DrTanPohTin

Education for Mental Fitness: “A Sharper Mind, Middle Age and Beyond”

2012-01-27T20:51:00.000-08:00

JAN 19, 2012

Kudos to Patricia Cohen for one of the best articles I have read in The New York Times in a long time: A Sharper Mind, Middle Age and Beyond, by Patricia Cohen. These are a few quotes — please do read the article in full, it is worth it.

“Some people are much better than their peers at delaying age-related declines in memory and calculating speed. What researchers want to know is why. Why does your 70-year-old neighbor score half her age on a memory test, while you, at 40, have the memory of a senior citizen? If investigators could better detect what protects one person’s mental strengths or chips away at another’s, then perhaps they could devise a program to halt or reverse decline and even shore up improvements.”
“As it turns out, one essential element of mental fitness has already been identified. “Education seems to be an elixir that can bring us a healthy body and mind throughout adulthood and even a longer life,” says Margie E. Lachman, a psychologist at Brandeis University who specializes in aging. For those in midlife and beyond, a college degree appears to slow the brain’s aging process by up to a decade, adding a new twist to the cost-benefit analysis of higher education — for young students as well as those thinking about returning to school.”
“Many researchers believe that human intelligence or brainpower consists of dozens of assorted cognitive skills, which they commonly divide into two categories. One bunch falls under the heading “fluid intelligence,” the abilities that produce solutions not based on experience, like pattern recognition, working memory and abstract thinking, the kind of intelligence tested on I.Q. examinations. These abilities tend to peak in one’s 20s.”
“Crystallized intelligence,” by contrast, generally refers to skills that are acquired through experience and education, like verbal ability, inductive reasoning and judgment. While fluid intelligence is often considered largely a product of genetics, crystallized intelligence is much more dependent on a bouquet of influences, including personality, motivation, opportunity and culture.
“At a time when the prospect of a longer life is shadowed by the fear of mental decline, the possibility that the aging can have some control over their mental fitness is an idea even William Osler would support.”

Full article: A Sharper Mind, Middle Age and Beyond, by Patricia Cohen.

Build Your Cognitive Reserve

2012-01-27T18:28:00.000-08:00

sharpbrains»JUL 23, 2007

Build Your Cognitive Reserve-Yaakov Stern
By: Alvaro Fernandez

Dr. Yaakov Stern is the Division Leader of the Cognitive Neuroscience Division of the Sergievsky Center, and Professor of Clinical Neuropsychology, at the College of Physicians and Surgeons of Columbia University, New York.
He is one of the leading proponents of the Cognitive reserve theory, which aims to explain why some individuals with full Alzheimer’s pathology (accumulation of plaques and tangles in their brains) can keep normal lives until they die, while others –with the same amount of plaques and tangles– display the severe symptoms we associate with Alzheimer’s Disease.
He has published dozens of peer-reviewed scientific papers on the subject.

The concept of a Cognitive Reserve has been around since 1989, when a post mortem analysis of 137 people with Alzheimer’s Disease showed that some patients exhibited fewer clinical symptoms than their actual pathology sugtested.
These patients also showed higher brain weights and greater number of neurons when compared to age-matched controlls.
The investigators hypothesized that the patients had a larger “reserve” of neurons and abilities that enable them to offset the losses caused by Alzheimer’s.
Since then, the concept of Cognitive Reserve has been defined as the ability of an individual to tolerate progressive brain pathology without demonstrating clinical cognitive symptoms.

Key take-aways-
Lifetime experiences, like education, engaging occupation, and leisure activities, have been shown to have a major influence on how we age, specifically on whether we will develop Alzheimer’s symptoms or not.
This is so because stimulating activities, ideally combining physical exercise, learning and social interaction, help us build a Cognitive Reserve to protect us.
The earlier we start building our Reserve, the better; but it is never too late to start.
And, the more activities, the better: the effect is cumulative.

The Cognitive Reserve
Alvaro Fernandez (AF): Dear Dr. Stern, it is a pleasure to have you here. Let me first ask you this: the implications of your research are pretty astounding, presenting major implications across sectors and age groups. What has been the most unexpected reaction so far?

YS: well…I was pretty surprised when, years ago, a reporter from Seventeen magazine requested an interview. I was really curious to learn why she felt that her readers would be interested in studies about dementia. What she told me showed a deep understanding and insight: she wanted to motivate children to stay in school. She understood that early social interventions could be very powerful for building reserve and preventing dementia.

AF: That’s great…so let’s now fast forward, say, 60 years from our high-school years, and suppose that persons A and B both technically have Alzheimer’s (plaques and tangles appear in the brain), but only A is showing the disease symptoms. What may explain this discrepancy?

