Green Tea Drinking in Elderly Linked to Lower Risk for Depression

From Medscape CME Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

December 29, 2009 — More frequent consumption of green tea is associated with a lower prevalence of depressive symptoms in the community-dwelling older population, according to the results of a cross-sectional study reported in the December issue of the American Journal of Clinical Nutrition.

"Green tea is reported to have various beneficial effects (e.g., anti–stress response and anti-inflammatory effects) on human health," write Hideko Takahashi, from Tohoku University Graduate School of Biomedical Engineering in Sendai, Japan, and colleagues. "Although these functions might be associated with the development and progression of depressive symptoms, no studies have investigated the relation between green tea consumption and depressive symptoms in a community-dwelling population."

Drinking green tea is a common social practice in Japan, and many people believe that this tea has salutary effects on the mind and spirit. However, a previous study by Shimbo and colleagues questions this possibility. They examined the effects of green tea consumption on self-perceptions of mental health among 600 Japanese adults. Their results, which were published in the December 2005 issue of Public Health Nutrition, failed to demonstrate a significant independent effect of green tea consumption on the mental health status of men or women. However, greater caffeine intake was associated with higher rates of poor mental health among women.

Mediterranean Diet Linked to Lower Risk for Stomach Cancer

From MedscapeCME Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD

December 29, 2009 — Greater adherence to a relative Mediterranean diet is associated with a significantly lower risk for incident gastric adenocarcinoma, according to the results of a prospective cohort study reported online in the December 9 issue of the American Journal of Clinical Nutrition.

"The Mediterranean dietary pattern is believed to protect against cancer, although evidence from cohort studies that have examined particular cancer sites is limited," write Genevieve Buckland, BS, from the Catalan Institute of Oncology, Idibell, in Barcelona, Spain, and colleagues from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study.

The Mediterranean diet includes a proportionately high intake of fruit, nuts, fiber, seeds, vegetables, olive oil, and a moderate intake of wine. These foods are rich in antioxidants that may help prevent cancer, such as vitamin C, carotenoids, phenols, and flavonoids. In addition, consumption of red and processed meat is relatively low.

Several studies have shown a protective effect of the Mediterranean diet on health and its association with a reduced risk for cancer and other chronic diseases. However, only breast cancer and colorectal cancer risks have been examined separately, and no studies to date have evaluated the association between adherence to a Mediterranean diet and the risk for gastric adenocarcinoma.

Tai Chi Improves Pain in Arthritis Sufferers

From Arthritis Care Research News Alerts

Posted: 12/02/2009; Arthritis Care Research News Alerts © 2009 Wiley InterScience

The results of a new analysis have provided good evidence to suggest that Tai Chi is beneficial for arthritis. Specifically, it was shown to decrease pain with trends towards improving overall physical health, level of tension and satisfaction with health status.

Musculoskeletal pain, such as that experienced by people with arthritis, places a severe burden on the patient and community and is recognized as an international health priority. Exercise therapy including such as strengthening, stretching and aerobic programs, have been shown to be effective for arthritic pain.
Tai Chi, is a form of exercise that is regularly practiced in China to improve overall health and well-being. It is usually preformed in a group but is also practiced individually at one’s leisure, which differs from traditional exercise therapy approaches used in the clinic.

Recently, a new study examined the effectiveness of Tai Chi in decreasing pain and disability and improving physical function and quality of life in people with chronic musculoskeletal pain. The study is published in the June issue of Arthritis Care & Research (http://www3.interscience.wiley.com/journal/77005015/home). Led by Amanda Hall of The George Institute in Sydney, Australia, researchers conducted a systematic review and meta-analysis. They analyzed seven eligible randomized controlled trials that used Tai Chi as the main intervention for patients with musculoskeletal pain. The results demonstrate that Tai Chi improves pain and disability in patients suffering arthritis.

The authors state, “The fact that Tai Chi is inexpensive, convenient, and enjoyable and conveys other psychological and social benefits supports the use this type of intervention for pain conditions such as arthritis.”

“It is of importance to note that the results reported in this systematic review are indicative of the effect of Tai Chi versus minimal intervention (usual health care or health education) or wait list control,” the authors note. Establishing the specific effects of Tai Chi would require a placebo-controlled trial, which has not yet been undertaken.

Article: “The Effectiveness of Tai Chi for Chronic Musculoskeletal Pain Conditions: A Systematic Review and Meta-Analysis,” Amanda Hall, Chris Maher, Jane Latimer, Manuela Ferreira, Arthritis Care & Research, June 2009.

[ CLOSE WINDOW ]

Stay Slim, Active, Smoke-Free: Live Long and Free of CVD

From Heartwire
Shelley Wood

men who smoked, were inactive, and who had a waist girth >94 cm had an overall life expectancy that was 14 years shorter

December 16, 2009 (Chicago, Illinois) — Everyone agrees: smoking, physical inactivity, and abdominal obesity increase the risks of coronary heart disease (CHD), but just how much are risks reduced in those who can claim "none of the above"?

A new study appearing in the December 14-28, 2009 issue of the Archives of Internal Medicine indicates that men with none of these risk factors had a 59% lower risk of CHD events and a 77% lower risk of dying of cardiovascular disease [1]. The authors say their study may be the first to estimate the "combined health benefits" of not smoking, having good cardiorespiratory fitness (measured by max treadmill test), and a normal waist girth.

Dr Chong-Do Lee and colleagues followed 23 657 men age 30 and older for a mean of almost 15 years (348 811 person-years) in the Aerobics Center Longitudinal Study (ACLS).

Over this period, 482 men had a fatal or nonfatal MI, and 1034 died of noncardiac causes. After adjusting for age, year of initial medical examination, and baseline risk factors, Lee et al found that risk of a CHD event or of dying of cardiac or noncardiac causes was inversely related to the presence of "low-risk factors."

Men with a normal waist circumference, who kept physically active, and who didn't smoke were significantly less likely to have a CHD event or die of cardiac causes, as compared with men with none of these low-risk factors. Risk of all-cause mortality was also dramatically lower in this group.
By comparison, men who smoked, were inactive, and who had a waist girth >94 cm had an overall life expectancy that was 14 years shorter.

Investigators underscore a number of limitations in their study: the study cohort comprised mainly white, middle- to upper-class men and importantly, did not address changes in low-risk factors over the follow-up period. But overall, they say, their findings speak to the importance of adhering to healthy behaviors and a healthy weight over the long term.

"The magnitude of having the three low-risk factors is impressive for both population-attributable risk and for longevity and indicates the clinical and public-health importance of these characteristics," Lee et al conclude.

Easier said than done, perhaps. Citing a 2006 paper by Chiuve et al [2], Lee and colleagues point out that "low-risk" Americans, who have a normal weight in combination with a healthy lifestyle, make up just 3% to 4% of the population.

References

Diagnosing Breast Cancer: Needle Biopsy Best?

From WebMD Health News

Jennifer Warner

December 17, 2009 — A less invasive needle biopsy may be nearly as effective as surgical biopsy at diagnosing breast cancer, and with far fewer side effects.

A new review of more than 80 studies on the two breast cancer screening methods shows breast needle biopsy was able to distinguish between cancerous and noncancerous breast lesions with about the same accuracy as surgical biopsy and less than half the risk of complications.

Women suspected of having breast cancer after initial screening are usually referred for a biopsy to determine whether the lesion is cancerous. In most cases, the lump or lesion is benign or noncancerous and does not require further treatment.

Biopsies may be performed via open surgery on the breast or with a less invasive core-needle biopsy in which a small sample of breast tissue from the affected area is removed through a special needle inserted through the skin.

Researchers say needle biopsy has fewer complications and a shorter recovery time than open surgical biopsy, but some women and doctors may have concerns about the accuracy of the procedure compared with traditional open surgery methods of breast cancer diagnosis.

In the study, published in the Annals of Internal Medicine, researchers reviewed 83 studies on the two methods.

The results showed that core needle biopsies were about as accurate as open surgery at detecting cancerous vs. noncancerous breast lesions.

Needle biopsies also had a much lower rate of complications (less than 1% compared with 2%-10% with open surgery).

In addition, the study showed women initially diagnosed with breast cancer with needle biopsy were more likely to be treated with a single breast cancer surgery than those initially diagnosed by open surgical biopsy.

"Based on currently available evidence, it appears reasonable to substitute core needle biopsy procedures for open surgical biopsy given the comparable sensitivity and lower complication rates," write researcher Wendy Bruening, PhD, of the ECRI Institute Evidence-Based Practices Center in Plymouth Meeting, Pa., and colleagues. They say additional studies are needed to find out what factors affect the accuracy of core-needle breast biopsy.

SOURCES:

Bruening, W. Annals of Internal Medicine, published online Dec. 15, 2009.

FOOD SAFETY

Question 1: What Behaviors Are Most Likely To Prevent Food Safety Problems?

The behaviors in the home that are most likely to prevent a problem with foodborne illnesses are

Cleaning hands, contact surfaces, and fruits and vegetables (but not meat and poultry, which should not be washed)

Separating raw, cooked and ready-to-eat foods while shopping, preparing, or storing

Cooking foods to a safe temperature

Chilling (refrigerate) perishable foods promptly

http://www.health.gov/dietaryguidelines/dga2005/report/HTML/D10_Conclusions.htm

Aging excellently

Nov 7, 2009

100 is the New 65: Living Longer and Better
By: Greater Good Magazine

100 is the New 65
- Why do some people live to 100? Researchers are trying to find out, reports Meera Lee Sethi, and they’re discovering how we might live better lives, not just longer ones.

Will Clark, 105, recently bought a van for a 5,000-mile road trip across the Midwest with his wife, Lois, who is 102. Elsa Brehm Hoffmann loves bridge and is always ready for a party. Rosa McGee enjoys singing hymns to herself all day long. Will Clark makes a mean spaghetti and meatballs. What connects these three? They belong to the single fastest growing segment of the United States population: people over a hundred years old.

Hoffmann, McGee, Clark, and the nearly 100,000 other centenarians in the U.S. provide inspiration to the rest of us. But they also provide researchers with a tantalizing puzzle: Why do some people live so long? For years, medical researchers have been studying this select group, identifying some key factors to a long life. Now, a growing body of research is suggesting that longevity isn’t just linked to good genes and a healthy lifestyle; it’s also tied to cultivating a positive, resilient attitude toward life. These results validate a simple idea: that centenarians can teach us how to live not just longer lives, but better ones.

