefit and the potential for harm."
As mentioned, the recommendations on breast cancer screening from Consumer Reports and the American Cancer Society are different, but Brawley calls these differences ''minimal."
"We recommend women in their 40s get a mammogram on an annual basis, but we also recommend those women get information on the limitations," he says.
These include missing some cancers and ordering additional tests when no cancer turns out to be there.

Some doctors took issue with the decision to use the task force recommendations as the basic source.

"I'm disappointed they followed the task force guidelines, because we feel they are inadequate to protect women," says Debra Monticciolo, MD, chair of the American College of Radiology's Quality and Safety Commission and vice chair of radiology at Scott & White Healthcare in Temple, Texas.

"Right now, we can't cure breast cancer, so we really need to find cancers early," she says. Research has found the best way to do that is by yearly mammograms beginning at age 40, she says.
The recommendation to avoid PSA tests refutes evidence that they work, say Dipen Parekh, MD, a professor and chair of urology at the University of Miami Miller School of Medicine's Sylvester Comprehensive Cancer Center.
"There is no question the decline in the incidence of advanced prostate cancer is due in large part to PSA screening," he says.
However, the recommendation for women at low risk for ovarian cancer not to seek screening is a good one, says J. Matt Pearson, MD, assistant professor and a gynecologic oncologist at the University of Miami Miller School of Medicine's Sylvester Comprehensive Cancer Center.
The lifetime risk of ovarian cancer in the general population is low. When you screen for a cancer that is not common, he tells women, "you are more likely to find a benign abnormality that pushes you toward [unneeded] surgery."

Cancer Tests: Making the Decision

Santa recommends educating yourself about cancer screening tests, then talking to your doctor about whether the benefits outweigh the risks for you.
"Don't go to a mobile van, don't go to a mammogram party," he says.
"Don't believe a billboard on the highway that tells you to get a PSA test when it comes from a hospital that has a robotic prostate cancer surgery program."

Cancer Prevention: Lifestyle, Lifestyle, Lifestyle

"If you are serious about preventing cancer, you don't smoke, you exercise, and you try to get to a normal weight," Santa says. Obesity has been linked with about 4% of men's new cancers and 7% of women's, he says.
Getting to a normal weight may especially lower the risk for uterine and esophageal cancers.
Regular exercise can reduce colon and breast cancer risk.
Smoking is linked with lung cancer as well as cancers of the larynx, oral cavity, esophagus, bladder, kidney, and pancreas.

Today's Topic: Stable Angina

Stable angina is chest pain or discomfort that usually occurs with activity or stress. Angina is chest discomfort due to poor blood flow through the blood vessels in the heart.
See also: Unstable angina

Causes, incidence, and risk factors

Your heart muscle is working all the time, so it needs a constant supply of oxygen. This oxygen is provided by the coronary arteries, which carry blood.
When the heart muscle has to work harder, it needs more oxygen. Symptoms of angina occur when the coronary arteries are narrowed or blocked by hardening of the arteries (atherosclerosis), or by a blood clot.
The most common cause of angina is coronary heart disease (CHD). Angina pectoris is the medical term for this type of chest pain.
Stable angina is less serious than unstable angina, but it can be very painful or uncomfortable.
There are many risk factors for coronary heart disease. Some include:

• Diabetes 
• High blood pressure
• High LDL cholesterol and low HDL cholesterol
• Smoking

Anything that makes the heart muscle need more oxygen can cause an angina attack in someone with heart disease, including:

• Cold weather
• Exercise
• Emotional stress
• Large meals

Other causes of angina include:

• Abnormal heart rhythms (usually ones that cause your heart to beat quickly)
• Anemia
• Coronary artery spasm (also called Prinzmetal's angina)
• Heart failure
• Heart valve disease
• Hyperthyroidism (overactive thyroid)

Symptoms

Symptoms of stable angina are most often predictable. This means that the same amount of exercise or activity may cause your angina to occur. Your angina should improve or go away when you stop or slow down the exercise.
The most common symptom is chest pain that occurs behind the breastbone or slightly to the left of it. The pain of stable angina usually begins slowly and gets worse over the next few minutes before going away.
The pain may feel like tightness, heavy pressure, squeezing, or crushing pain. It may spread to the:

• Arm (usually the left)
• Back
• Jaw
• Neck
• Shoulder

Some people say the pain feels like gas or indigestion.
Some patients (women, older adults, and people with diabetes) may have different symptoms, such as:

• Back, arm, or neck pain
• Fatigue
• Shortness of breath
• Weakness

The pain of stable angina usually:

• Occurs after activity or stress
• Lasts an average of 1 - 15 minutes
• Is relieved with rest or a medicine called nitroglycerin

Angina attacks can occur at any time during the day, but a higher number occur between 6 a.m. and noon.
Other symptoms of angina include:

• A feeling of indigestion or heartburn
• Dizziness or light-headedness
• Nausea, vomiting, and sweating
• Palpitations
• Shortness of breath
• Unexplained tiredness after activity (more common in women)

Signs and tests

Your doctor or nurse will examine you and measure your blood pressure. Tests that may be done include:

• Coronary angiography
• Coronary risk profile (special blood tests)
• ECG
• Exercise tolerance test (stress test or treadmill test)
• Nuclear medicine (thallium) stress test
• Stress echocardiogram

Treatment

The options for treating angina include lifestyle changes, medications, and procedures such as coronary angioplasty with stent placement or coronary artery bypass surgery.
You and your doctor should agree on a plan for treating your angina on a daily basis. This should include:

• What medicines you should be taking to prevent angina
• What activities are okay for you to do, and which ones are not
• What medicines you should take when you have angina
• What are the signs that your angina is getting worse
• When you should call the doctor or 911

MEDICATIONS
You may be asked to take one or more medicines to treat blood pressure, diabetes, or high cholesterol levels. Follow your doctor's directions closely to help prevent your angina from getting worse.
Nitroglycerin pills or spray may be used to stop chest pain.
Taking aspirin and clopidogrel (Plavix) or prasugrel (Effient) helps prevent blood clots from forming in your arteries, and reduces your risk of having a heart attack. Ask your doctor whether you should be taking these medications.
Your doctor may give you one or more medicines to help prevent you from having angina.