YS: Individuals who lead mentally stimulating lives, through education, occupation and leisure activities, have reduced risk of developing Alzheimer’s. Studies suggest that they have 35–40% less risk of manifesting the disease. The pathology will still occur, but they are able to cope with it better. Some won’t ever be diagnosed with Alzheimer’s because they don’t present any symptoms. In studies that follow healthy elders over time and then get autopsies, up to 20% of people who did not present any significant problem in the daily lives have full blown Alzheimer’s pathology in their brains.

AF: What exactly may be going on in the brain that provides that level of protection?

YS: There are two ideas that are complementary. One idea (called Brain Reserve by researchers) postulates that some individuals have a greater number of neurons and synapses, and that somehow those extra structures provide a level of protection. In a sense, we have more “hardware”, providing a passive protection against the attacks of Alzheimer’s.
The other theory (called Cognitive Reserve) emphasizes the building of new capabilities, how people can perform tasks better through practice, and how these skills become so well learned that they are not too easy to unlearn. Like developing new and refined “software”.

AF: But, both seem to go hand in hand, correct? Neuroplasticity means that what you call “hardware” and “software” are two sides of the same coin and they influence each other, right?

YS: Correct. So these days we don’t make a sharp distinction, and are conducting more neuroimaging studies to better understand the relationship between both.

Building Your Cognitive Reserve

AF: OK, so our goal is to build that Reserve of neurons, synapses, and skills. How can we do that? What defines “mentally stimulating activities” or good “brain exercise”?

YS: In summary, we could say that “stimulation” consists of engaging in activities. In our research almost all activities are seen to contribute to reserve. Some have challenging levels of cognitive complexity, and some have interpersonal or physical demands.
In animal studies, exposure to an enriched environment or increased physical activity result in increased neurogenesis (the creation of new neurons).
You can get that stimulation through education and/ or your occupation. There is clear research showing how those two elements reduce the risk.
Now, what is very exciting is that, no matter one’s age, education and occupation, our level of participation in leisure activities has a significant and cumulative effect.
A key message here is that different activities have independent, synergistic, contributions, which means the more things you do and the earlier you start, the better.
But you are never stuck: better late than never.

AF: Can you give us some examples of those leisure activities that seem to have the most positive effects?
YS: For our 2001 study we evaluated the effect of 13 activities, combining intellectual, physical, and social elemenus.
Some of the activities with the most effect were reading, visiting friends or relatives, going to movies or restaurants, and walking for pleasure or going on an excursion.
As you can see, a variety. We saw that the group with high level of leisure activities presented 38% less risk (controlling for other factors) of developing Alzheimer’s symptoms.
And that, for each additional type of activity, the risk got reduced by 8%.
There is an additional element that we are starting to see more clearly.
Physical exercise, by itself, also has a very beneficial impact on cognition. Only a few months ago researchers were able to show for the first time how physical activity promotes neurogenesis in the human brain. So, we need both mental and physical exercise.
The not-so-good news is that, as of today, there no clear recipe for success. More research is needed before we prepare a systematic set of interventions that can help maximize our protection.

AF: We typically emphasize the importance of a good nutrition, physical exercise, stress management and mental exercise that presents novelty, variety and challenge. What do you think of the relatively recent appearance of so many computer-based cognitive training programs, some more science-based than others?

YS: Those elements you mention make sense. The problem is that, at least from the point of view of Alzheimer’s, we cannot be much more specific. We don’t know if learning a new language is more beneficial than learning a new musical instrument or using a computer-based program. A few of the cognitive training computer programs we have seen, like the one you discussed with Prof. Daniel Gopher to train the mental abilities of pilots, seem to have clear effects on cognition, generalizing beyond the training itself. But, for the most part, it is too early to tell the long-term effects. We need better designed clinical trials with clear controls. Right now, the most we can say is that those who lead mentally stimulating lives, through education, occupation and leisure activities seem to have the least risk of developing Alzheimer’s Disease.

Research interests
AF: Tell us know a bit more about your current research
YS: We are studying a number of related areas, applying neuroimaging techniques to understand how exactly all these Cognitive Reserve concepts are implemented in the brain.One, we want to understand individual differences in how people approach tasks. We want to measure their efficiency and capacity the brain networks that mediate tasks performance with the idea that those with greater efficiency and capacity might cope better with age-related problems.
For example, we can all understand that a competitive swimmer is going to swim better than I would even if he has some weights in his legs, but we haven’t yet identified what exactly is the equivalent in the brain.Second, we want to understand how old people compensate for the areas of decline.
For example, do they begin to use new brain areas when the ones that are typically used start to fail.Third, whether the Cognitive Reserve presents benefits beyond the prevention of Alzheimer’s symptoms. Does having a higher reserve result in better attention, better executive functions, more successful aging overall?

AF: All very important topics. And I am sure everyone reading this interview will devour any new details on how to build our Cognitive Reserves. Thank you for your time, and please keep us informed.