At the fore of this research is the New England Centenarian Study (NECS), which has enrolled more than 1,500 centenarians from around the world over the past 15 years. The study’s director, Thomas Perls, says these participants dispel the belief that the older someone gets, the sicker he or she becomes. Instead, he says, “the older you get, the healthier you’ve been.” In other words, people who demonstrate exceptional longevity tend to have had a lifelong history of good health.

Indeed, people who die in their 70s or 80s are plagued by degenerative illnesses in the years before their death; in contrast, Perls has found that nearly two thirds of centenarians either delay the onset of diseases such as heart disease, stroke, and diabetes—or escape them altogether. Plus, a substantial proportion of centenarians who survive such age-related illnesses do so without developing physical disabilities, enabling them to remain socially, mentally, and physically active. As a result, in a culture that romanticizes youth, Perls argues that centenarians embody “a thoroughly optimistic view of aging”—one that shows that prolonging life and enjoying it go hand-in-hand.

How do they do it?

To reach 100, research suggests that it definitely helps to have the right genes. Longevity clusters in families; Perls has documented as many as eight siblings in one generation who lived to 100. He’s also found that the children of centenarians have only one-third the risk of dying from cancer as the rest of us, and one-sixth the risk of dying from heart disease. Although specific genetic mechanisms behind long life are notoriously difficult to prove, there is some evidence that centenarians may be less likely to possess specific genetic variations that predispose people to problems like cardiovascular disease, diabetes, and high cholesterol. Perls is currently studying the entire human genome, searching for genetic variations associated with other diseases that centenarians lack, as well as variations that may actively promote longevity.

But long life isn’t just a lucky break. Scientists’ best estimate, largely based on a landmark Swedish study of identical and fraternal twins, is that genetic factors account for only 20 to 30 percent of a person’s lifespan. Environmental and behavioral factors dictate the other 70 to 80 percent.

Much of what researchers know about how to reach extreme old age sounds like basic public health advocacy: Don’t smoke. Drink in moderation. Eat healthy. Exercise regularly. “What we can do to live longer is no secret,” says Peter Martin, who directs the Gerontology Program at Iowa State University and was a key contributor to a study of centenarians in Georgia, the Georgia Centenarian Study, which ran from 1988 to 2006.

But what is new is the growing evidence that our personalities affect our longevity. It’s easy to know what it takes to stay healthy. More difficult is believing we have the power to control our lifespans, mustering the will to make good choices, and simply loving life enough to make long-term investments in our health. “It’s personality,” says Martin, “that turns these things on.”

Though every centenarian is unique—they vary widely in terms of education, socioeconomic status, religion, and ethnicity—Martin reports that, as a group, they exhibit a distinct constellation of personality traits. For instance, they tend to display relatively high levels of what psychologists label “competence”—the ability to achieve goals—and “conscientiousness,” or self-discipline. These qualities may make it easier to follow through on the healthy habits the rest of us resolve to keep each New Year’s Eve but abandon by the end of January.

“It’s amazing how cognizant they are of the need to exercise and not just leave it to chance or nature,” says Lynn Peters Adler, who runs the National Centenarian Awareness Project, an advocacy group that celebrates the pleasures and accomplishments of aging. “One woman I know walks a mile every morning, no matter the temperature.” This may sound like a strict and dreary regimen, but Adler notes that there’s an exciting reason for it: This woman loves hiking the Grand Canyon, which she has done nearly a dozen times since her 75th birthday.

Martin’s research suggests that centenarians also seem to be more inclined to embrace new skills and experiences, defying the stereotype of the elderly as stuck in their ways. Will Clark is living proof. Now 105, he just acquired his first computer, which he uses to email friends and to research authors and golfers in which he’s interested. He’s even taken to Googling family members. “I can’t believe the things you can call up on this gadget,” chuckles the former dentist and military man.

Elsa Hoffmann, 102, epitomizes two other traits centenarians display at relatively high levels: extraversion and trust. “I love people and I like to find out their interests in life,” she says. “We get to be intimate almost when we meet.” Hoffmann’s schedule includes lunch dates, theater outings, fundraisers, shopping excursions, bridge and gin tournaments, and—every year for the past few years—a cruise with fellow country club members.

Though she derives boundless joy from all this social activity, it also happens to be good for her: A considerable body of epidemiological research has linked low levels of social connection with higher risks for mortality. (See Jill Suttie’s Greater Good article this month for more on the cognitive benefits of social connection.)

But even when life isn’t all about world travel and intellectual discovery, centenarians still seem to have a leg up on the rest of us: Their results on personality tests show that they may be better equipped to handle difficult situations without literally worrying themselves to death. Rosa McGee, for instance, has lived through cancer, the death of her husband of 25 years, and a foot condition that renders her essentially homebound. Yet her daughter Clara Jean describes her personality simply as “sweetness. She never fusses, never argues, never complains. It’s a contentment that is beautiful.”

Indeed, research also shows that centenarians are more likely than younger adults to engage in “cognitive coping,” using mental strategies to tackle difficult situations. Martin says he has seen centenarians take a variety of approaches to combating stress and negative emotions. Some write poetry about the loneliness of old age or the misery of illness; others replace lost physical pursuits with mental ones, like reading, or take comfort in deep religious beliefs.

None of these coping strategies are particularly innovative. But Perls, Martin, and their colleagues argue that they can add up to a lifetime’s worth of healthy stress-management. Centenarian research shows that avoiding anxious or neurotic behavior may not only help us increase our lifespans but better enjoy those extra years.

A higher bar for aging

Given how “fantastically well” he has seen his study participants doing in the later stages of their lives, Perls is frustrated by what he sees as our culture’s obsession with youth. He laments the fact that “we have an entire industry that tries to stop aging—it’s all nonsense.”

Leonard Poon, who heads the Georgia Centenarian Study and is a professor of public health and psychology at the University of Georgia, says it’s not just popular culture but politicians who are short-sighted in this regard. Poon bemoans the lack of congressional support for the fields of gerontology and geriatrics. “The White House Conference on Aging is held every 10 years to get grassroots recommendations,” explains Poon. “In the last one, President Bush did not show up.”

Their lack of political clout is ironic; in his interviews with centenarians, Martin has found that many are acutely interested in politics, and love discussing issues like the national debt. He says this vigorous involvement in community life is a joy that old age shares with youth.

But there are also new joys that take shape as one gets older. There is, for instance, the pleasure of what Martin calls “weaving your own life story and making sense of why we’re here.” It’s a pleasure that McGee clearly enjoys when she talks about her role orchestrating a year’s supply of food for a church in Mexico, and that Hoffmann feels when she fixes broken toys for her great-grandchildren and speaks to elementary schoolchildren about her life’s experiences. And there is, still, the pleasure of exploration. Clark reveled in it recently, when he bought a van and went on a 5,000-mile road trip across the Midwest with his wife, herself 102.

Rising life expectancy rates mean that most of us will live longer than previous generations. What remains in question is the quality of life we’ll have at 80, 90, or 100. Martin contends that the answer lies in the attitude we cultivate in our younger years. “Imagine that you’re 95,” he says. “You can’t see, you can’t hear, you’re lonely and dependent on other people—and it’s because of the anxious, disagreeable attitude you had all your life.”

On the other hand, he says, developing a positive attitude towards life while we’re young, though challenging at times, can set us up to be happy, healthy, and independent in old age.

In other words, aging well isn’t just a project for the elderly. It’s something we can work toward our entire lives.

“For our parents, the standard was aging gracefully,” says Adler. “The bar has been raised. Let’s aspire instead to age excellently.”

– Meera Lee Sethi is a Chicago-based freelance writer who reports on current issues in biomedicine, public health, social psychology, and neuroscience. She is a contributing editor for Utata.org. Copyright Greater Good. Greater Good Magazine, based at UC-Berkeley, is a quarterly magazine that highlights ground breaking scientific research into the roots of compassion and altruism.

Related articles by Greater Good Magazine:

Arts and Smarts: Test Scores and Cognitive Development
Cognitive and Emotional Development Through Play
Mindfulness and Meditation in Schools for Stress Management

Brain Autopilot

Nov 22, 2009

The Brain Advantage: Train your Autopilot…and how to turn it off
By: Madeleine Van Hecke, Ph.D.

Brain-imaging techniques allow researchers to witness the brain’s activity reflected in a rainbow of colors on a computer screen. When brain cells are highly active—working harder—the result shows up as brighter colors on the computer screen. Brilliant reds and yellows indicate brain areas that are most active. In contrast, the blues and greens on a scan show a quieter, less active brain.

What would we expect to find if we examined the brain scans of people with high versus average IQ scores? We might picture the active brain of an Einstein as a hotbed of smoldering colors—but we’d be wrong. Neurologist Richard Restak summarized a UCLA study that compared individuals with high IQs to those with average IQs. Restak wrote, “The researchers started off with the seemingly reasonable idea that ‘smarter’ brains work harder, generate more energy, and consume more glucose. Like light bulbs, the brains of ‘bright’ people were expected to illuminate more intensely than those of ‘dimwits’ with a reduced wattage.” What they discovered instead was exactly the opposite. Higher IQ people had cooler, more subdued brain scans “while their less intellectually gifted counterparts lit up like miniature Christmas trees.” ….

Why would “smarter” brains work less hard? One strong bet is that when we are inexperienced—when we still have a lot to learn—we have to make a conscious effort to think about what we’re doing. But later, after we’ve become more adept, much of what initially took effort becomes automatic.

The good news is that functioning on autopilot allows us to expend less brain energy on the routine aspects of the work. Our expertise allows us to direct our energy elsewhere. For example, novices use different parts of their brains than experts do. This happens in areas as different as playing chess and swinging a golf club.These studies show that less-experienced people think more about carrying out the mechanics of the task and encoding information.Experts, on the other hand, function on automatic pilot in these areas. In fact, experts sometimes falter—flubbing a basketball free throw or a golf putt—when their focus shifts back to the mechanics.

So functioning on autopilot can be a great advantage. But it can also work against us. As mentioned in chapter 1, international rock climber Lynn Hill was preparing to climb a wall in Buoux, France in 1989. She threaded her rope through her harness but then, instead of tying the knot, she stopped to put on her shoes. While tying her shoes, she talked to another woman. “The thought occurred to me that there was something I needed to do before climbing,” she later recalled.29 But Hill “dismissed the thought” and climbed the wall. When she leaned back to rappel to the ground, she fell seventy-two feet. Fortunately, tree branches broke her fall and Hill survived.

Lawrence Gonzales, who tells this story in his book Everyday Survival, points out that more training would not have helped Lynn Hill. “In fact,” as Gonzales writes, “experience contributed to her accident.” She could tie her rope to her harness on autopilot but the similarity between tying shoes and tying the rope “tricked” her brain into thinking she had done what she needed to do.