• ACE inhibitors to lower blood pressure and protect your heart
• Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart
• Calcium channel blockers to relax arteries, lower blood pressure, and reduce strain on the heart
• Nitrates to help prevent angina
• Ranolazine (Ranexa) to treat chronic angina

NEVER STOP TAKING ANY OF THESE DRUGS ON YOUR OWN. Always talk to your doctor first. Stopping these drugs suddenly can make your angina worse or cause a heart attack. This is especially true of anti-clotting drugs (aspirin, clopidogrel, and prasugrel).
Your doctor may recommend a cardiac rehabilitation program to help improve your heart's fitness.
SURGICAL TREATMENT
Some people will be treated with medicines and will not need surgery to treat a blockage or narrowing. Others will need a procedure to open narrowed or blocked blood vessels that supply blood to the heart.

• Angioplasty and stent placement (also called percutaneous coronary intervention)
• Blockages that cannot be treated with angioplasty may need a heart bypass

Expectations (prognosis)

Stable angina usually improves with medication.

Celiac Disease: New Hope for a Pill Treatment?

The only current treatment for celiac disease is a gluten-free diet. A new study, however, offers some potential for hope. Researchers have re-engineered a naturally occurring enzyme, kumamolisin-As, to break down gluten in the stomach into much smaller protein pieces, called peptides. They say these are less likely to trigger the autoimmune response that can create a wide range of painful and irritating symptoms.
The re-engineered enzyme, named KumaMax, appears to be highly effective, at least in a test tube. It dismantled more than 95 percent of a gluten peptide that is thought to cause celiac disease, according to the study, which was published recently in the Journal of the American Chemical Society.
Ideally, the team could develop the enzyme into a food additive such as the gas remedies Beano or Gas-X and offer it without a prescription, said lead study author Justin Siegel, assistant professor of chemistry and biochemistry at the University of California, Davis. But this could take a few years to develop. If the researchers opt to make a prescription drug, the process of clinical trials and obtaining U.S. Food and Drug Administration approval could take a decade or more, he said.
An enzyme is a protein that performs a chemical reaction. Proteins are the workhorses in every cell of every living thing, and their function is defined by their shape and structure.
In this case, the researchers re-engineered the natural enzyme to recognize the peptide that triggers celiac disease and modified the protein in the laboratory so it would survive the acidic stomach environment. "We did the engineering to change the genes and sent that into standard microorganisms to create the protein," Siegel said.
The next step is to show that the enzyme is not toxic and functions as designed in animals. "It shouldn't be toxic; it's just a protein you're eating," Siegel said.
How effective might the enzyme be? "For some people, even flour in the air makes them stop breathing. Some are very sensitive, and in some it just upsets their stomach a little," Siegel said. "For those who are hypersensitive, this probably is not going to solve the problem, but it would allow them to go to dinner, and in case any gluten ended up in their meal, they wouldn't have to worry about it."
"For those less sensitive, they could pop one before each meal and eat anything they want," he added.


The process of identifying the precise trigger for a disease or condition and engineering a drug to circumvent the disease-causing process is part of what some call the personalized medicine revolution, Siegel said. "We can design a small molecule, a pill, that can be specific to an exact target and have few side effects, if any," he said.
Some experts identified limitations to the research.
"This is the earliest phase, and you now have to show that it actually breaks down the gluten peptides that trigger a response in the stomach at a speed that will protect the human," said Dr. Joseph Murray, a professor of medicine in the division of gastroenterology and the department of immunology at the Mayo Clinic, in Rochester, Minn. "Let's see how it goes with a whole slice of bread."
Murray said that dismantling 95 percent of the protein component that is thought to trigger celiac disease may still not be enough to provide celiac patients protection. "It will probably be helpful to someone who gets a low-level exposure [to glutens] by accident," he said.
But celiac disease is a common problem, with about 2 million to 3 million Americans suffering from it. "People need alternatives, and this is an example of the scientific community taking novel approaches to helping people with celiac disease," Murray said.

C-Section May Disrupt 'Good' Bacteria in Babies

Being born by cesarean section has been tied to higher risks for various health problems in children, and now a new study finds these babies also have fewer "good" bacteria in their digestive tract.
Similarly, babies who were exclusively or even partially formula-fed rather than breast-fed also had markedly different gut flora than babies who were breast-fed, according to the study appearing in the Feb. 11 issue of the CMAJ (Canadian Medical Association Journal).
"Since other [researchers] have found associations between cesarean section delivery or formula-feeding and infant gut changes and conditions like allergy [and] asthma, we speculate that our observations may lead to poor health in later life," said study senior author Anita Kozyrskyj.
The findings support current clinical practice guidelines which favor vaginal delivery whenever possible, added Kozyrskyj, who is research chair and an associate professor of pediatrics at the University of Alberta, in Edmonton.
About a third of all U.S. births occur by C-section, a number considered by many to be far too high and potentially harmful to both the child and the mother.
Vaginal delivery, among other advantages, fosters the growth of trillions of good bacteria that reside peacefully in the human body (collectively know as a person's microbiome), many of them in the intestine.
Meanwhile, C-sections interfere with the newborn's exposure to bacteria in the vaginal tract, bacteria that essentially trains the immune system to react appropriately to future events, according to study background information.
Mothers who have C-sections also tend to start breast-feeding later and require antibiotics, both of which could also affect the baby's microbiome.
In the new study, researchers analyzed DNA from fecal samples taken from 24 healthy infants in four Canadian provinces at 4 months of age.
Compared with children who had been born vaginally, children who had been delivered by C-section had less diverse flora, lower levels of Shigella bacteria and none of the bacteria known as Bacteroides at all.
"Shigella and Bacteroides are organisms picked up from mom and considered first colonizers," Kozyrskyj explained. "They lay the foundation for further microbes that become part of our normal microbiome."
Meanwhile, infants who were fed formula as opposed to breast milk also had less diverse flora and, in addition, had more of the bacteria Clostridium difficile, which had been associated with the development of allergies.
The study was a small one, but the researchers have collected fecal samples on 200 children and will be analyzing those in the future. They hope to eventually enroll 2,500 children in the study.
It's too soon to say definitively that the changes in the gut microbiome of children born by C-section will develop health problems. And it's possible that changes in the bacterial composition of the intestine as people age will compensate for diminished levels of bacteria in newborns, Kozyrskyj added.
A pediatric expert praised the new study.
"This is an important first step to make an association between intestinal bacteria and mode of delivery and type of feeding," said Dr. Michael Morowitz, a pediatric surgeon with Children's Hospital of Pittsburgh, at the University of Pittsburgh Medical Center.
Although follow-up studies will be needed, Morowitz added, "This is the latest piece of pretty convincing evidence that determinants very, very early in life can have an impact that lasts for months or years."