YS: My pleasure. Thank you for your great educational initiative.————————————

Sexual Activity n Heart cases

2012-01-24T22:29:00.001-08:00

From Heartwire
Lisa Nainggolan
January 19, 2012 (Houston, Texas)

New advice indicates that sexual activity is safe for the majority of heart disease patients and that doctors--as well as patients and their partners--should endeavor to bring up the subject of sex in discussions.
The guidance comes from the first-ever American Heart Association (AHA) scientific statement to address the issue, which is published online today in Circulation.
Lead author Dr Glenn N Levine (Baylor College of Medicine, Houston, TX) told heartwire that the recommendations are probably the most comprehensive on the subject to date and have been compiled by experts from various fields, including cardiology, exercise physiology, sexual counseling, and urology. Physicians, patients, and partners are reluctant to talk about sexual activity, but it is something "that is important to quality of life for most people, and we would not want to see patients refraining from sex out of undue concern about precipitating a heart attack or sudden death," he observes.

We would not want to see patients refraining from sex out of undue concern about precipitating a heart attack or sudden death.
The only patients who should refrain from sex are those with unstable heart disease or severe symptoms; they should be assessed and stabilized with appropriate treatment before engaging in sexual activity, says Levine. And drugs that can improve cardiovascular symptoms or survival should not be withheld due to concerns that they may have an impact on sexual function, he notes.

He also stresses that while use of phosphodiesterase-5 (PDE-5) inhibitor erectile-dysfunction drugs, such as sildenafil (Viagra, Pfizer) are generally safe for men who have stable cardiovascular disease, these agents are absolutely contraindicated in patients receiving nitrate therapy, either long-acting preparations or sublingual ones.Fear, Anxiety, and Depression Can Underlie Avoidance of Sex

The AHA guidance gives general recommendations for sexual activity and CVD but also advice pertaining to patients with specific conditions: coronary artery disease; heart failure; valvular heart disease; those with arrhythmias and/or pacemakers or implantable cardioverter defibrillators (ICDs); congenital heart disease; and hypertrophic cardiomyopathy. And it covers cardiovascular drugs and sexual function as well as pharmacotherapy for sexual dysfunction.

One of the main purposes of the statement "is to make physicians and healthcare providers aware that this is a real issue that is not appropriately addressed with the patient and partner and truly should be," says Levine."

At the same time--because we are getting a lot of lay press attention to this issue--we hope to make patients and their partners aware that sexual activity is something they should feel free to discuss with their healthcare providers during an office visit or before hospital discharge.
We hope to make patients and their partners aware that sexual activity is something they should feel free to discuss with their healthcare providers.
"The important thing to emphasize is that the risk of heart attack with sexual activity is only extremely modestly increased during sexual activity and represents only a miniscule amount of a person's overall risk."
Levine also wants to highlight the fact that anxiety and depression should be important considerations in patients with cardiovascular disease and can contribute to reduced or impaired sexual activity.
"Sexual counseling of CVD patients and their partners is an important component of recovery; unfortunately, it is rarely provided," he and his coauthors observe.
Advice Should Help All Doctors to Advise CVD Patients on SexThe scientific statement has been published in a cardiology journal, Levine notes, because "the cardiologist is going to be asked to comment on this, and frequently the GP will often refer the patient to the cardiologist to address issues" relating to sexual activity, he notes.
For example, one subject he is frequently consulted about by other doctors is whether patients can use erectile-dysfunction drugs.Levine hopes, however, that the new recommendations will embolden other specialists to confidently advise patients: "One of the aims is to allow GPs, family doctors, and others to, at least for the majority of patients, give reasonable guidance."Another important consideration raised in the AHA statement--which is also endorsed by the American Urological Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association of Cardiovascular and Pulmonary Rehabilitation, International Society of Sexual Medicine, American College of Cardiology Foundation, Heart Rhythm Society, and Heart Failure Society of America--is that cardiac rehabilitation and regular physical activity can reduce the risk of cardiovascular complications in people with heart disease.
Exercise testing can also provide additional information as to the safety of sexual activity in patients with indeterminate or unclear risk, the authors note.

They conclude that further research is needed on sexual activity in specific cardiovascular conditions, particularly with regard to the effects in females and in older adults.
Levine has reported that he has no conflicts of interest. Disclosures for the coauthors are listed in the paper.