So there are two sides to our ability to function on autopilot. Doing so can lead to major mistakes, as Lynn Hill’s story illustrates. On the other hand, there are distinct benefits as well. When we are trying to become more expert, in many cases our goal is to get good enough so that we can be on autopilot!

Interesting, but so what?

How can I use this information as a business leader?

Among their many challenges, leaders have two key responsibilities: developing their people and increasing efficiency. Increasing efficiency often involves standardizing, automating or simplifying processes. However, carrying out routines more automatically also has one major drawback. It increases the risk that, like Lynn Hill failing to knot her rope, people will at times implement these procedures “mindlessly.”

In an ideal world, for efficiency’s sake, employees would conduct much of their work on autopilot. Then they would shift off autopilot when the situation required more conscious thought. The key question for business leaders is how to ensure that people stick to autopilot when it’s working well, yet make the shift to more conscious deliberation when it’s needed…

What if …

1. What if business leaders use automated systems to remind them to periodically go off autopilot?

Professionals often step back from recently-completed projects and debrief. They assess how things went and consider what they might do differently next time. Why not extend this practice to well-established routines? Team members could, for example, look at the plans they are creating for carrying out a project. Then they could take some time to discuss questions like “Is this the most efficient possible way to do this?” and “Is there someone else whose perspective we should get on this before we start?”

Similarly, individuals can take a few minutes before they jump into their own work to ask “Is there a better way to do this?” “Would it be better to have someone else do this?”One business leader experimented with sending herself questions like these as instant messages that appeared throughout the day. When one of these “prompts” appeared, it didn’t usually change her behavior immediately because it didn’t apply directly to what she was doing. But over time, she internalized the questions and they started popping into her head at times when they did apply…

In many organizations, quality or continuous improvement reviews are intended to serve a similar purpose. But all too often, the reviews themselves become scripts that are executed with little thought or consideration. Leaders should shift their mindset from thinking of quality or other reviews as administrative tasks and instead approach them as opportunities to turn off autopilot.

– Madeleine Van Hecke, Ph.D., is one of the authors of The Brain Advantage: Become a More Effective Business Leader Using the Latest Brain Research, with Lisa P. Callahan, Brad Kollar and Ken A. Paller, Ph.D. Ms. Van Hecke is a licensed clinical psychologist, speaker, consultant, and author.

Related Articles:

To Think or To Blink
Why Smart Brains Make Stupid Decisions

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H1N1 Vaccine as Safe as Seasonal Vaccine, WHO Says

From Medscape Medical News

Emma Hitt, PhD

November 19, 2009 — The H1N1 2009 pandemic influenza vaccine appears to be as safe as the seasonal flu vaccine, according to the World Health Organization (WHO).

About 1 adverse event is being reported for every 10,000 doses, said Dr. Marie-Paule Kieny, director of the WHO's Initiative for Vaccine Research, at a virtual press briefing today. Of those adverse event reports, about 5 of 100 are considered serious.

According to Dr. Kieny, serious adverse events so far include 30 deaths and about 12 cases of Guillain-Barré syndrome; however, she emphasized that none of the deaths reported to date has been confirmed as being caused by the vaccine.
In addition, all cases of Guillain-Barré syndrome have been transient, and only a few have been linked to the vaccine.

Dr. Kieny added that there appears to be no difference between the safety profile of the seasonal and pandemic influenza vaccines, and the number of adverse events is comparable between the 2 vaccines. In addition, the safety profiles of the different forms of pandemic vaccine are also similar.

Adverse reactions associated with the pandemic vaccine include a variety of local reactions including "pain at injection site, swelling, redness, and reactions such as fever, headache, muscle pain, or fatigue," Dr. Kieny said. "These generally resolve within 1 or 2 days."

"No new safety issues have been identified from reports received to date," she said.

At least 80 million doses of vaccines have been distributed and 65 million doses have been administered. "These are figures that we have received from 16 countries, but we think they are conservative estimates because immunization campaigns are under way now in 40 countries," Dr. Kieny added.

The WHO expects to start shipment of the vaccine to developing countries at the end of this month. According to Dr. Kieny, this represents a slight delay, but they expect that all vaccine doses will reach 95 eligible countries during the next 3 months.

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Microdermabrasion May Rejuvenate Aging Skin

From WebMD Health News

Bill Hendrick

October 21, 2009 — Microdermabrasion using a coarse diamond-studded instrument may induce molecular changes in the skin that help rejuvenate it, a new study shows.

The procedure may improve the appearance of wrinkles, acne scars, and other signs of aging, University of Michigan scientists report in the October issue of Archives of Dermatology.

The process involves buffing the skin using grains of diamond or another hard substance, the researchers say.

To change the appearance of skin, the procedure would have to induce the production of collagen, the major structural protein in skin, and it appears to do so, according to the study.

The researchers note that previous studies have shown that microdermabrasion using aluminum oxide may not always stimulate collagen production.

It's not known, the researchers say, whether more aggressive methods -- not involving the destruction of skin tissue -- could trigger collagen production.

Darius J. Karimipour, MD, and colleagues at the University of Michigan, conducted biochemical analysis of skin biopsy specimens before and four hours to 14 days after a microdermabrasion procedure on the aged forearm skin of 40 volunteers.

Twenty-six men and 14 women, ages 50 to 83, took part in the study, each undergoing microdermabrasion with a diamond-studded hand piece of either a coarse-grit or medium-grit abrasiveness.

Microdermabrasion with the coarse-grit hand piece resulted in increased production of a wide array of compounds that are associated with wound healing and skin remodeling, including collagen, compared to untreated forearm skin. These molecular changes weren't seen in participants who received treatments using the medium-grit hand piece, the researchers say.

All participants experienced a mild period of redness that lasted, typically, less than two hours.

"We demonstrate that aggressive non-ablative microdermabrasion (not involving destruction of skin tissue) is an effective procedure to stimulate collagen production in human skin in vivo," the researchers write. "The beneficial molecular responses, with minimal downtime, suggest that aggressive microdermabrasion may be a useful procedure to stimulate remodeling and to improve the appearance of aged human skin."

Further study is needed, they add, to determine if microdermabrasion, performed aggressively, has the capacity to become a worthwhile resurfacing procedure that results in noticeable cosmetic improvement while minimizing" other problems and lifestyle interruptions.

SOURCES:

News release, University of Michigan.

Karimipour, D. Archives of Dermatology, October 2009; vol 145.

Cell Phones and Brain Cancer -- Jury Still Out

From Medscape Medical News
Roxanne Nelson

October 14, 2009 — Cellular telephones have become an integral part of everyday life; they are now used by an estimated 4 billion people worldwide. But this is a relatively new technology, and there are lingering concerns about health risks, in particular a risk for brain cancer.

A new report suggests that that regular use of cell phones can result in a "significant" risk for brain tumors. But previous studies have been inconsistent. Even so, some European countries have taken precautionary measures, aimed specifically at children.

In the United States, a recent Senate hearing examining the safety of cell phones was inconclusive, saying that although more research is needed, it might be wise to begin taking precautionary measures right now. The National Cancer Institute also said that additional research is needed.

In this special feature, Medscape Oncology presents the views of experts from both sides of the case.

The new report, "Cellphones and Brain Tumors: 15 Reasons for Concern. Science, Spin and the Truth Behind Interphone," was released in August by the International Electromagnetic Field (EMF) Collaborative, a group that includes Powerwatch and the Radiation Research Trust in the United Kingdom, and the EMR Policy Institute, ElectromagneticHealth.org, and The Peoples Initiative Foundation in the United States.

More than 40 scientists and officials from 14 countries endorsed the report, which concluded that:

Studies that are independent of the telecom industry consistently show there is a "significant" risk for brain tumors from cell phone use.

The EMF exposure limits advocated by industry and used by governments are based on a false premise that a cell phone's electromagnetic radiation has no biological effects except for heating.
The danger of brain tumors from cell phone use is highest in children, and the younger a child is when he/she starts using a cell phone, the higher the risk.
"We have had zero reaction from the industry about the paper," Lloyd Morgan, a retired electronics engineer, an active member of several international science organizations, and the report's lead author, told Medscape Oncology. "What they're doing is a nonresponse response; they haven't challenged anything in it."

This report has intensified a controversy that has been brewing for nearly 2 decades and still remains largely unresolved. Approximately 30 epidemiologic studies have attempted to evaluate a possible association between cell phone use and the risk for brain and salivary gland tumors. There have also been a number of experimental studies involving cell cultures and animal models.

Results, however, have been inconclusive or even contradictory. But studies independent of industry funding have more consistently found higher risks for brain tumors when exposure was 10 or more years, explained Mr. Morgan, adding that "even some industry-funded studies show that there is a connection between cell phone use and the risk of brain tumors."

Interphone Results Flawed

The issue of cell phone safety was to have been settled once and for all by the huge 13-nation industry-funded Interphone study, which was begun nearly 10 years ago. Even though data collection was completed in 2004, the results have still not been published. The European Parliament has called the delay "deplorable," and has demanded an explanation for it. Although the combined results have not yet been released, 14 Interphone studies (11 single country and 3 multicountry studies) with partial results have been published.

"Results of Interphone have been delayed by about 4 years," said Elizabeth Barris, founder of the nonprofit People's Initiative Foundation and coauthor of the new report, in an interview. "It was supposed to be released this September. We wanted to make sure that our report was released before Interphone. We wanted to bring attention to the issue, including the fact that Interphone has been delayed for so long."

With only 4 exceptions, the industry-funded Interphone studies found no increased risk for brain tumors from cell phone use, explained Mr. Morgan. In contrast, a series of Swedish studies, led by Lennart Hardell, MD, PhD, from the Department of Oncology, Orebro Medical Center, in Sweden, which were independent of industry funding, reported numerous findings of significantly increased brain tumor risk from cell phone and cordless phone use.

As you review these studies, you begin to get strong evidence of extremely improbable results.
An analysis of the results from the Interphone studies suggests that the use of a cell phone actually protects the user from a brain tumor, or that the studies had serious design flaws. "In any one study, you can see this incredibly skewing toward protection," said Mr. Morgan. "As you review these studies, you begin to get strong evidence of extremely improbable results."

In fact, Mr. Morgan and his coauthors identified 11 flaws in the Interphone studies: selection bias, insufficient latency time, definition of "regular" cell phone use, exclusion of young adults and children, no investigation of brain tumor risk from cell phones radiating higher power levels in rural areas, exclusion of exposure to other transmitting sources, exclusion of some brain tumor types, exclusion of tumors outside the cell phone radiation plume, exclusion of brain tumor cases because of death or illness, recall accuracy of cell phone use, and funding bias.