Folic Acid in Pregnancy May Lower Autism Risk

A new study suggests that women who start taking folic acid supplements either before or early in their pregnancy may reduce their child's risk of developing autism.
"The study does not prove that folic acid supplements can prevent childhood autism. But it does provide an indication that folic acid might be preventive," said study lead author Dr. Pal Suren, from the division of epidemiology at the Norwegian Institute of Public Health in Oslo.
"The findings also provide a rationale for further investigations of possible causes, as well as investigations of whether folic acid is associated with a reduced risk of other brain disorders in children," he said.
Taking folic acid supplements during pregnancy is already known to prevent birth defects such as spina bifida, which affects the spine, and anencephaly, which causes part of the brain to be missing.
Alycia Halladay, senior director of environmental and clinical sciences at Autism Speaks, said that "parents always wonder what they can do to reduce the risk [of autism], and this [folic acid] is a very inexpensive item that mothers can do both before pregnancy and very early in their pregnancy."
As to why folic acid may be beneficial, Halladay speculated that the nutrient might blunt a genetic risk for autism or boost other processes during pregnancy that are protective.
Another expert, Dr. Roberto Tuchman, director of the Autism and Neurodevelopment Program at Miami Children's Hospital's Dan Marino Center, said, "This study suggests that in some kids autism spectrum disorders may be preventable. As a clinician who works with autism spectrum disorders it is exciting that we can look at potentially preventable factors in autism. This is really encouraging."
Still, Tuchman cautioned that the study findings are very preliminary, and it isn't possible to tell which autism spectrum disorders, if any, folic acid may prevent.
The study findings were published in the Feb. 13 issue of the Journal of the American Medical Association.
To see whether folic acid might protect children from autism, Suren's team collected data on more than 85,000 children born in Norway from 2002 to 2008.
Over an average of six years of follow-up, 270 children were diagnosed with autism spectrum disorders, 114 with autism, 56 with Asperger syndrome and 100 with an unspecified autism disorder.
Among those mothers who took folic acid supplements, 0.10 percent of their children were diagnosed with autism, compared with 0.21 percent of children whose mothers didn't take folic acid. That's a 39 percent lowered risk for the neurodevelopment disorder, Suren said.
Suren's group did not find a connection between folic acid and either Asperger syndrome or unspecified autism disorder. "For Asperger syndrome, the number of children was too low to obtain sufficient statistical power in the analyses," Suren explained.
The protective affect of folic acid seemed to work even if not taken until early pregnancy. No protection from folic acid was seen if taken at mid- pregnancy, the researchers noted.
"The results support the current recommendations of taking folic acid supplements during pregnancy and emphasize the importance of starting early, preferably before conception," Suren said.
Halladay said the study finding confirms the results of another study that showed that folic acid might reduce the risk of autism. "The benefits of prenatal care, including taking vitamins, has been well-documented for things like birth defects and even language delay," she said.
Whether or not folic acid supplementation will make a dent in the growing number of children diagnosed with autism spectrum disorder isn't known. An estimated one in 88 children in the United States has been diagnosed with some form of autism spectrum disorder, according to the federal Centers for Disease Control and Prevention.
In the United States and other countries many foods, such as breads and pasta, are fortified with folic acid to help prevent birth defects. But, it isn't clear yet how much folic acid might guard against autism, so a woman should discuss her options with her doctor, Halladay said.

Red Wine, Green Tea, and the Fight Against Alzheimer's

We’ve all heard that drinking one glass of red wine a day is good for your heart, and the medicinal properties of green tea have been touted for centuries, but new research from the University of Leeds, published in the Journal of Biological Chemistry, shows that the natural chemicals found in these two beverages may also help treat Alzheimer’s disease.
Green tea and red wine contain natural chemicals called ‘polyphenols’—also called antioxidants—such as EGCG and resveratrol, which are known to protect against a number of diseases, including certain cancers, stroke, and heart disease, said study co-author Jo Rushworth of the University of Leeds.
Using purified extracts of EGCG and resveratrol, Rushworth and her colleagues were able to identify and interrupt the process that allows harmful clumps of protein to latch onto and destroy brain cells. These findings could serve as a potential targets for developing drugs to treat Alzheimer's.
"This is an important step in increasing our understanding of the cause and progression of Alzheimer's disease," said lead researcher Nigel Hooper of the University's Faculty of Biological Sciences in a press release. "It's a misconception that Alzheimer's is a natural part of aging; it's a disease that we believe can ultimately be cured through finding new opportunities for drug targets like this."

The Nitty-gritty Details

In the U.S. alone, 5.4 million people currently live with Alzheimer's disease, making it the sixth leading cause of death in the nation. It is also “the only cause of death among the top 10 in the United States that cannot be prevented, cured, or even slowed,” according to the  Alzheimer’s Association. And according to the 2010 World Alzheimer Report, “Alzheimer’s Disease International estimated that there are 35.6 million people living with dementia worldwide in 2010, increasing to 65.7 million by 2030 and 115.4 million by 2050.”
Alzheimer’s disease is characterized by the build-up of amyloid proteins in the brain that can clump together to form balls of different shapes and sizes. These balls latch on to the surface of nerve cells in the brain, causing them to misfire and eventually die.
However, researchers found that when they formed their own amyloid balls in a test tube and added red wine and green tea extracts to human and animal brain cells, the shape of the amyloid balls changed. They could no longer bind to proteins on the surface of nerve cells, eventually killing them.
“In our study, we showed that the major causative agent of Alzheimer’s disease—poisonous clumps of amyloid protein—can be prevented from latching on to, and killing, brain cells,” said Rushworth in an interview with Healthline. “In addition to using green tea and red wine extracts, we also looked at the specific parts of brain cells that allow the poisonous amyloid clumps to latch on like Velcro. We found that by removing a certain protein from brain cells, the amyloid clumps couldn’t attach and cause brain cell death. This may provide another target for developing anti-Alzheimer’s drugs.”