Even Mild Dehydration May Cause Emotional, Physical Problems

2012-01-24T22:10:00.000-08:00

From WebMD Health NewsDenise MannJanuary 20, 2012 Even mild dehydration may affect our moods and ability to concentrate.In a new study of 25 healthy women, mild dehydration dampened moods, increased fatigue, and led to headaches.The women in the study were aged 23, on average. They were neither athletes nor couch potatoes. Women participated in three experiments separated by 28 days. In two of these, dehydration was induced via walking on a treadmill with or without a diuretic pill. These pills encourage urination, and can lead to dehydration.The women were given a battery of tests measuring their concentration, memory, and mood when they were dehydrated and when they were not.Overall, women’s mental ability was not affected by mild dehydration. But they did have an increase in perception of task difficulty and lower concentration.But “women were more fatigued and this was true during mild exercise and when sitting at a computer,” says researcher Lawrence E. Armstrong, PhD. He is a professor of environmental and exercise physiology at the University of Connecticut's Human Performance Laboratory in Storrs, Conn.The findings appear in The Journal of Nutrition.Armstrong and colleagues previously looked at the effects of mild dehydration in men. Although men did experience some subtle mental difficulties when dehydrated, the risks were pretty similar between the sexes.The message is clear, he says: “We should focus on hydration and continue to drink during meals and when we are not at meals.”Avoid Dehydration: Drink More WaterYou are often already dehydrated once you become thirsty, but subtle cues like a headache and/or fatigue can be your body’s way of telling you to drink more water, Armstrong says.The new study should serve as a reminder for healthy, young women who frequently exercise to drink water, says Robert Glatter, MD. He is an emergency medicine physician at Lenox Hill Hospital in New York City.“Consume moderate quantities of water both during and after exercise in order to avoid mild dehydration, which may lead to headaches, fatigue, and difficulty concentrating,” he says in an email. “Just a small change in state of hydration was enough to affect mood, ability to concentrate, and lead to development of headaches.”It is unclear if these findings apply to other populations at risk for dehydration, such as the elderly, people with diabetes, and children, Glatter says.The best way to avoid becoming dehydrated is to drink an adequate amount of water. Olveen Carrasquillo, MD, agrees. He is the chief of the division of general internal medicine at University of Miami Miller School of Medicine.So, how much water do we need? “For most healthy people, six to eight glasses of 8 ounces of water a day is what we recommend,” he says. The effects of even mild dehydration are likely to be even more pronounced in high-risk groups, such as the elderly and young children.Knowing the signs of dehydration can also keep you out of the danger zone. Another sign is dark urine. “Your urine should be a light yellow color,” Glatter tells WebMD.Not everyone needs to drink this much water. “People with congestive heart failure and people with certain kinds of kidney disease may want to limit their fluid intake, and should talk to their doctor about how much water they should drink,” he says.SOURCES:Armstrong L.E. Journal of Nutrition, 2102.

Physical Activity Yields Better Academic Performance in Children

2012-01-24T22:05:00.001-08:00

From Medscape Education Clinical BriefsNews Author: Larry HandCME Author: Penny Murata, MD01/10/2012 Clinical ContextThe evidence for a relationship between physical activity and academic performance is not conclusive. A review by Trudeau and Shephard in the February 25, 2008, issue of the International Journal of Behavioral Nutrition and Physical Activity found a positive link between physical activity and academic performance, based on cross-sectional studies. A review by Taras in the August 2005 issue of the Journal of School Health reported possible acute benefits of physical activity on academic performance.This systematic review by Singh and colleagues assesses the longitudinal relationship between physical activity and academic performance in children.Study Synopsis and PerspectiveConcerned that physical activity times in schools might be cut back to make room for more academic study to improve test scores, researchers in the Netherlands conducted a systematic review of published studies and found that moderate to vigorous physical activity may actually improve academic performance in children and adolescents.In an article published in the January issue of the Archives of Pediatrics and Adolescent Medicine, researchers led by Amika Singh, PhD, from the Vrije Universiteit University Medical Center at EMGO Institute for Health and Care Research in Amsterdam, the Netherlands, write, "According to the best-evidence synthesis, we found strong evidence of a significant positive relationship between physical activity and academic performance."After searching 4 databases, the researchers screened 844 potentially related articles and determined that 14 qualified as relevant to their hypothesis. Of those 14 studies, 12 were performed in the United States, 1 was Canadian, and 1 was South African. Sample sizes ranged from 53 to 12,000 individuals aged 6 through 18 years, and follow-up duration ranged from 8 weeks to more than 5 years. The researchers rated only 2 of the 14 studies as having high methodologic quality. One of those studies was observational and the other was interventional."[B]oth high-quality studies supported our hypothesis of physical activity being positively related to academic performance in children," they write.The studies they reviewed measured physical activity based on school athletic participation, self-reported physical activity questionnaires, or in the case of intervention studies, increased physical activity in schools during the study period.The studies measured academic achievement by self-reported grades, by cognitive test scores, or by both. The academic areas included reading, math, world studies, and history.The researchers concluded that although few published studies have assessed the link between physical activity and academic performance, enough evidence exists to report that "physical activity is positively related to academic performance in young people." They call for more high-quality studies to explore the mechanisms of such a relationship and to explore more physical activities than just school sports participation.The authors have disclosed no relevant financial relationships.Arch Pediatr Adolesc Med. 2012;166:49-55. Abstract