"Almost all flaws caused an underestimation of risk," he said, "and for exposure under 10 years, they found protection for cell phones."

The Cellular Telecommunications Industry Association (CTIA), the wireless association's industry trade group, has not specifically responded to the new report, according to Mr. Morgan. However, John Walls, vice president of public affairs at CTIA, told Medscape Oncology that "since we are not a scientific organization, with respect to the matter of health effects associated with wireless base stations and the use of wireless devices, CTIA and the wireless industry have always been guided by science and the views of impartial health organizations."

Peer-reviewed scientific evidence has overwhelmingly indicated that wireless devices do not pose a public health risk, Mr. Walls said. "In addition, there is no known mechanism for microwave energy within the limits established by the [Federal Communications Commission] to cause any adverse health effects," he said. "That is why the leading global heath organizations, such as the American Cancer Society, the National Cancer Institute, the World Health Organization, and the US Food and Drug Administration, all have concurred that wireless devices are not a public health risk."

Initial Red Flags

In the United States, the possible connection between tumors and cell phone use became highly publicized in 1993, when Florida resident David Reynard appeared on the popular television show Larry King Live and blamed cell phones for causing his wife's lethal brain tumor. Mr. Reynard filed a lawsuit against the manufacturer; he ultimately lost the case, but dozens of other lawsuits followed in its wake, along with numerous scientific studies that attempted to find or disprove a link. Most of the lawsuits have been dismissed, and thus far, none have gone to trial.

But the subject was picked up by the media, and scientists and experts argued publicly on opposing sides of the issue. Reports in the popular media prompted Congressional hearings on the safety of cell phone use, and during those sessions, it became clear that cell phones had not been tested for "safety prior to going into commerce," said George Carlo, PhD, MS, JD, during a 2008 radio interview with CFRO, a co-op radio station based in Vancouver, British Columbia. "Because the food and drug industry had not required that testing, Congress asked the industry to fill in those data gaps."

The industry invested $28.5 million and launched the first telecommunications industry-backed studies to investigate possible health risks stemming from cell phone use. Dr. Carlo, who is a Fellow of the American College of Epidemiology and has served on the faculty of several medical schools, headed the Wireless Technology Research program, which ran from 1993 to 1999. It was the largest program in the world to look at the potential dangers of cell phone use and electromagnetic radiation.

"In the middle of 1998, we began to have some of our long-term studies completed and it became clear that we were seeing things that no one expected," said Dr. Carlo. "We found that cell phone radiation caused leakage in the blood–brain barrier, it caused genetic damage in the form of disruption of normal DNA repair, and it caused more than a doubling of the risk of rare neuroepithelial tumors."

"After 6 years," he continued, "we found that cell radiation caused an increased risk of acoustic neuromas."

During the time these Wireless Technology Research studies were being carried out, the use of cell phones mushroomed. In 1993, there were 15 million cell phone users in North America; by 1999, there were more than 100 million.

"We went back to the industry and suggested that they issue warnings, but they promptly said no," Dr. Carlo said in the interview. "Those of us running the research program knew we had an ethical responsibility to go public with those findings, and we did go public, independent of the industry and independent of the government agencies that were overseeing the work."

In 2001, Dr. Carlo coauthored a book entitled Cell Phones. Invisible Hazards in the Wireless Age: An Insider's Alarming Discoveries, which discussed the findings.

I don't think they ever really expected to find that cell phones were dangerous.
Dr. Carlo felt that part of the reason for the refusal to issue warnings was that the telecommunications industry was not prepared for the results of the research. "I don't think they ever really expected to find that cell phones were dangerous, and when we presented our findings, they were ill prepared for them. They also didn't want to compromise their industry."

As for the lack of action on the part of government regulatory agencies, Dr. Carlo pointed out that agencies in the United States and Canada did not require any premarket testing of cell phones. "The only legal jurisdiction step that they had available in 1999 was to ban cell phones. And from a political point of view, banning cell phones would not be an easy thing to do, especially since our findings were the first ones of their type," he said.

These were "red flags of risk"; there weren't enough data at the time to actually prove that the risk was real, Dr. Carlo emphasized. "That is not the case now; there has been confirmatory evidence. But in 1999, regulatory agencies did not have the scientific evidence to be able to sustain the types of legal challenges that would have come from the industry had they tried to ban cell phones."

Trail of Research

Much of the more recent research on the safety of cell phones has not specifically found a health risk; however, researchers have pointed out the limitations of their studies and left the door open. Part of the problem in assessing the potential connection between brain tumors and cell phone use is the relatively short period of time that the devices have been heavily in use in a large population and the long latency period for many tumors.

A National Cancer Institute study published in 2001, for example, did not support the hypothesis that the use of cell phones caused brain tumors, but the researchers noted that a limitation of their work was that they did not assess risks after a potential induction period of more than several years or among people with very high levels of daily or cumulative use (N Engl J Med. 2001;344:79-86).

A 2009 review from researchers at the Karolinska Institutet in Stockholm, Sweden, reported that studies published to date do not demonstrate an increased risk after approximately 10 years of use for any brain tumor or other head tumor (Epidemiology. 2009;20:639-652). Thus far, data do not suggest a causal association between cell phone use and fast-growing tumors, but they note that for slow-growing tumors, such as meningioma and acoustic neuroma, "the absence of association reported thus far is less conclusive because the observation period has been too short."

Another recent review, the third in a series of updates to an original report issued by the Royal Society of Canada, concluded that although there is no clear evidence of adverse health effects associated with radiofrequency fields during the period from 2004 to 2007, continued research is recommended to address specific areas of concern, including the use of cell phones by children (J Toxicol Environ Health B Crit Rev. 2009;12:250-288).

The Interphone studies to date have largely reported negative results, finding no association between tumors and cell phone use. One study did not find a link between an increased risk for malignant or benign parotid gland tumors and exposure to radiofrequency electromagnetic fields, but the authors concluded that cell phones "have not been used long enough to exclude their possible carcinogenic effect after long-term use, and more epidemiologic studies including long-term users are clearly warranted" (Am J Epidemiol. 2006;164:637-643).

However, the results of an Israeli Interphone study suggest a positive association between cell phone use and the development of parotid gland tumors (Am J Epidemiol. 2008;167:457-467). The authors noted that this was a single study, and therefore did not provide enough evidence to assume causality. They recommend additional investigations of this association, with longer latency periods and large numbers of heavy users, to confirm the findings. "Until more evidence becomes available, we believe that the precautionary approach currently adopted by most scientific committees and applied by many governments should continue to be used," they wrote.

Some of the strongest evidence supporting a link between brain tumors and cell phone use comes from a series of Swedish studies, led by Dr. Hardell. Overall, the reserachers found that risk increased with the number of cumulative hours of use, higher radiated power, and length of cell phone use. They also reported that younger users had a higher risk. In fact, the highest risk was among people who were younger than 20 years at the time of first use (Int J Oncol. 2006;28:509-518; Int Arch Occup Environ Health. 2006;79:630-639; Arch Environ Health. 2004;59:132-137; Pathophysiology. 2009;16:113-122).

A meta-analysis that incorporated 11 long-term epidemiologic studies in this field also reported a link between cell phone use and brain tumors. Using a cell phone for 10 years or longer was positively associated with the development of an ipsilateral brain tumor; in fact, it doubled the risk (Surg Neurol. 2009;72:205-214).

Melange of Reactions

As in the literature, there is no consensus among physicians and scientists about the severity of risk, or even if it exists. On its Web site, the National Cancer Institute notes that although a consistent link has not been demonstrated between cell phone use and cancer, "scientists feel that additional research is needed before firm conclusions can be drawn." Likewise, the American Cancer Society points out that although the weight of the evidence has shown no association between cell phone use and brain cancer, information on the potential health effects of very long-term use, or use in children, is not available.

Sam Milham, Jr. MD, MPH, former chronic disease epidemiologist at the Washington State Department of Health and clinical associate professor at the University of Washington School of Public Health in Seattle, has published several critiques on cell phones and health risks. "I personally think there is a real risk, and have felt this way even before the studies were published, based on animal work," he told Medscape Oncology.

Dr. Milham contends that all of the negative studies have been seriously flawed. "The fact that same-sided tumors with long latency are showing increased risks is bad news, since brain tumors have very long latencies," he said. "The same-sided risks are very important since dose is important. The most worrisome fact is the number of people who are being exposed."

Putting a cell phone against your head is like putting one side of your head against a microwave oven.
"Putting a cell phone against your head is like putting one side of your head against a microwave oven," he added.

Last year, Ronald B. Herberman, MD, director of the University of Pittsburgh Cancer Institute and UPMC Cancer Centers in Pennsylvania, sent a memo to faculty and staff advising them to limit cell phone use based on his interpretation of recent research. In 2008, he testified before a Congressional Subcommittee on the subject of tumors and cell phones, and urged more independent and definitive research.

However, many experts are not convinced that there is a link. Currently, there is no evidence that cell phones cause brain cancer, said John Moulder, PhD, professor and director of radiation biology at the Medical College of Wisconsin in Milwaukee.

"The published data have rather consistently shown the absence of evidence for a human health hazard," he told Medscape Oncology. "Conclusive cancer epidemiology requires long follow-up time and accurate exposure assessment. The exposure assessment in this field has been very weak, as it depends on peoples' memories of how they were using mobile phones 10 or more years ago."

He emphasized that the studies based on what side of the head people used their phones are particularly weak, since most people use them on both sides, at least some of the time.

"Until we can find a way to measure actual exposure over long periods of time, the epidemiology will never be conclusive," he added.

Dr. Moulder pointed out a number of flaws in the new report. "The authors seem to have combed the literature for reports that support their concerns, and have ignored everything that would contradict their views," he said. "A scientific risk assessment needs to looks at all the evidence."

Although the report states that cell phone radiation has been shown to cause the blood–brain barrier to leak, Dr. Moulder noted that only 1 group has found that effect. "Other groups have been unable to replicate the effect."

Part of the problem with this research is that it is nearly impossible to prove that something doesn't cause cancer. "The closest you can come is to repeatedly try to show that it does and repeatedly fail," he said.

The Road Ahead

On the heels of the release of the new cell phone report, a Senate hearing on the health effects of cell phone use was held in September, and chaired by Sen. Tom Harkin (D-Iowa). The take-away message from expert testimony was that more and better research is needed to determine if there is a risk to human health. And nearly all of the researchers and scientists who spoke at the hearing advocated a precautionary approach in the meantime.