Green Tea and Red Wine in the Spotlight

Do the results of this study mean you should load up on red wine and green tea? According to Rushworth, this isn’t necessarily the case.
“In our study, we used purified extracts from red wine and green tea, instead of using the complete red wine or green tea,” she said. “This means that we can’t predict how much red wine or green tea would have to be drunk to have a potentially beneficial effect.”
In fact, it is difficult for substances contained in food or drink to penetrate the brain, so it’s unlikely that a cup of green tea or a glass of red wine would provide the required amount of these substances to prevent Alzheimer’s, Rushworth said.
“But it is possible to modify the chemistry of these substances to improve their uptake into the brain, thereby creating a potential drug for Alzheimer’s disease, and this would be the next step in our research,” she said. “However, it is interesting to note that the Mediterranean diet, which tends to include red wine, is renowned for its health benefits.”

The Next Step Toward Finding a Cure

While this research provides valuable insight into the cause and possible treatment of Alzheimer’s, more research must to be done before scientists can find a cure for this devastating disease.
“Another big problem to tackle is the fact that Alzheimer’s disease is very hard to diagnose and, by the time a diagnosis has been made, it is often too late to administer useful drug treatments,” Rushworth said. “The latest research suggests that, to be effective, we need to be treating Alzheimer’s before it can currently be detected.”
Finding the key processes that trigger Alzheimer’s disease is one of the most important steps toward finding a cure, said Rushworth.
“When we understand what causes Alzheimer’s disease, then we will be able to design a drug to stop it from happening, in the same way that we have drugs to cure other diseases,” she said. “With more funding for scientific research, we will defeat Alzheimer’s disease.”

Needleless Vaccinations a Huge Step Toward Eradicating Infectious Disease

In his first appearance on The Colbert Report last week, billionaire philanthropist Bill Gates made a bold prediction: “Polio was down to 250 cases last year in the entire world. In the next six years we’ll get it down to zero and it’ll become the second disease to ever be eradicated.” Gates is putting his money where his mouth is by financing cutting-edge vaccination programs in the areas hardest hit by infectious disease.
Live vaccines—which contain active viruses or bacteria—are notoriously hard to deliver in resource-deprived areas because they must be continually refrigerated to keep them viable. However, with funding from the Bill and Melinda Gates Foundation, researchers at King’s College London have found a way to administer a dried live vaccine directly to the skin—without needles—that remains effective at room temperature.
Besides solving the problem of refrigeration, needle-less vaccine delivery eliminates a host of other issues: the pain of injections and fear of needles that keep some people from being immunized, the risk of needle contamination with blood-borne illnesses like HIV, and the cost of purchasing many thousands of sterilized hypodermic needles.
If the technology becomes commonplace, it could also better the lives of millions who use needles every day to check their blood sugar levels, administer insulin, and inject anti-inflammatory drugs. In fact, clinical trials of a peptide-based vaccine for type 1 diabetes, led by Professor Mark Peakman of King’s College London, dovetail with these efforts to find better, less painful ways to administer life-saving drugs.
The groundbreaking research on room-temperature vaccine delivery was published this week in Proceedings of the National Academy of Sciences.

How Does Needle-free Vaccination Work?

Mary Poppins says “a spoonful of sugar helps the medicine go down,” but in this case, the sweet stuff helps the drug get under your skin.
The King’s College team dried an experimental live HIV vaccine in sugar (sucrose), and then used a specialized mold to shape the concoction into a microneedle array—a small disc with several tiny points that dissolve when imbedded in the skin.
“Current licensed vaccines for humans are mostly injected into muscle or into the deeper fatty layer of the skin, which can be quite painful,” said Dr. Linda Klavinskis, lead study author and a researcher in the Department of Immunobiology at King’s College London. “We anticipate that the shallow penetration of the sugar needles, simply dissolving into the upper layer of the skin, should be more patient friendly.”
Thus far, the technique has only been tested on mice, but the results are more than promising. Researchers were able to identify, for the first time, a group of cells in the skin that can detect this type of vaccine and put the body’s immune system on alert.
With the help of these specialized cells, the new, room-temperature vaccine produced the same immune response as traditional liquid medicine stored in a freezer and injected with a needle.

What Can I Do to Protect Myself Now?

Klavinskis says that before the sugar “micro-needle” technique reaches consumers, her team will need to scale-up their production, file for and conduct clinical trials on human subjects, and seek approval from agencies like the FDA.

Is “Male Menopause” a Real Condition?

There is some disagreement among experts regarding the term “male menopause.” A number of experts believe that it is not a real condition, but simply reflects the effects of aging, while other experts feel it is a real condition that should be treated. Though many men definitely experience hormonal changes as they get older, these changes, most commonly in testosterone levels, are usually more gradual than the changes seen with female hormones in female menopause.  Many experts prefer the term “andropause,” “low testosterone (Low T),” or testosterone deficiency over “male menopause.”


While there is disagreement over the exact terminology that should be used, what is real is that many men gradually become aware of symptoms that can be correlated to the lower blood levels of testosterone. These symptoms can become more obvious and more troubling as men get older. What is also real is that low testosterone has been associated with an increased risk of death.

What Are the Functions of Testosterone in a Man?

During puberty, testosterone is responsible for the development of male characteristics such as increased muscle mass; a deeper voice; hair on the chest, face, and underarms; increased genital size; and development of normal erections. During the adult years, testosterone helps maintain muscle and bone strength and maintains a man’s sexual drive and sexual interest.

What Are the Common Symptoms of Low Testosterone?