1 in 3 US Adults, 1 in 6 US Children Obese

2012-01-18T19:48:00.000-08:00

From Medscape Medical NewsLaura Newman, MAJanuary 17, 2012 — The US prevalence of obesity continues to be high, with one third of US adults and 1 in 6 US children and adolescents affected, according to 2009 to 2010 data from the National Health and Nutrition Examination Survey (NHANES). The data were presented in 2 papers published online January 17 in JAMA. As alarming as these rates are, the data suggest that they may be topping out, according to the researchers."[Obesity prevalence] increased significantly over the 12-year period from 1999 through 2010 for men and for non-Hispanic black and Mexican American women, but did not change between 2003-2009 and 2010 for men or women," write Katherine M. Flegal, PhD, distinguished consultant from the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, Hyattsville, Maryland, and colleagues in the first article.In addition, trends in US children and teenagers followed a similar pattern — unchanged, but at 17% — since the last review of 2007-2008, explain Cynthia L. Ogden, PhD, MRP, NCHS epidemiologist, and colleagues in the second article, on children and teenagers. Noting the linear increase in obesity prevalence in children, and predictions that obesity prevalence among children and teenagers may reach 30% by 2030, the authors write that "the data presented herein suggest that the rapid increases in obesity prevalence seen in the 1980s and 1990s have not continued in this decade and may be leveling off."Among US adults, the age-adjusted obesity prevalence was 35.7% (95% confidence interval [CI], 33.8% - 37.7%). Non-Hispanic black men and women had the highest obesity prevalence rates, at 38.8% (95% CI, 33.9% - 43.9%) for men and 58.5% (95% CI, 52.4% - 64.3%) for women. When age-adjusted prevalence of overweight and obesity were combined (body mass index [BMI] of at least 25 kg/m2), it was 68.8% overall (95% CI, 65.9% - 71.5%), 73.9% for men (95% CI, 70.0% - 77.8%), and 63.7% among women (95% CI, 60.9% - 66.4%. Grade 2 obesity, defined as a BMI of 35 kg/m2 or more, and grade 3 obesity (BMI, 40 kg/m2 or more) again show the highest rates for non-Hispanic blacks, at 20.0% (95% CI, 16.4% - 24.3%) for non-Hispanic black men and 30.7% (95% CI, 26.4% - 35.2%) for non-Hispanic black women.In the study of children and teenagers, investigators used high weight for recumbent length (BMI 95th percentile or higher of the BMI-for-age growth charts). Between 2009 and 2010, 16.9% of US children and adolescents were obese (95% CI, 15.4% - 18.4%), with 31.8% either overweight or obese (95% CI, 29.8% - 33.7%). Boys were consistently more likely to be obese than girls, at 18.6% vs 15.0%. =Racial differences were also striking, with black children and adolescents having an obesity of prevalence of 24.3% (95 CI, 20.5% - 28.6%) compared with 21.2% (95 CI, 19.5% - 23.0%) for Hispanics and 14.0% (95% CI, 11.7% - 16.7%) for non-Hispanic whites. Older children had higher prevalence rates than each successive younger age group.NHANES analyses are based on at-home interviews and physical examinations collected continuously since 1999 in children, and since 1960 in adults, and released in 2-year cycles. NHANES is designed as a cross-sectional survey nationally representative of the US noninstitutionalized population. Data from other industrialized countries also suggest that obesity trends may be leveling off worldwide.The authors have disclosed no relevant financial relationships.JAMA. Published online January 17, 2012. Flegal full text, Ogden full text

The Rain of God's Favor

2011-12-30T04:52:00.000-08:00

Wishing all my readers peace to you n your family in the coming year.
May it bring wonderful surprises!

Taking a break from medical stuff to personal reflections:

Rain,
its ability to percolate and find,
all the dry places,
and behold,
the dry dead-looking seed,
breaks forth,new shoot.
Life revealed,
hidden and protected,
for such a time as this.
Your rain O God,
falling alike on sinners and man of ill will,
the same ability to cause dryness to flee.
You are -power concealed,
power revealed,in us.
Rising on the winds of the favor of a great and loving God,
to achieve ,
that which already is.
Our life,a canvas,not blank.
already in existence in the artist's imagination.
Already,a completed work of art.
Beautifuland complete.
Shalom