We just don't know what the answer is.
"We just don't know what the answer is," said Sen. Arlen Specter (D-Pennsylvania) during the hearing. "Precautions are not a bad idea. They may not be a good idea, but they are not a bad idea. And the issue of children is something we should look at a little more closely."

Several countries, including Israel, France, and Finland, and the United Kingdom have decided not to wait for additional data; instead, they have issued warnings about the use of cell phones and advise taking precautionary measures, especially for children. New legislation in France, for example, will ban advertising of cell phones that is directed to children younger than 12 years of age and the sale of cell phones designed for children younger than 6 years. In addition, France will introduce new limits for radiation from the phones and require cell phones to be sold with earphones.

Realistically, it is going to be difficult to change behaviors now that cell phones are so entrenched in daily use, explained Mr. Morgan. "In some parts of the world, it is nearly impossible to get a land-line telephone, so cell phones are the only option."

Cell phones can be made safer, and the technology to do so exists right now. For example, said Mr. Morgan, "you can get a 10,000-fold reduction in exposure simply by keeping the phone 6 inches away from the head."

There are also steps that can be taken right now to make cell phones safer to use, he said. These include using a wired headset (not a wireless headset such as a Bluetooth), using speaker-phone mode, or sending text messages; keeping the phone away from the body when not in use; avoiding use in a moving car, train, or bus, or in rural areas at some distance from a cell tower, because any of these uses will increase the power of the cell phone's radiation; and keeping the cell phone turned off until you need to use it.

The authors also recommend using a corded land-line phone whenever possible, instead of a wireless phone, and to avoid cell phones when inside buildings, particularly with steel structures. Since children face a greater health risk, they should not be allowed to sleep with a cell phone under their pillows or at the bedside, said Mr. Morgan. Ideally, those younger than 18 years should not use a cell phone at all, except for emergencies.

Passive Smoking Linked to Loss of Genetic Protection Against Respiratory Illness

From Reuters Health Information

NEW YORK (Reuters Health) May 12 - Investigators at the University of Southern California in Los Angeles report evidence that second-hand exposure to tobacco smoke negates the protection against respiratory illness afforded by the glutathione S-transferase P1 (GSTP1) variants.

The study, by Dr. Frank D. Gilliland and colleagues, involved 1132 Hispanic and non-Hispanic fourth-grade children in the Children's Health Study and is published in the May issue of Pediatrics.

The investigators assessed tobacco smoke exposure, respiratory-related school absences and status of four GSTP1 single-nucleotide polymorphisms, which account for 93% of the variation across the locus.

Three of the four SNPs were associated with a decreased risk of respiratory illness. However, "the protective effect of GSTP1 variants was lost among individuals exposed to in utero and secondhand tobacco smoke," Dr. Gilliland and colleagues report.

"The paradigm of loss of genetic protection among those exposed to tobacco smoke has clinical and public health implications that warrant broader consideration in research and practice," the team concludes.

Pediatrics 2009;123:1344-1351.

Surgical Mask May Be Comparable to N95 Respirator in Halting Flu Transmission

From Medscape Medical News
Laurie Barclay, MD

October 1, 2009 — Use of a surgical mask may not be inferior to the N95 respirator in halting influenza transmission in healthcare workers, according to the results of a noninferiority, randomized controlled trial published online October 1 and to be published in the November 4 print issue of the Journal of the American Medical Association.

"Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse," write Mark Loeb, MD, MSc, from McMaster University in Hamilton, Ontario, Canada, and colleagues. "Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance."

The goal of this study was to compare the surgical mask with the N95 respirator in protecting healthcare workers from influenza infection.

At 8 tertiary-care Ontario hospitals during the 2008 to 2009 influenza season, 446 nurses in emergency departments, medical units, and pediatric units were randomly assigned to use either a fit-tested N95 respirator or a surgical mask when caring for patients with febrile respiratory illness. Laboratory-confirmed influenza, measured by polymerase chain reaction or a 4-fold rise in hemagglutinin titers, was the main study endpoint.

Surgical mask efficacy was defined as being noninferior to the N95 respirator, with noninferiority defined as the lower limit of the 95% confidence interval (CI) for the reduction in incidence (N95 respirator minus surgical group) greater than −9%.

Of 478 nurses evaluated for eligibility from September 23 to December 8, 2008, 446 nurses were enrolled and randomized, with 225 assigned to use surgical masks and 221 to use N95 respirators. In the surgical mask group, influenza infection occurred in 50 nurses (23.6%) compared with 48 (22.9%) in the N95 respirator group (absolute risk difference, −0.73%; 95% CI, −8.8% to 7.3%; P = .86, with the lower confidence limit being inside the noninferiority limit of −9%). Noninferiority of the surgical mask was also shown for influenza A (H1N1).

"Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza," the study authors write. "Our findings apply to routine care in the health care setting. They should not be generalized to settings where there is a high risk for aerosolization, such as intubation or bronchoscopy, where use of an N95 respirator would be prudent."

Study limitations include the inability to determine compliance for all participants, that audits were conducted only on medical and pediatric units and not in the emergency department, the inability to account for the effect of indirect contact, and the inability to determine whether participants acquired influenza from hospital or community exposure.

"In routine health care settings, particularly where the availability of N95 respirators is limited, surgical masks appear to be non-inferior to N95 respirators for protecting health care workers against influenza," the study authors conclude.

In an accompanying editorial, Arjun Srinivasan, MD, from the Centers for Disease Control and Prevention in Atlanta, Georgia, and Trish M. Perl, MD, MSc, from the School of Medicine and Bloomberg School of Public Health at Johns Hopkins University in Baltimore, Maryland, note that appropriately designed and worn N95 respirators protect wearers from small-particle exposure.

For most patient care, the World Health Organization and the Society for Healthcare Epidemiology of America recommend the use of surgical masks, whereas the Centers for Disease Control and Prevention and the Institute of Medicine recommend wearing N95 respirators when caring for patients infected with H1N1 influenza.

"That this study is, to our knowledge, the first and only published randomized trial assessing respiratory protection for preventing influenza transmission is a sad commentary on the state of research in this area," Dr. Srinivasan and Dr. Perl write. "Uncovering the truth and identifying the most appropriate way to protect health care personnel will require that other investigators build on this study. Ultimately, accumulating a body of evidence on this topic will provide much-needed answers."

They also stress the importance of other measures to prevent influenza transmission, including vaccination and hand hygiene.

"While the debate over the role of respiratory protection in preventing influenza transmission will continue, neither the ongoing discussion nor the need for more research should excuse anyone from failing to implement other measures that are known to protect patients and HCP from influenza," they conclude.

The Public Health Agency of Canada supported this study. The study authors and editorialists have disclosed no relevant financial relationships.

JAMA. Published online October 1, 2009. Study, Editorial

New Guidelines Issued for Immunization of Infants, Children, Teens, Adults

From Medscape Medical News
Laurie Barclay, MD

September 22, 2009 — An Expert Panel of the Infectious Diseases Society of America (IDSA) has prepared updated, evidence-based guidelines for immunization of infants, children, adolescents, and adults. The new guidelines, which are published in the September 15 issue of Clinical Infectious Diseases, replace the previous IDSA clinical practice guideline for quality standards for immunization, published in 2002

"The IDSA updates its guidelines when new data or publications change prior recommendations or when the Expert Panel decides that clarification or additional guidance is warranted," write Larry K. Pickering, from the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues. "For the 2009 guidelines, vaccine licensure, approval, recommendations, safety, financing, barriers, and implementation issues were reviewed. This report does not include issues involving vaccines and autism and other potential adverse events."

These guidelines are intended to assist clinicians who care for either immunocompetent or immunocompromised people of all ages to provide recommended vaccinations. Since the previous clinical practice guideline was published in 2002, there have been significant improvements in the ability to prevent more infectious diseases.

New Vaccines, Recommendations

New vaccines that have been licensed since 2002 include human papillomavirus vaccine; live, attenuated influenza vaccine; meningococcal conjugate vaccine; rotavirus vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine; and zoster vaccine. New combination vaccines that have become available are measles, mumps, rubella, and varicella vaccine; tetanus, diphtheria, and pertussis and inactivated polio vaccine; and tetanus, diphtheria, and pertussis and inactivated polio/Haemophilus influenzae type b vaccine.

For young children, hepatitis A vaccines are now universally recommended.
All children aged 6 months through 18 years and adults who are 50 years or older should receive annual administration of influenza vaccines.
The routine childhood and adolescent immunization schedule now includes a second dose of varicella vaccine.
The adolescent and adult immunization schedules have expanded to accommodate many of these new recommendations.

Other areas highlighted in the updated guidelines include the need to remove barriers to immunization, to eliminate racial and ethnic disparities in access to and compliance with vaccine recommendation, to address issues regarding vaccine safety, and to fund the cost of implementing recommended vaccinations.

The updated guidelines also provide specific recommendations for vaccination of special groups, including healthcare providers, immunocompromised patients, pregnant women, international travelers, and internationally adopted children.

Specific vaccine recommendations for infants, children, adolescents, and adults, and their accompanying level of evidence rating, are as follows:

Infants, children, adolescents, and adults should be given all age-appropriate vaccines as recommended by the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics

When a vaccine dose is not given at the recommended age, it should be given at any subsequent medical visit when indicated and feasible, without restarting the series

For people who have delayed immunizations or who want to accelerate their vaccination schedule, recommendations for the minimum interval between doses should still be followed
All indicated vaccines should be administered simultaneously when appropriate and feasible
Licensed combination vaccines may be given provided the following conditions apply: any components of the combination are indicated, other components are not contraindicated, and the US Food and Drug Administration (FDA) has licensed the vaccine for that dose of the series (
For childcare, schools and colleges, and nursing homes, specific immunization requirements should be followed
Vaccinations delivery should be coordinated with other preventive healthcare services recommended for children, adolescents, and adults
Storage and administration of all vaccines should follow recommendations of the manufacturer and licensing requirements from the FDA


Clin Infect Dis. 2009;49:817–840. Abstract

Aerobic Exercise May Reduce Risk for Fatty Liver Disease

From Medscape Medical News
Deborah Brauser

September 11, 2009 — Obese individuals with a sedentary lifestyle can lower their risk for nonalcoholic fatty liver disease (NAFLD) by engaging in routine physical activities, according to results of a small randomized study published online June 15 in Hepatology.