The symptoms associated with low testosterone or Low T can be grouped into categories. The Endocrine Society lists the following “red flag” symptoms that should alert someone to the possibility of low testosterone levels:

• Problems with sexual function that can include erectile dysfunction (ED), decreased desire for sexual activity (decreased libido), and a decrease in the number and quality of erections.
• Some men may notice smaller testes (hypogonadism). The amount and force of the ejaculate may also decrease. 
• Emotional problems, including depression, irritability, anxiety, problems with memory or concentration, or decreased self-confidence can occur.
• Sleep and energy issues occur that may range from problems getting to sleep or staying asleep to unexplained drowsiness, increased fatigue, or a general lack of energy.
• Body changes can take place—these can include increased belly fat, decreased muscle mass (along with decreased strength and endurance), decreases in cholesterol levels and osteopenia (softening of the bones), and osteoporosis (decreased bone density). 
• Some men can experience swollen or tender breasts (gynecomastia) or a loss of body hair. Some men experience hot flashes similar to those experienced by women during menopause. 
•  

• How Is Low T Diagnosed?

  Your physician can diagnose Low T through a combination of a physical exam and a blood test to measure your testosterone levels. He or she may also want to rule out other possible conditions such as low thyroid function, depression, high blood pressure, heart disease, diabetes, or the side effects of medications you may already be taking. Be prepared to undergo a full physical exam, including a genital exam, and to answer a number of personal questions. It is important to give complete answers, because the treatment options will differ depending on your particular set of problems.
  The blood test for testosterone is not necessarily the definitive answer—these tests have to be interpreted by your physician, who has to consider your unique situation.  For example, about 30 percent of those tested for testosterone will show low levels on their first test, but when it is repeated, they show normal levels. Also, the most important lab value is the “free” or “bioavailable” testosterone as opposed to the total testosterone—and the bioavailable testosterone is not always easy to measure.
  
  A low testosterone level can be caused by:
• aging
• injury to the testicles
• type 2 diabetes
• obesity
• alcoholism
• medication side effects
• testicular cancer or the treatments for testicular cancer
• other hormonal disorders
• infections such as HIV/AIDS
• chronic liver or kidney disease

What Are the treatment options?

Treatment depends on the underlying cause of the low testosterone levels. Once other conditions have been ruled out, your doctor may discuss testosterone therapy (TT) with you.  There are many approaches to TT, including injections, patches, topical gels, and oral dosing. TT does have some risks and side effects associated with it. Some of the side effects are:

• increased swelling or tenderness of the breasts
• acne
• swelling of the ankles
• increased numbers of red blood cells, which may increase the risks of blood clots and heart attacks or strokes.

Today's Topic: Female Infertility

What Is It?

For a man and a woman who are having frequent intercourse without using any birth control, the average amount of time that it takes to conceive is six months. Most couples are able to achieve a pregnancy within one year if they have intercourse frequently (twice per week or more often). Between 10% and 15% of couples will continue to have difficulty conceiving after one year of trying. When pregnancy is this slow to occur, the man and woman are diagnosed as infertile.

Infertility can be caused by health problems in the man, the woman or both partners. In some infertile couples, no cause can be found to explain the problem. In approximately 20% of couples, more than one cause of the infertility is found. The cause of infertility occurs about as often in men as in women.

Normal aging reduces a woman's ability to become pregnant. Ovulation, the process of forming and releasing an egg, becomes slower and less effective. Aging begins to reduce fertility as early as age 30, and pregnancy rates are very low after age 44, even when fertility medications are used. Even though fertility is less reliable for women of older ages, approximately 20% of women in the United States have their first child at or after age 35.
Symptoms

The primary symptom of infertility is difficulty getting pregnant. Various causes of infertility may result in additional symptoms. Any of the following problems may cause infertility:


Infrequent ovulation (egg release from the ovary) accounts for 20% of female infertility problems. If your ovulation is infrequent, your periods will be spaced apart by longer than a month, or they will be absent. Common causes of infrequent ovulation include body stresses such as eating disorders, unusually ambitious exercise training, rapid weight loss, low body weight and obesity. Some hormonal abnormalities such as thyroid problems, pituitary-gland problems, adrenal-gland problems and polycystic ovary syndrome can delay or prevent the ovaries from releasing an egg. Some symptoms that might suggest a hormone abnormality include unexpected weight loss or gain, fatigue, excessive hair growth or hair loss, acne and ovarian cysts. Cysts in the ovary can cause pelvic pain and also can interfere with the normal process of ovulation.


Scarring in the fallopian tubes can prevent pregnancy because it stops the egg from traveling into the uterus. Fallopian-tube problems are the cause in approximately 30% of female infertility problems. Damage can be from a previous surgery, a previous ectopic (tubal) pregnancy, tubal scarring from endometriosis or from pelvic inflammatory disease. Pelvic inflammatory disease is a bacterial infection in the pelvis, caused by sexually transmitted bacteria such as gonorrhea or chlamydia. It often scars, damages or blocks the fallopian tubes. A history of pelvic pain, with or without fever, may suggest a diagnosis of endometriosis or pelvic infection.


Abnormalities in the shape or lining of the uterus account for almost 20% of female infertility problems. Fibroid tumors or uterine polyps sometimes result in heavy menstrual bleeding, pelvic pain or enlargement of the uterus. Scar tissue can develop within the uterine cavity as a complication of uterine infections, miscarriages, abortions, or surgical procedures such as a dilation and curettage (D&C). Such scar tissue can lead to infrequent periods or minimal menstrual flow.
Diagnosis

An important first step in diagnosing female infertility is figuring out whether ovulation is occurring at predictable intervals. When an egg is released, it causes a shift in the body's sex hormones. This shift in sex hormones can be detected with these tests:


The body's early-morning core body temperature is affected by hormone shifts. By using a precise thermometer (called a basal body thermometer) to take your temperature every day when you first wake up in the morning, you will be able to detect a slightly higher temperature during the second half of your monthly cycle. This slight temperature change occurs after ovulation.


An ovulation predictor test is an over-the-counter urine test that can predict egg release. The urine test checks for high levels of luteinizing hormone. A positive test near the middle of your cycle means it is likely you have ovulated recently or are about to ovulate. The ovulation predictor test kit is available at most drug stores and pharmacies, and can be performed in your home.