poh tin 30th Dec 2011

Current Status of Knowledge on Public-speaking Anxiety

2011-12-28T18:27:00.000-08:00

From Current Opinion in PsychiatryCharles B. Pull12/19/2011; Curr Opin Psychiatry. 2012;25(1):32-38. © 2012 Lippincott Williams & Wilkins AbstractPurpose of review: This review examines the current knowledge on public-speaking anxiety, that is, the fear of speaking in front of others. This article summarizes the findings from previous review articles and describes new research findings on basic science aspects, prevalence rates, classification, and treatment that have been published between August 2008 and August 2011.Recent findings: Recent findings highlight the major aspects of psychological and physiological reactivity to public speaking in individuals who are afraid to speak in front of others, confirm high prevalence rates of the disorder, contribute to identifying the disorder as a possibly distinct subtype of social anxiety disorder (SAD), and give support to the efficacy of treatment programs using virtual reality exposure and Internet-based self-help.Summary: Public-speaking anxiety is a highly prevalent disorder, leading to excessive psychological and physiological reactivity. It is present in a majority of individuals with SAD and there is substantial evidence that it may be a distinct subtype of SAD. It is amenable to treatment including, in particular, new technologies such as exposure to virtual environments and the use of cognitive–behavioral self-help programs delivered on the Internet.IntroductionPublic-speaking anxiety, also termed fear of speaking in public, fear of public speaking, or fear of speaking in front of others, is a highly prevalent disorder. The fear causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.This article reports on the recent data concerning the psychological and physiological reactivity to public speaking in individuals who are afraid of speaking in front of others, prevalence rates, the position of the disorder as a possibly distinct subtype of social anxiety disorder (SAD), and the development of new treatment modalities, including, in particular, exposure in virtual reality environments and Internet-based self-help programs.

Who Is Governing Whom? Senior Managers, Governance and the Structure of Generosity in Large U.S. Firms

2011-11-16T21:38:00.001-08:00

Published: July 29, 2011Paper Released: May 2011Authors: Christopher Marquis and Matthew LeeExecutive Summary:Analyzing several Fortune 500 firms over the period of 10 years, Christopher Marquis and Matthew Lee discuss the factors that influence corporate philanthropy, using the subject to theorize about and test how structural features of organizations help senior leaders to shape firm strategy. Key concepts include: Many practitioners today view corporate philanthropy as a strategic activity that addresses both social and economic goals. Corporate philanthropy is highest in corporations with new CEOs, and decreases with the length of CEO tenure. The greater the proportion of female senior managers in a company, the greater the corporate philanthropic contributions will be. Companies with larger boards tend to have higher philanthropic contributions.Christopher Marquis is an associate professor in the Organizational Behavior unit at Harvard Business School. AbstractWe examine how organizational structure influences strategies over which corporate leaders have significant discretion. Corporate philanthropy is our setting to study how a differentiated structural element, the corporate foundation, constrains the influence of individual senior managers and directors on corporate strategy. Our analysis of Fortune 500 firms from 1996 to 2006 shows that leader characteristics at both the senior management and director levels affect corporate philanthropic contributions. We also find that organizational structure constrains the philanthropic influence of board members, but not senior managers, a result that is contrary to what existing theory would predict. We discuss how these findings advance understanding of how organizational structure and corporate leadership interact, and how organizations can more effectively realize the strategic value of corporate social responsibility activities.Paper Information