In addition, this lower risk was not contingent upon weight loss, but was a direct result of the increased exercise program.

"These data provide the first direct experimental evidence demonstrating that regular aerobic exercise reduces hepatic lipids in obesity even in the absence of body-weight reduction," write Nathan A. Johnson, from the Discipline of Exercise and Sport Science and the Institute of Obesity, Nutrition and Exercise at the University of Sydney in Australia, and colleagues.

"Physical activity should be strongly promoted for the management of fatty liver," add the study authors.

The location of body fatness, particularly visceral adipose tissue (VAT), is increasingly recognized as being of greater importance in determining the metabolic and cardiovascular consequences of excess adiposity, the authors report.

In addition, evidence is emerging that excessive storage of hepatocellular triglyceride is a common feature of obesity, with hepatic steatosis (or NAFLD) possibly affecting 30% of the adult population and the majority of obese individuals.

However, there is a paucity of evidence regarding the effects of diet and exercise interventions on reducing hepatic triglyceride concentration (HTGC), and no definitive pharmacotherapy exists for it.

Strategies Besides Those Aimed at Weight Loss Are Needed

"Although intervention aimed at weight loss is advocated, reductions in weight by dietary restriction are typically modest and are increasingly viewed as an unsustainable outcome of lifestyle modification," write the study authors. "Therefore, appropriate therapeutic strategies for reducing HTGC, which are not contingent upon weight loss, are needed."

Although the effect of aerobic exercise on liver fat independent of weight loss has not been clarified, the investigators sought to assess its effect on hepatic, blood, abdominal, and muscle lipids for this study.

Dr. Johnson and his team enrolled 23 obese adults who had a body mass index of 30 kg/m2 or higher and who reported a sedentary lifestyle and low alcohol intake (0-20 g/day).

Baseline measurements were performed to determine HTGC and saturation index, abdominal VAT and subcutaneous adipose tissue (SAT) area and volume, intramyocellular triglyceride concentration, cardiorespiratory fitness, anthropometry, and blood biochemistry.

A total of 19 patients were then randomly allocated to receive either 4 weeks of supervised aerobic exercise training (n = 12) made up of 3 cycle ergometer sessions (30–45 minutes each) per week or 4 weeks of a sham intervention (placebo, n = 7). Those in the placebo group received 1 supervised stretching session at treatment initiation and were then directed to perform the stretches 3 times per week at home.

The investigators measured HTGC with noninvasive proton magnetic resonance spectroscopy and measured abdominal lipids by magnetic resonance imaging. Cardiorespiratory fitness was assessed using the Physical Work Capacity test undertaken on a cycle ergometer. All measurements for both groups were repeated at completion of the allocated exercise programs.

After 4 weeks of aerobic cycling exercise, VAT volume was significantly reduced by 12% (P < .01) and HTGC was reduced by 21% (P < .05).

The aerobic exercise regime was also associated with a significant (14%) reduction in plasma free fatty acids (P < .05).

Exercise training did not alter body weight, vastus lateralis intramyocellular triglyceride, abdominal SAT volume, magnetic resonance spectroscopy-measured hepatic lipid saturation, or homeostasis model assessment of insulin resistance (P > .05).

First Direct Evidence

"Using a short-term aerobic cycling training intervention in previously sedentary obese adults, we provide the first direct experimental evidence demonstrating that regular aerobic exercise training reduces hepatic lipids without concurrent changes in body weight or abdominal SAT content," write the study authors. "Thus, regular exercise may mitigate the metabolic and cardiovascular consequences of obesity, including fatty liver."

"Our observation of a beneficial effect of regular exercise itself . . . should refocus the debate, and hence policy, on the role of physical activity in the prevention and management of obesity and NAFLD. In other words, physical activity should be strongly promoted for the management of fatty liver," conclude the study authors.

Hepatology. 2009;50:000-000. Abstract

Baldness and Myocardial Infarction in Men?

From American Journal of Epidemiology
The Atherosclerosis Risk in Communities Study
Eyal Shahar; Gerardo Heiss; Wayne D. Rosamond; Moyses Szklo

Abstract
Because hair loss may be a surrogate measure of androgenic activity -- possibly a determinant of coronary atherosclerosis -- several studies have explored the presence and magnitude of an association between male pattern baldness and myocardial infarction (MI). In particular, vertex baldness, but not frontal baldness alone, was strongly associated with incident MI in a large, hospital-based, case-control study.

The authors examined these associations in a cross-sectional sample of 5,056 men aged 52-75 years, of whom 767 had a history of MI. The sample was derived from the Atherosclerosis Risk in Communities (ARIC) Study (1987-1998).

As compared with a baldness-free reference group, the estimated odds ratios for prevalent MI from a multivariable model were 1.28 (frontal baldness), 1.02 (mild vertex baldness), 1.40 (moderate vertex baldness), and 1.18 (severe vertex baldness). Other regression models have yielded similar results, including the absence of a monotonic "dose-response relation" between the extent of vertex baldness and prevalent MI.

The authors also examined the relation of baldness pattern to carotid intimal-medial thickness, a measure of atherosclerosis, among those who were free of clinical cardiovascular disease. The estimated mean differences in carotid intimal-medial thickness between groups of men with various types of baldness and their baldness-free counterparts were all close to zero.

The results of this study suggest that male pattern baldness is not a surrogate measure of an important risk factor for myocardial infarction or asymptomatic atherosclerosis.

http://www.medscape.com/viewarticle/578402

Haze & Your Heart

Hi everyone who has to put up with the haze the last few weeks,
Do be careful if you have had heart attacks before.

Air Pollution Can Induce Arrhythmias (irregular heart beat) in Some MI Patients
From Reuters Health Information

Aug 07 - A history of myocardial infarction can increase the risk of ventricular arrhythmias when patients are exposed to airborne particulate matter, according to Italian researchers. Failure to take beta-blockers appears to make these patients more prone to autonomic dysregulation.

As reported in the July issue of the European Heart Journal, Dr. Antonio F. Folino of the University of Padua and colleagues assessed the impact of air pollution on arrhythmias and autonomic function in 39 patients with a prior myocardial infarction.

"We accurately assessed the exposure to air pollution...by means of personal samplers worn by the subjects in backpacks for 24 hours, analyzing the particulate matter to which they were exposed," Dr. Folino told Reuters Health.

At the same time as air pollution monitoring, all of the subjects underwent continuous ECG recording. Thirty-two of the patients were taking beta blockers.

Overall, there was no correlation between heart rate variability and exposure to particulate matter. However, there was a negative correlation between heart rate variability and exposure to PM-0.25 in the patients not taking beta-blockers. More severe ventricular arrhythmias were observed at the highest concentrations of PM-10 and PM-2.5.

"We showed a direct negative influence of particulate matter on the cardiovascular system," Dr. Folino said. "In particular, the inhalation of the larger particles has been correlated with increased arrhythmias, while the ultrafine (particles) induced an increase in sympathetic autonomic activity, a negative factor in the prognosis of patients with heart disease."

These results, he concluded, show that "patients with coronary artery disease are particularly vulnerable to the effect of air pollution and that the effects of air pollutants can worsen the prognosis of these subjects."

Eur Heart J 2009;30:1614-1620.

DASH-Style Diet May Help Protect Against Kidney Stones

From Medscape Medical News
Laurie Barclay, MD

August 18, 2009 — The Dietary Approaches to Stop Hypertension (DASH) diet may help protect against kidney stones, according to the results of a prospective study reported online August 13 in the Journal of the American Society of Nephrology.

"Despite previously observed associations between individual dietary factors and kidney stone risk, relatively few studies have examined the impact of overall diet or dietary patterns on risk," write Eric N. Taylor, MD, from Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, and colleagues.

"The [DASH] diet, which is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein represents a novel potential means of kidney stone prevention. The consumption of fruits and vegetables increases urinary citrate, an important inhibitor of calcium stone formation, and a diet with normal to high calcium content but low in animal protein and sodium decreases the risk of calcium oxalate stone recurrence by 51%," the researchers state.

The investigators studied the association between a DASH-style diet and incident kidney stones in the Health Professionals Follow-up Study (n = 45,821 men; 18 years of follow-up), Nurses' Health Study I (n = 94,108 older women; 18 years of follow-up), and Nurses' Health Study II (n = 101,837 younger women; 14 years of follow-up).

To determine degree of compliance with the DASH-style diet, the investigators constructed a DASH score based on 8 components: high consumption of fruits, vegetables, nuts and legumes, low-fat dairy products, and whole grains, and low consumption of sodium, sweetened beverages, and red and processed meats. Cox hazards regression allowed adjustment for age, body mass index (BMI), fluid intake, and other clinical factors.

During a combined follow-up of 50 years, there were 5645 incident kidney stones. Intakes of calcium, potassium, magnesium, oxalate, and vitamin C were higher in participants with higher DASH scores, and sodium intakes were lower.

The observed reductions in kidney stone risk were independent of age, BMI, fluid intake, and other factors. Even in participants with lower calcium intake, higher DASH scores predicted lower risk for kidney stones. The findings were unaffected by excluding participants with hypertension.

"Consumption of a DASH-style diet is associated with a marked decrease in kidney stone risk," the study authors write. "In contrast to our previous studies of individual dietary factors and kidney stone risk in these populations, the impact of a DASH-style diet was similar in men and women, in older and younger individuals, and in participants with both low and high BMI."

Limitations of this study include lack of data on stone composition reports from all stone formers, failure to examine the effect of DASH score on 24-hour urine calcium, poor measurement of sodium intake, and limited generalizability.

"Although we think it reasonable for calcium oxalate stone formers with high levels of urinary oxalate to avoid intake of some individual foods very high in oxalate (such as spinach and almonds), our data do not support the common practice of dietary oxalate restriction in calcium stone formers, particularly if such advice results in lower intake of fruits, vegetables, and whole grains. Because of the adverse side effect profile of many current medical therapies for nephrolithiasis, a randomized trial is needed to determine the efficacy of a DASH-style diet compared with medical intervention for the secondary prevention of calcium oxalate kidney stones."


J Am Soc Nephrol. Published online August 13, 2009.

Adherence to a Low-Fat, High-Fiber Diet Lowers Risk of Polyp Recurrence

From Reuters Health Information

Sep 04 - Patients who strictly follow a low-fat, high-fiber, and high-fruit and -vegetable diet have a lower risk of colon adenoma recurrence.

"The Polyp Prevention Trial was designed to test the effect of (this) dietary intervention on the recurrence of adenomas in the colon," Dr. Leah B. Sansbury of the National Cancer Institute, Bethesda, Maryland, and colleagues write in the September issue of the American Journal of Epidemiology.