You also can examine your vaginal mucus at home. With careful instruction, some women are able to interpret changes in the appearance of the vaginal mucus and consistency of the cervix as a sign of hormone shifts that show ovulation has occurred.

After your doctor examines your vagina and pelvic organs, a sample of mucus from your cervix and vagina may be tested for possible infection. If necessary, blood tests also can be used to confirm normal ovulation by measuring a high progesterone level in the later part of your menstrual cycle. Blood levels of two additional sex hormones, follicle stimulating hormone and estradiol, can help show that the ovaries are functioning well enough to release eggs. These blood tests usually are done at specific times in your menstrual cycle. Other blood tests may be needed to measure the function of your thyroid gland, your pituitary gland and your adrenal glands.

Other tests that are used to understand the cause of infertility examine the physical structure of pelvic organs.


A hysterosalpingogram is an X-ray study done after a liquid X-ray dye is allowed to flow into your uterus through a slender catheter positioned just inside the cervix. The dye outlines the shape of your uterine cavity and reveals problems such as polyps, fibroid tumors or other variations in the shape of the inside of your uterus. The dye also flows through the fallopian tubes and can reveal problems such as partial or complete blockage.


An ultrasound reveals the shape and size of the uterus, and gives some information about the uterine cavity or inner lining. This test cannot determine if the fallopian tubes are blocked. An ultrasound can identify the ovaries, their shape and size, and the presence of developing cysts. Ultrasound of the pelvis does not involve the use of X-rays or dye.


Hysteroscopy and laparoscopy are surgical procedures performed by a gynecologist. Both procedures use a small video camera to view the pelvic organs. Your gynecologist can see the inside of your uterus during a hysteroscopy procedure, can obtain biopsies, and, in some cases, can remove polyps, fibroids or scar tissue. Laparoscopy allows your doctor to view the outside of your uterus, and to inspect your ovaries. Sometimes, it is possible to remove cysts or scar tissue from an ovary using laparoscopy.

When a couple's difficulty in getting pregnant is caused by a fertility problem in the woman, an explanation for her infertility can be found in about four out of five cases. It is important for the man in the couple to be checked for fertility problems, too. It is OK to continue sexual activity during a fertility evaluation unless your doctor advises you otherwise. With continued frequent sexual intercourse, even without treatment, you have between a 1% and 3% chance of getting pregnant during each new menstrual cycle after a single unsuccessful year.
Expected Duration

A fertility evaluation usually extends over several months because it requires numerous tests, and because some tests must be done during a specific time in the menstrual cycle. The treatments also require time, careful planning and repeated office visits. The time that it takes to complete a fertility evaluation can be frustrating, since couples who need this evaluation already have spent a full year trying for a pregnancy.
Prevention

You can optimize your chances of getting pregnant in a number of ways.


Exercise moderately. If you are exercising so heavily that your menstrual periods are infrequent or absent, your fertility is likely to be impaired.


Avoid extremes of weight. An optimum body mass index (BMI) is at least 20 and below 27.


Avoid alcohol, smoking and excesses of caffeine (more than one cup of coffee per day) and avoid marijuana and cocaine.


Review your medicines with your doctor. Drugs such as digoxin (Lanoxin); bodybuilding steroids; some drugs for treatment of thyroid conditions, depression, hypertension, seizure and asthma; and some prescription antacids can affect your ability to conceive or carry a normal pregnancy.

If you are thinking about parenthood, it is also important to optimize your health before you get pregnant by making sure that your immunizations are up-to-date, by avoiding alcohol, by reviewing whether any medicines you take are safe during pregnancy, and by taking 0.4 milligrams (400 micrograms) of the vitamin folic acid every day, beginning at least one month before planning to conceive. Starting to take folic acid supplements a few months before conception greatly reduces the chance of abnormal development of the baby's spinal column.

Some treatments for cancer, including chemotherapy and radiation, can cause infertility. Techniques are now available to help a woman planning to undergo these treatments to later have a baby from her own egg. Two strategies have been successful:


Frozen storage — The woman's eggs are removed from her ovary surgically and are frozen.


Ovary cell transplantation — Ovary cells are transplanted into an area of the woman's body that will not be exposed to radiation, such as the arm.

When the woman is ready to have a baby, a fertility expert can combine the egg with sperm and insert it into the woman's uterus. In some cases, if the woman's uterus has been removed by surgery, a surrogate (different) woman may volunteer to carry the pregnancy in her uterus.
Treatment

Treatment depends on the results of your infertility evaluation. Some causes of infertility have a specific treatment, such as surgery to remove a fibroid tumor or medicines to treat a thyroid problem.

Infertility associated with infrequent or absent ovulation often can be treated with hormone medications called fertility drugs. All fertility medications have potential side effects, and can cause twins or even more than two babies in one pregnancy. Most fertility treatments require the supervision of a fertility specialist. Examples of fertility medicines include:


Clomiphene citrate (Clomid, Milophene, Serophene) is a medicine that stimulates the ovary to release one or more eggs. This medicine works indirectly by adjusting levels of your natural hormones.


Injected forms of luteinizing hormone and follicle-stimulating hormone may be used when supervised by an infertility specialist. These medications encourage the ovaries to release more than one egg at a time. This is known as superovulation, or ovulation induction. These medicines are sometimes given after a course of treatment by another hormone medicine, known as a GnRH analogue, that quiets down all natural hormone stimulation to the ovary in preparation for a precisely timed cycle of ovulation.

After fertility drug treatment, the eggs that mature in your ovary can be allowed to travel naturally into the uterus if the fallopian tubes are healthy. Sometimes surgery is used to harvest the eggs that mature after fertility drug treatment, so they can be fertilized with greater certainty in the laboratory and then placed into the uterus. Procedures that can help you to start a pregnancy include:


Intrauterine insemination is a procedure in which sperm are inserted into the uterus directly. Semen is collected by the man, usually after he stimulates himself to ejaculate, and is inserted into the uterus using a special catheter or a syringe.