Creating a Positive Professional Image

2011-11-16T21:20:00.001-08:00

Q&A with: Laura Morgan RobertsPublished: June 20, 2005Author: Mallory Stark http://hbswk.hbs.edu/item/4860.htmlExecutive Summary:In today’s diverse workplace, your actions and motives are constantly under scrutiny. Time to manage your own professional image before others do it for you. An interview with professor Laura Morgan Roberts.As HBS (Harvard Business School) professor Laura Morgan Roberts sees it, if you aren't managing your own professional image, others are."People are constantly observing your behavior and forming theories about your competence, character, and commitment, which are rapidly disseminated throughout your workplace," she says. "It is only wise to add your voice in framing others' theories about who you are and what you can accomplish."There are plenty of books telling you how to "dress for success" and control your body language. But keeping on top of your personal traits is only part of the story of managing your professional image, says Roberts. You also belong to a social identity group—African American male, working mother—that brings its own stereotyping from the people you work with, especially in today's diverse workplaces. You can put on a suit and cut your hair to improve your appearance, but how do you manage something like skin color?Roberts will present her research, called "Changing Faces: Professional Image Construction in Diverse Organizational Settings," in the October issue of the Academy of Management Review.She discusses her research in this interview.Mallory Stark: What is a professional image?Laura Morgan Roberts: Your professional image is the set of qualities and characteristics that represent perceptions of your competence and character as judged by your key constituents (i.e., clients, superiors, subordinates, colleagues).Q: What is the difference between "desired professional image" and "perceived professional image?"A: It is important to distinguish between the image you want others to have of you and the image that you think people currently have of you.Most people want to be described as technically competent, socially skilled, of strong character and integrity, and committed to your work, your team, and your company. Research shows that the most favorably regarded traits are trustworthiness, caring, humility, and capability.Ask yourself the question: What do I want my key constituents to say about me when I'm not in the room? This description is your desired professional image. Likewise, you might ask yourself the question: What am I concerned that my key constituents might say about me when I'm not in the room? The answer to this question represents your undesired professional image.You can never know exactly what all of your key constituents think about you, or how they would describe you when you aren't in the room. You can, however, draw inferences about your current professional image based on your interactions with key constituents. People often give you direct feedback about your persona that tells you what they think about your level of competence, character, and commitment. Other times, you may receive indirect signals about your image, through job assignments or referrals and recommendations. Taken together, these direct and indirect signals shape your perceived professional image, your best guess of how you think your key constituents perceive you.Q: How do stereotypes affect perceived professional image?A: In the increasingly diverse, twenty-first century workplace, people face a number of complex challenges to creating a positive professional image. They often experience a significant incongruence between their desired professional image and their perceived professional image. In short, they are not perceived in the manner they desire; instead, their undesired professional image may be more closely aligned with how their key constituents actually perceive them.What lies at the source of this incongruence? Three types of identity threats—predicaments, devaluation, and illegitimacy—compromise key constituents' perceptions of technical competence, social competence, character, and commitment. All professionals will experience a "predicament" or event that reflects poorly on their competence, character, or commitment at some point in time, due to mistakes they have made in the past that have become public knowledge, or competency gaps (e.g., shortcomings or limitations in skill set or style).Members of negatively stereotyped identity groups may experience an additional form of identity threat known as "devaluation." Identity devaluation occurs when negative attributions about your social identity group(s) undermine key constituents' perceptions of your competence, character, or commitment. For example, African American men are stereotyped as being less intelligent and more likely to engage in criminal behavior than Caucasian men. Asian Americans are stereotyped as technically competent, but lacking in the social skills required to lead effectively. Working mothers are stereotyped as being less committed to their profession and less loyal to their employing organizations. All of these stereotypes pose obstacles for creating a positive professional image.Even positive stereotypes can pose a challenge for creating a positive professional image if someone is perceived as being unable to live up to favorable expectations of their social identity group(s). For example, clients may question the qualifications of a freshly minted MBA who is representing a prominent strategic consulting firm. Similarly, female medical students and residents are often mistaken for nurses or orderlies and challenged by patients who do not believe they are legitimate physicians.Q: What is impression management and what are its potential benefits?A: Despite the added complexity of managing stereotypes while also demonstrating competence, character, and commitment, there is promising news for creating your professional image! Impression management strategies enable you to explain predicaments, counter devaluation, and demonstrate legitimacy. People manage impressions through their non-verbal behavior (appearance, demeanor), verbal cues (vocal pitch, tone, and rate of speech, grammar and diction, disclosures), and demonstrative acts (citizenship, job performance).My research suggests that, in addition to using these traditional impression management strategies, people also use social identity-based impression management (SIM) to create a positive professional image. SIM refers to the process of strategically presenting yourself in a manner that communicates the meaning and significance you associate with your social identities. There are two overarching SIM strategies: positive distinctiveness and social recategorization.Positive distinctiveness means using verbal and non-verbal cues to claim aspects of your identity that are personally and/or socially valued, in an attempt to create a new, more positive meaning for that identity. Positive distinctiveness usually involves attempts to educate others about the positive qualities of your identity group, advocate on behalf of members of your identity group, and incorporate your background and identity-related experiences into your workplace interactions and innovation.Social recategorization means using verbal and non-verbal cues to suppress other aspects of your identity that are personally and/or socially devalued, in an attempt to distance yourself from negative stereotypes associated with that group. Social recategorization involves minimization and avoidance strategies, such as physically and mentally conforming to the dominant workplace culture while being careful not to draw attention to identity group differences and one's unique cultural background.Rather than adopting one strategy wholesale, most people use a variety of strategies for managing impressions of their social identities. In some situations, they choose to draw attention to a social identity, if they think it will benefit them personally or professionally. Even members of devalued social identity groups, such as African American professionals, will draw attention to their race if it creates mutual understanding with colleagues, generates high-quality connections with clients, or enhances their experience of authenticity and fulfillment in their work. In other situations, these same individuals may choose to minimize their race in order to draw attention to an alternate identity, such as gender, profession, or religion, if they feel their race inhibits their ability to connect with colleagues or clients.Successful impression management can generate a number of important personal and organizational benefits, including career advancement, client satisfaction, better work relationships (trust, intimacy, avoiding offense), group cohesiveness, a more pleasant organizational climate, and a more fulfilling work experience. However, when unsuccessfully employed, impression management attempts can lead to feelings of deception, delusion, preoccupation, distraction, futility, and manipulation.Q: How do authenticity and credibility influence the positive outcomes of impression management attempts?A: In order to create a positive professional image, impression management must effectively accomplish two tasks: build credibility and maintain authenticity. When you present yourself in a manner that is both true to self and valued and believed by others, impression management can yield a host of favorable outcomes for you, your team, and your organization. On the other hand, when you present yourself in an inauthentic and non-credible manner, you are likely to undermine your health, relationships, and performance. Most people use a variety of strategies for managing impressions of their social identities.Most often, people attempt to build credibility and maintain authenticity simultaneously, but they must negotiate the tension that can arise between the two. Your "true self," or authentic self-portrayal, will not always be consistent with your key constituents' expectations for professional competence and character. Building credibility can involve being who others want you to be, gaining social approval and professional benefits, and leveraging your strengths. If you suppress or contradict your personal values or identity characteristics for the sake of meeting societal expectations for professionalism, you might receive certain professional benefits, but you might compromise other psychological, relational, and organizational outcomes.Q: What are the steps individuals should take to manage their professional image?A: First, you must realize that if you aren't managing your own professional image, someone else is. People are constantly observing your behavior and forming theories about your competence, character, and commitment, which are rapidly disseminated throughout your workplace. It is only wise to add your voice in framing others' theories about who you are and what you can accomplish.Be the author of your own identity. Take a strategic, proactive approach to managing your image:Identify your ideal state. What are the core competencies and character traits you want people to associate with you? Which of your social identities do you want to emphasize and incorporate into your workplace interactions, and which would you rather minimize?Assess your current image, culture, and audience. What are the expectations for professionalism? How do others currently perceive you?Conduct a cost-benefit analysis for image change. Do you care about others' perceptions of you? Are you capable of changing your image? Are the benefits worth the costs? (Cognitive, psychological, emotional, physical effort)Use strategic self-presentation to manage impressions and change your image. Employ appropriate traditional and social identity-based impression management strategies. Pay attention to the balancing act—build credibility while maintaining authenticity.Manage the effort you invest in the process. Monitoring others' perceptions of you Monitoring your own behavior Strategic self-disclosure Preoccupation with proving worth and legitimacyAbout the authorMallory Stark is a career information librarian at Baker Library.