The authors note that the goals of the dietary intervention were to limit fat to 20% of energy intake and to consume at least 18 g of fiber and 3.5 servings of fruits and vegetables per 1000 kcal.

"After 4 years of the trial, no difference in the rate of adenoma recurrence between the intervention group and the control group was observed," they note. "The number of dietary goals met by the intervention group varied greatly; thus, it is possible that lack of adherence in fully attaining the intervention goals may account for the lack of observed effect."

The researchers examined data from the Polyp Prevention Trial to determine whether strict adherence to the low-fat, high-fiber, and high-fruit and -vegetable intervention goals influenced the risk of adenoma recurrence. Included were 1095 subjects recruited between 1991 and 1994 (control group, n = 947; intervention group, n = 958). Annual food-frequency questionnaires were used to assess dietary intake and supplement use.

Colonoscopies were performed at baseline, the 1-year visits, and the end of the trial intervention.

Of 821 participants in the intervention group who completed the study, 245 (29.8%) were classified as poor compliers, 366 (44.6%) as inconsistent compliers, and 210 (25.6%) as super compliers. Subjects classified as super compliers consistently reported that they met or exceeded each of the dietary goals at all four annual visits.

In unadjusted analyses, super compliers had a 30% statistically significant decreased odds of adenoma recurrence compared with controls (odds ratio = 0.69). The association remained unchanged in fully adjusted models. Strict compliance to the intervention over the entire 4 years led to a nearly 50% statistically significant decreased odds of multiple adenomas. A nonsignificant inverse association was observed for multiple and advanced adenoma recurrence.

"To focus on testing the biologic effects of an intervention or treatment on the trial, future dietary and treatment trials could target and randomize individuals most likely to comply," Dr. Sansbury and associates conclude. "Findings from such trials would enhance the validity of our own findings."

Am J Epidemiol 2009;170:576-584.

What If Regular Exercise Were as Good as a Stent for Stable Angina?

From Heartwire
Shelley Wood
Medscape Conference Coverage, based on selected sessions at the:
European Society of Cardiology (ESC) Congress 2009

September 8, 2009 (Barcelona, Spain) - Investigators for the multicenter PET study were keen to build on the surprising findings from their pilot trial: that 12 months of exercise training was just as good as PCI for myocardial perfusion and symptom relief in patients with stable angina and even better in terms of preventing cardiovascular events. Those hopes, however, were dashed when the multicenter PET study ground to a halt due to a lack of enthusiasm among patients and enrolling centers.

But in new findings presented by Dr Rainer Hambrecht (Klinikum Links der Weser, Bremen, Germany) at the European Congress of Cardiology 2009 Congress, combined data from the PET pilot study and the aborted PET multicenter trial suggest that regular exercise training is superior to PCI at preventing subsequent cardiovascular events.

The original PET study [1] randomized 102 patients to either exercise or PCI and reexamined patients after 12 months using coronary angiography, technetium-99m scintigraphy, and ergospirometry, as well as a range of clinical end points. Results, which were published in Circulation in 2004, showed clear and comparable improvements in symptoms and myocardial perfusion from baseline with both treatment strategies, and a trend toward better event-free survival in the training group at both 12 and 48 months.

"Our expectation was that exercise training would not be inferior to PCI; however, what we saw after 12 months was a clear, significant improvement in exercise over PCI in patients with stable CAD," Hambrecht told heartwire .

Exercise benefits

Inspired by the PET pilot, Hambrecht et al launched the PET multicenter trial at four hospitals in Germany, Austria, Switzerland, and Romania. By design, patients were randomized either to PCI or to two weeks of a supervised exercise training program every day, made up of five short periods of exercise daily. Patients were then given bicycles at home and asked to exercise on them every day, plus attend a supervised exercise program one or two times per week. The bikes, Hambrecht told heartwire , were equipped with sensors that monitored the amount and duration of exercise and ensured that it was actually the study participant--and not another family member--who was using the equipment.

But according to Hambrecht, the trial had major problems recruiting and was halted with just over 100 of the original 400 patients it had hoped to enroll. The study had plenty of funding; enrollment problems lay with both the recruiting centers and the patients themselves, he said. "There was some reluctance among the centers to join us in performing this study and also difficulties recruiting patients for the study" and explaining the randomization process. "If you get the stent you are free of symptoms within a few minutes, [whereas] in the training group, you have to work a lot, for several months, to reduce the angina threshold."

As with the pilot study, there were striking improvements with both PCI and exercise training in angina class and improvements in event-free survival that were nonsignificantly better for the training patients.

However, when the patients from both the multicenter and pilot studies were combined for a total of 202 patients with two-year follow-up, investigators achieved the statistical significance not met in the multicenter trial, Hambrecht reported. In a pooled analysis of event-free survival, 21 events occurred in the training group as opposed to 32 events in the PCI group (p=0.039). The differences speak to the direct benefits of exercise on the cardiovascular system globally, as opposed to the palliative, more localized benefits of PCI. Whereas both strategies improve myocardial perfusion, angina threshold, and exercise capacity, only exercise improves endothelial function and slows disease progression, he noted. Moreover, he stressed, improvements in both arms were seen on top of optimal medical therapy.

Forces work against exercise

In an interview with heartwire , Hambrecht acknowledged that there are multiple forces working against a scenario in which regular exercise is prescribed instead of stenting. For one, patients are not motivated to take responsibility for improving their own cardiovascular health--even if it means better event-free survival. For another, encouraging exercising is financially less appealing for hospitals, Hambrecht observed: "That was my feeling, that hospitals were reluctant to participate in this study, because they derive revenue from PCI procedures."

Hambrecht believes his data support calls to take the time between the diagnostic angiogram and the revascularization procedure to discuss the options with the patient, rather than stenting every patient.

"We have enough evidence from several studies, including COURAGE and our PET studies, comparing PCI vs more conservative strategies, and the data are quite convincing that PCI is not superior" in stable angina, he concluded.

Hoarseness

Otolaryngol Head Neck Surg. 2009;141:S1-S31.

Clinical Context

Hoarseness is a common presenting symptom in many different practice settings, affecting approximately one third of individuals at some point during their lifetime, but many people in the United States are unaware of the possible causes and appropriate treatment of hoarseness. Although most patients with hoarseness have benign, self-limiting conditions, persistent hoarseness may be a warning signal of underlying cancer.

A multidisciplinary panel convened by the AAO-HNSF developed a practical clinical guideline for management of hoarseness, targeting consumers as well as all clinicians who are likely to diagnose and treat patients with hoarseness. Dysphonia, or hoarseness, is characterized by altered vocal quality, pitch, volume, or vocal effort that hinders communication or decreases voice-related quality of life.


Study Highlights

The history and physical examination of the patient with hoarseness should identify factors that may affect management.
These risk factors may include recent surgery on the neck or in the recurrent laryngeal nerve territory, recent endotracheal intubation, neck radiation therapy, history of tobacco abuse, and occupation as a singer or vocal performer.
Although most causes of hoarseness are benign or self-limiting conditions, laryngeal tumor or other serious underlying condition should be ruled out, as well as adverse effects of medication.
The examining physician or consultant should perform laryngoscopy in the office to visualize the larynx if hoarseness persists for more than 3 months or if the underlying cause is not easily diagnosed or is thought to be serious.
Laryngoscopy is considered the primary diagnostic modality for hoarseness and should be done before any other imaging procedures.
Imaging studies, such as computed tomography or magnetic resonance imaging scans, should not be done before the larynx is visualized with laryngoscopy in patients whose primary complaint is hoarseness.
Unless there are signs or symptoms of significant gastroesophageal reflux disease, hoarseness should not be treated with antireflux medications. These may be prescribed when laryngoscopy suggests chronic laryngitis.
The clinician should not routinely prescribe antibiotics or oral corticosteroids to treat hoarseness.
Voice therapy is recommended for patients of all ages diagnosed with hoarseness that decreases voice-related quality of life.
Laryngoscopy should be performed before voice therapy is started, and the speech-language pathologist should be informed of the findings.
The usual regimen for voice therapy is 1 to 2 sessions per week for 4 to 8 weeks.
Most causes of hoarseness do not require surgery, but it may be indicated for suspected cancer, other tumors or growths, abnormal vocal cord movement, or abnormal vocal cord muscle tone.
For hoarseness caused by adductor spasmodic dysphonia, the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections.

Clinical Implications

Although most causes of hoarseness are benign or self-limiting conditions, laryngeal tumor or other serious underlying condition should be ruled out, as well as adverse effects from medication. Laryngoscopy is considered the primary diagnostic modality for hoarseness and should be done before any other imaging procedures.
Unless there are signs or symptoms of significant gastroesophageal reflux disease, or chronic laryngitis, hoarseness should not be treated with antireflux medications. Antibiotics or oral corticosteroids are not routinely recommended. Voice therapy is recommended for patients of all ages diagnosed with hoarseness that decreases voice-related quality of life.

http://cme.medscape.com/viewarticle/708571?sssdmh=dm1.526917&src=nldne&uac=71630FV

Where do Eggs Fit in a Heart-healthy Diet?

Role of Eggs in the American Diet
From American Journal of Lifestyle Medicine
Joanne Curran Celentano PhD

Abstract
Eggs make up a relatively small contribution to the energy consumption of the average American, in part because of the perception that the cholesterol content makes them a for-bidden food for a heart-healthy diet. The relationship between egg cholesterol, blood cholesterol, and cardiovascular disease risk is complex and not clearly understood. In addition, eggs provide many valuable and bioavailable nutrients. Thus, the place of eggs in meal planning should be reconsidered while keeping in mind the diet and lifestyle recommendations of the American Heart Association.

Introduction
As far as single-component foods are concerned, there are few more nutrient dense than eggs. Yet this food category accounts for a very limited amount of energy consumption (1.3%) by the average American.[1] The perception of eggs as a forbidden food can be traced back to the 1970s recommendation by the American Heart Association to reduce the consumption of eggs and other sources of dietary cholesterol to lower the risk of cardiovascular disease (CVD).[2]

Since that time, compelling research suggests that the relationship between eggs and heart disease risk is not so simple, especially when examining free-living populations. There are responders and nonresponders to dietary cholesterol and, in some cases, paradoxical responses including lower cholesterol in egg consumers and/or elevated cholesterol with no change in the CVD risk ratio. The question of where eggs fit in a heart-healthy diet gets more interesting when considering the potential benefits of eggs in the diet, especially for infants and elderly persons. Eggs are a good or excellent source of many essential nutrients, are relatively low cost, and serve as an effective vehicle for functional ingredients in the diet.