In vitro fertilization (commonly called IVF, and known in the early days of the procedure as "test tube baby") combines egg and sperm in a laboratory dish. Surgery is required to collect the eggs that your ovary has been stimulated to release. The eggs and sperm are combined in the laboratory, and the embryos are inserted into your uterus. Multiple embryos may be placed inside the uterus, but IVF does not guarantee that a pregnancy will result. Sometimes, more than one embryo implants itself in the uterus, which can result in twins, triplets or higher-order multiple pregnancies. This procedure requires treatment with hormones beforehand.


Zygote intrafallopian transfer (ZIFT) and gamete intrafallopian transfer (GIFT) are variations of the surgical IVF procedure and require the presence of at least one healthy fallopian tube. In ZIFT, eggs are removed from the ovary by surgery and are combined with sperm in a laboratory. The resulting embryos are placed in the fallopian tube. GIFT is when eggs and sperm are placed in the fallopian tube before the sperm and egg have fertilized together, allowing the eggs and sperm to fertilize inside the woman. As with IVF, these procedures require hormone pretreatment.

It is important for you to get counseling about all options for parenthood, including procedures for adoption. Some health insurance plans do not pay for infertility treatment or limit coverage to women only up to a certain age.
When To Call A Professional

Although it may be possible to become pregnant on your own after one year of trying to conceive, it is wise to speak with a physician after one year and possibly begin an infertility evaluation. If you are over 35 and want to become pregnant, you may want to consult your physician after four to six months of trying to conceive, because pregnancy is less likely to occur without fertility treatment at your age.

If you are undergoing fertility treatment, including taking medications to stimulate your ovaries, it is important for you to notify your infertility specialist about symptoms of pelvic pain and abdominal swelling. Unusually stimulated ovaries can lead to significantly enlarged ovaries and cause excessive accumulation of fluid in your pelvic area and abdomen as a complication of treatment.
Prognosis

The chance of any woman having a successful pregnancy depends on the cause of her infertility problem. It is currently possible for more than half of couples who seek infertility treatments to eventually have a pregnancy.

Image of the day

A 64-year-old man presented with a 6-month history of epigastric pain, weight loss, and nausea. In the previous 3 months, he had lost 10 kg. On examination, he was noted to have a nontender, firm, fixed, left supraclavicular lymph node measuring 3.0 by 2.5 cm. Upper endoscopy revealed an adenocarcinoma of the gastric corpus. Computed tomography of the abdomen showed liver metastasis. Virchow's node, or Troisier's node, refers to carcinomatous involvement of the supraclavicular nodes at the junction of the thoracic duct and the left subclavian vein. Usually, nodal enlargement is caused by metastatic gastric carcinoma, although supraclavicular nodal involvement can also be seen in other gastrointestinal, thoracic, and pelvic cancers. Gastric cancers tend to metastasize to this region by means of migration of tumor emboli through the thoracic duct, where subdiaphragmatic lymphatic drainage enters the venous circulation in the left subclavian vein. Given the patient's low performance status, according to his Karnofsky performance-status score and his score on the Eastern Cooperative Oncology Group Performance Status scale, chemotherapy was contraindicated, and he was referred for palliative radiotherapy.

Source: New England of Medicine

Clinical Case: An Aortoenteric Fistula

An 81-year-old man presented to the emergency department with hematochezia and hematemesis, which began after he was awakened by an urgent need to move his bowels. He did not have abdominal pain, black stools, dysphagia, or odynophagia.

An aortoenteric fistula is a communication between the aorta and the gastrointestinal tract. Primary aortoenteric fistulas are extremely rare and most often occur in the presence of an atherosclerotic aortic aneurysm, but they can also be associated with infectious aortitis, enteric ulcers, trauma, tumor, radiation therapy, foreign-body ingestion, and other sources of intraabdominal inflammation (e.g., diverticulitis). Secondary aortoenteric fistulas typically occur in patients with a prosthetic abdominal aortic vascular graft, and are most commonly due to graft infection. Aortoenteric fistulas have also been reported after repair of an endovascular aortic stent.
Clinical Pearls

• How common is an aortoenteric fistula after graft surgery and where do they typically occur?

The incidence of aortoenteric fistulas after aortic graft surgery is approximately 1 to 3%. The time between aortic repair and fistula formation is usually 3 to 5 years, but fistulas have been reported to occur as early as several days to as long as 20 years after the repair. Aortoenteric fistulas are most commonly located in the distal duodenum, especially the third portion, since the duodenum is fixed and located just anterior to the aorta; however, they can also occur in other areas of the small bowel, colon, stomach, and even the esophagus.

• What is the typical presentation of a patient with an aortoenteric fistula?

Patients with aortoenteric fistulas classically present with a “herald bleed” consisting of hematochezia, melena, or hematemesis. This episode may spontaneously remit and is followed by more massive bleeding several hours to months later. Some patients, such as the one described here, have repeated episodes of intermittent bleeding. Patients with aortoenteric fistulas can also present with abdominal or low back pain or a pulsatile abdominal mass, as well as fever and bacteremia if they have an associated graft infection.
Morning Report Questions

Q: What should the initial evaluation entail in a patient with a suspected aortoenteric fistula?

A: The initial evaluation of patients with a suspected aortoenteric fistula should include abdominal imaging and consultation with a vascular surgeon. CT with intravenous administration of contrast material can show evidence of graft infection, such as perigraft soft-tissue thickening or fluid, perigraft or intraluminal gas, thickening of the adjacent bowel wall, loss of tissue planes, disruption of the aneurysmal wrap, pseudoaneurysm, or extravasation of contrast material, or some combination of these findings. When there is a high degree of suspicion for aortoenteric fistula, CT should be performed before other types of gastrointestinal evaluation, since CT can generally be performed promptly, is noninvasive, and is not likely to disrupt a clot and cause further bleeding. Upper endoscopy may be performed to evaluate the distal duodenum, especially the third portion, and to rule out other, more common sources of bleeding. However, endoscopy has a reported sensitivity for aortoenteric fistula of less than 40%, and endoscopic treatment is not possible if a fistula is identified. Tagged red-cell scanning and angiography are rarely helpful in the diagnosis of aortoenteric fistulas, given the intermittent nature of the bleeding.

Q: What is the appropriate treatment in a patient with an aortoenteric fistula?

A: Patients with untreated aortoenteric fistulas and associated bleeding have a mortality rate of nearly 100%. Surgical repair of secondary aortoenteric fistulas typically involves graft excision and extra-anatomical bypass, which is often complicated and associated with considerable morbidity and mortality. Endovascular techniques have been developed for both temporary and definitive management of aortoenteric fistulas. Observational studies suggest that endovascular repair, as compared with open surgical repair, is associated with lower rates of postoperative morbidity and mortality but higher long-term risks of infection and recurrent bleeding and may therefore be a better choice in patients with major coexisting conditions or hemodynamic instability.

Source: New England Journal Of Medicine

Internet Addiction & Health Effects

The Internet has become an integral part of many people's work and personal lives. The number of people online daily has nearly doubled over the past decade, according to research conducted by the Pew Internet and American Life Project.

Physical Effects

Internet overuse can lead to sedentary lifestyles, weight gain and a decline in physical fitness. Other symptoms can include carpal tunnel syndrome, dry eyes, migraine headaches, a decline in personal hygiene and back aches, according to Maressa Hecht, founder of Computer Addiction Services and a member of the Harvard Medical School.

Depression

Depression has also been linked to Internet overuse by researchers at the Institute of Psychological Sciences in Leeds, UK. Researchers found that study participants who exhibited signs of Internet overuse engaged disproportionately than the normal population in sites devoted to pornography, gaming, social networking and chat rooms. They theorized that Internet addicts' use of these sites as replacements for real-life socializing was resulting in depression. However, there is debate as to whether depression results from, or is a cause, or internet overuse. A study published in the "Archives of Pediatrics and Adolescent Medicine" found depression, as well as ADHD and social phobia, to increase the chances of excessive Internet use in adolescents.
Sleep Disturbances

Evidence also suggests that internet overuse can contribute to sleep disturbances. Studies of Chinese and American children, published in the "Journal of Sleep" and the "Journal of the American Academy of Pediatrics," found that computer use among adolescents was associated with later bed times, later waking times, less restful sleep and an overall decrease in sleep. The use of computers before bedtime has also raised concerns among sleep experts, including Phyllis Zee, a neuroscience professor at Northwestern University, that the light from screens is affecting circadian rhythms and possibly contributing to insomnia.

7 Pregnancy Warning Signs

1. Bleeding

Bleeding means different things throughout your pregnancy. “If you are bleeding heavily and have severe abdominal painand menstrual-like cramps or feel like you are going to faint during first trimester, it could be a sign of an ectopic pregnancy,” Peter Bernstein, MD, ob-gyn professor at New York's Albert Einstein College of Medicine and Montefiore Medical Center, says. Ectopic pregnancy, which occurs when the fertilized egg implants somewhere other than the uterus, can be life-threatening.

Heavy bleeding with cramping could also be a sign of miscarriagein first or early second trimester. By contrast, bleeding with abdominal pain in the third trimester may indicate placental abruption, which occurs when the placenta separates from the uterine lining.

“Bleeding is always serious,” women’s health expert Donnica Moore, MD, says. Any bleeding during pregnancy needs immediate attention. Call your doctor or go to the emergency room.
2. Severe Nausea and Vomiting

It's very common to have some nausea when you're pregnant. If it gets to be severe, that may be more serious.

“If you can’t eat or drink anything, you run the risk of becoming dehydrated,” Bernstein says. Being malnourished and dehydrated can harm your baby.

If you experience severe nausea, tell your health care provider. Your doctor may prescribe medication or advise changing your diet.
3. Baby’s Activity Level Significantly Declines

What does it mean if your previously active baby seems to have less energy? It may be normal. But how can you tell?

Some troubleshooting can help determine if there is a problem. Bernstein suggests that you first drink something cold or eat something. Then lie on your side to see if this gets the baby moving.

Counting kicks can also help, Nicole Ruddock, MD, assistant professor of maternal and fetal medicine at University of Texas Medical School at Houston, says. “There is no optimal or critical number of movements,” she says, “but generally you should establish a baseline and have a subjective perception of whether your baby is moving more or less. As a general rule, you should have 10 or more kicks in two hours. Anything less should prompt a phone call to your doctor.”

Bernstein says to call your doctor as soon as possible. Your doctor has monitoring equipment that can be used to determine if the baby is moving and growing appropriately.
4. Contractions Early in the Third Trimester

Contractions could be a sign of preterm labor. “But a lot of first-time moms may confuse true labor and false labor,” Ruddock says. False labor contractions are called Braxton-Hicks contractions. They’re unpredictable, non-rhythmic, and do not increase in intensity. “They will subside in an hour or with hydration,” Ruddock says. “But regular contractions are about 10 minutes apart or less and increase in intensity.”

If you're in your third trimester and think you're having contractions, call your doctor right away. If it is too early for the baby to be born, your doctor may be able to stop labor.

5. Your Water Breaks

You walk into the kitchen for a drink and feel a flood of water rush down your legs. “Your water could have broken,” Ruddock says, “but during pregnancy the enlarged uterus can cause pressure on your bladder too. So it could be urine leakage.” Ruddock says that sometimes water breaking is a dramatic gush of fluid, but other times it is more subtle.

“If you are not sure if it is urine versus a true rupture of the membrane, go to the bathroom and empty your bladder," she says. "If the fluid continues, then you have broken your water.” Call your doctor or go to the hospital.
6. A Persistent Severe Headache, Abdominal Pain, Visual Disturbances, and Swelling During Your Third Trimester

These symptoms could be a sign of preeclampsia. That’s a serious condition that develops during pregnancy and is potentially fatal. The disorder is marked by high blood pressure and excess protein in your urine that typically occurs after the 20th week of pregnancy.

“Call your doctor right away and get your blood pressure tested,” Bernstein says. “Good prenatal care can help catch preeclampsia early.”
7. Flu Symptoms

Our experts say it’s important for pregnant women to get the flu vaccine since pregnant women are more likely to get sick and have serious complications from the flu than other women during flu season.

But if you do get the flu, "don’t rush into a hospital or doctor’s office where you can spread it to other pregnant women," Bernstein says. "Call your doctor first."