Does Eating Eggs Increase Serum Cholesterol and Heart Disease Risk?
The relationship of dietary cholesterol to serum cholesterol has been demonstrated most clearly in experimental feeding studies. Such studies have shown that the consumption of an additional egg per day will lead to a modest increase (1%–3%) in serum cholesterol.[2] However, population studies examining the association between egg consumption and serum cholesterol concentration have not been so convincing.[3] Several large epidemiological studies have examined the association of egg consumption and serum cholesterol. The Framingham Heart Study[4] examined the serum cholesterol in high versus low egg consumption and found no significant difference in either men or women. The association between self-reported dietary intake of eggs and serum cholesterol was examined in a population of 12 000 men in the Multiple Risk Factor Intervention Trial. Paradoxically, those consuming more eggs had lower serum cholesterol than those men consuming fewer eggs.[5] Similarly, in the Third National Health and Nutrition Examination Survey (NHANES III), the diets of 20 000 participants were evaluated, and participants consuming less than 1 egg per week had a higher average serum cholesterol than those consuming more than 4 eggs per week.[6]

Recently, the association between egg consumption and the risk of CVD and mortality was investigated using data from the Physician's Health Study.[7] In this prospective cohort study, egg consumption was assessed using an abbreviated food-frequency questionnaire. In an average follow-up of 20 years, there was no association between egg consumption and myocardial infarct or stroke. However, egg consumption was positively related to all-cause mortality in a dose-dependent way, and this relationship was stronger among diabetic subjects. The researchers concluded from these data that infrequent egg consumption did not influence the risk of CVD in male physicians. The relationship of egg consumption with all-cause mortality required further investigation. A possible explanation for this finding was offered in a letter to the editor.[8] It was suggested that a nonadherer bias might be responsible for the association because there is no biological basis for an increased association of noncardio-vascular causes of death with high egg consumption. It was suggested that such bias is a limitation of observational studies. For example, high egg consumers tend to smoke more, and egg consumption is often associated with other high-fat foods such as bacon and butter. The "guilt by association" has to be parsed out in such studies to ensure that eggs are not inadvertently associated with risk.

Heart failure (HF) represents a subtype of CVD and may be underrepresented in studies investigating associations of diet and CVD, especially in younger cohorts with lower incidence of this subtype.[9] Little dietary-related research specific to HF is available; however, as the population ages, HF is increasingly adding to the health care burden and affecting the quality of life.[10] A recent study examined the association between egg consumption and risk of HF in a prospective cohort study of 21 275 male physicians.[11] Egg consumption up to 6 times per week was not associated with incident HF; however, consumption equal to or greater than 7 times per week was associated with increased risk of HF in male physicians. The Atherosclerosis Risk in Communities study evaluated incident HF and diet in a longitudinal cohort study including 14 153 African American and white men and women aged 45 to 64 years. During the 13-year follow-up, there were 1140 cases of HF. Whole-grain intake was associated with lower HF risk, whereas intake of eggs and high-fat dairy was associated with a greater risk of incident HF.[9]

Responders versus Nonresponders

Despite extensive research, the link between egg consumption and risk for coronary heart disease (CHD) is not clearly established. The relationship is likely influenced by variability in individual responses to dietary cholesterol. This variability was examined in relation-ship to the blood cholesterol response to egg consumption.[12,13] For some individuals, consuming eggs did cause a rise in blood cholesterol. These individuals are considered hyperresponders to a cholesterol challenge. However, 70% of the population experience little to no change in blood cholesterol following consumption of dietary cholesterol (hyporesponders). In addition, the egg cholesterol increased both circulating low-density lipoprotein (LDL-C) and high-density lipoprotein (HDL-C) in those individuals who experience changes in blood cholesterol following egg consumption. Moreover, eggs have been shown to promote the formation of large LDL particles, shifting individuals to a less atherogenic lipid profile. Such individual variations in the response to dietary cholesterol can be attributed to a variety of factors, including ethnicity, body mass index, and hormone status.[14] Genetics certainly has a role. Recently, it was reported that polymorphism in the ATP-binding cassette G (ABCG5) is thought to influence the response to dietary cholesterol.[15] In this study, 40 men and 51 postmenopausal women were randomly assigned to consume eggs (equivalent to 640 mg/d additional dietary cholesterol) or placebo for 30 days in a crossover design. It was found that genotype influenced the response to cholesterol, with one specific group experiencing a greater increase in LDL-C in response to the cholesterol challenge. Although this study was small, the results suggest that genetic makeup influences an individual response to cholesterol and may explain some of the controversy surrounding the questions and recommendations about dietary cholesterol in relationship to blood cholesterol and disease risk.

The data from the NHANES III (1988–1994) were examined to assess the nutritional contribution of eggs in the American diet and to estimate the strength of the association between egg consumption and serum cholesterol. Nutrient intake from 24-hour recall and egg intake from food-frequency questionnaires were used to group 27 378 participants into egg consumers and nonconsumers. Egg consumers had considerably greater nutrient density contributing vitamin A, E, folate, and B12. The results also indicated that egg consumption was negatively correlated with serum cholesterol. In this population, those who reported eating 4 or more eggs per week had significantly lower mean serum cholesterol than those who reported eating less than or equal to 1 egg per week. In this cross-sectional and population-based study, egg consumption made important nutritional contributions to the American diet and was not associated with high serum cholesterol concentrations.[6]

Thus, it is important to look at eggs as more than a cholesterol-delivery sys-tem. Eggs are an inexpensive and low-calorie source of high-quality protein and other nutrients, including folate, riboflavin, selenium, choline, and vitamins B12 and A, D, and K.[15] In addition, the lipid matrix of the egg yolk enhances the bio-availability of valuable carotenoid pigments, including lutein and zeaxanthin.[16] Thus, the positive contribution of eggs to a healthy diet should be considered in the risk–benefit analysis.[17]

This may be particularly true for elderly persons. The incidence of age-related diseases will continue as our population ages. By the year 2020, the number of people older than 60 years is expected to top 1 billion.[18] The burden of treating chronic disease is significant both in dollars spent and lost productivity. The need to identify risk factors for disease must be evaluated along with diet and lifestyle factors that promote healthy aging.

For elderly persons, it has been suggested that the widely accepted risk factors for CHD may not be applicable.[19] Whereas elevated total cholesterol and LDL-C values are considered predictive of CHD risk in the middle years, this may not be relevant for the elderly population. In this population, a low-fat diet prescription may actually lead to a diet pattern that increases CHD risk. A higher carbohy-drate, especially simple carbohydrate, diet is associated with elevated triglycerides, low HDL-C, and the production of small, dense LDL particles. In cases in which fat/ cholesterol restriction is practiced over energy restriction, a high-carbohydrate diet may have the net effect of promoting insulin resistance.[14] To promote energy restriction instead, eggs may provide a low-calorie and nutrient-dense option for meal planning. In addition, the protein quality of eggs reflects its balanced amino acid profile, and the high-quality egg protein may be helpful in avoiding the loss of muscle mass associated with aging.[20]

While not typically recommended, carbohydrate-restricted diets (CRD) have been popular for rapid weight loss and are associated with lower glucose and insulin levels and improve dyslipidemia. Studies have shown that the improved lipid profile (elevated HDL-C and lower triglycerides) are associated with a higher intake of dietary cholesterol.[21] Eggs have been shown to modulate the inflammatory response to CRD. Daily egg consumption along with CRD in overweight men was associated with decrease in C-reactive protein and increased adiponectin compared with CRD without eggs.[20]

Egg Carotenoids and Eye Health
The leading cause of irreversible blind-ness in the United States is age-related macular degeneration (AMD).[22] Although the causes of AMD are complex and multifaceted, a lifetime exposure to oxidative damage is clearly implicated. Although both light and oxygen are essential for normal vision, the accumulated by-products from oxidative metabolism in the retina over time can cause damage. Lutein and zeaxanthin (L/Z) accumulate in the macular region of the retina and are collectively referred to as macular pigment (MP). Because of its antioxidant and light-filtering properties, the MP may protect the retina and reduce the risk of developing AMD. Studies have shown that individuals who consume foods rich in L/Z have a lower risk for AMD,[23] higher blood levels of L/Z,[24,25] and higher MP density.[26–28]

Several studies have shown that eggs provide a highly bioavailable source of L/Z.[16,24,29] While the average content of L/Z in the yolk is ~200 to 300 μg, the lipid matrix allows for efficient uptake of these pigments. As little as 1 egg per day or 6 eggs per week have been shown to increase serum L/Z and MP, respectively.[16,29] The concentration of L/Z in the egg yolk can be easily modified by alterations in the animal diet, and the difference in the L/Z content of grocery store eggs varies widely depending on the type and care of the animal.[16] Many local egg producers allow their animals to graze in appropriate weather, and their egg yolks may range from pale yellow to deep orange depending on the L/Z avail-able in the diet. Consumers can identify lutein as associated with eye health, reflecting the media's attention in magazine articles and advertisements. For example, a recent article titled "Eat for Your Eyes"[30] discussed 5 food strategies to help you "see more clearly." The inclusion of eggs in the diet was one of the recommendations, citing a study in which consuming 2 eggs per day was associated with increased circulating L/Z with no change in blood LDL-C. The recommendation was to "go ahead and enjoy eggs regularly unless advised otherwise by your doctor." The article did include the caveat to stay within the American Heart Association guidelines, as noted below.

Current Recommendations
The American Heart Association[31,32] Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction are listed in Table 1. The current recommendations reflect a shift toward looking at dietary patterns and overall diet quality rather than focusing on specific nutrients and a diet based more on inclusion of a wide range of foods and less on avoidance of particular foods or ingredients. Whereas there was previously a stated recommendation to limit eggs to 4 yolks per week, this food-specific recommendation is not in the current guidelines. The American Heart Association recommendation is to limit dietary cholesterol to <300 mg/d. The average egg yolk contains on average 213 mg of cholesterol.

If eggs are judged on their nutritional content, convenience, and cost, the positive contributions of eggs may outweigh the potential risk associated with the cholesterol. This may be particularly true for healthy elderly individuals whose cholesterol risk and nutritional needs differ from earlier years. For individuals with diabetes or major risk factors for CHD, the recommendation to limit dietary cholesterol to <200 mg/d[33] allows for less frequent use of unmodified egg products. Along with the numerous modified egg products on the market today (eg, Egg Beaters), there will likely be additional egg and egg products with higher lutein and lower cholesterol in the future.[34,35]