The Ultimate Question in Management

2011-11-16T21:03:00.001-08:00

November 3, 2011Author: James Hesketthttp://hbswk.hbs.edu/item/6788.htmlExecutive Summary:Forum Open: Is there one key to management success, an ultimate question that needs to be answered? Jim Heskett has a nominee. What's yours?James Heskett is a Baker Foundation Professor, Emeritus, at Harvard Business School. The publication this month of The Ultimate Question 2.0 (revised from an earlier edition) provides us with an opportunity to ask ourselves just what is the ultimate question in management.In their book, Fred Reichheld and Rob Markey remind us of the simplicity of the Net Promoter Score (NPS). It's the product of answers to one question, "How likely is it you would recommend us to a friend?" The NPS has become so popular that, as a customer, you quite likely have been asked that question in the past couple of months. Those replying with a 9 or 10 (the most positive) on an 11-point scale (0 to 10) are "promoters"; a 7 or 8 labels you as a "passive"; and anything from a 0 to a 6 makes you a "detractor." Subtract the proportion of detractors from the proportion of promoters and you get a "net promoter score" that can range anywhere from +100 to -100.And that's it. Tracking the net promoter score, according to the authors, can lead to improvements in both management and performance.As managers and students of management, we have a tendency to want to simplify things. Evidence of this is the plethora of management books with single word titles such as Accountability, Transparency, and Teamwork. We search for the one key to management success. Based on recent research, I have my own candidate for that "one key thing:" trust. (There's precious little trust in government, Wall Street, and business in general these days.) I found a strong correlation between trust, loyalty, engagement, and "ownership" among employees in a sample of organizations I examined. Respondents in the study made a convincing case that trust was absolutely essential to the successful implementation of policies and practices necessary to implement any strategy. For example, several managers testified to the importance of the relationship between trust and the ability to achieve speed in getting things done. It's a topic that Stephen M. R. Covey wrote persuasively about several years ago in his book, The Speed of Trust. So for me one candidate "ultimate question" would be "Do you trust your manager?" or "Do you trust your organization?"My study led to an exploration of the underpinnings of trust, as suggested by related survey data. One major determinant is whether a manager or the organization does what it says it will do, whether it lives up to "the deal" on things important to an employee, whether it meets that employee's expectations. So another "ultimate question" might well be "Does your manager do what she says she will do?" or "Does your organization do what it says it will do?"What is the ultimate question in management? Or do you object to playing this game?--The Net Promoter Score certainly has its detractors. All of these are efforts to provide simple guideposts in a very complex process. Performance measurement can be a confusing process, leading to inaction or, worse yet, inappropriate action. Can an "ultimate question" have a useful management function? If so, what's yours? What do you think?To read more:Stephen M. R. Covey with Rebecca R. Merrill, The Speed of Trust: The One Thing That Changes Everything (New York: Free Press, 2006).Fred Reichheld and Rob Markey, The Ultimate Question 2.0 (Revised and Expanded Edition): How Net Promoter Companies Thrive in a Customer- Driven World (Boston: Harvard Business Press, 2011).Jim Heskett's latest book,The Culture Cycle, was published in September.

The Most Powerful Workplace Motivator

2011-11-03T05:26:00.000-07:00

The Most Powerful Workplace MotivatorOctober 31, 2011Author: Carmen Nobel Executive Summary:When evaluating compensation issues, economists often assume that both an employer and an employee make rational, albeit self-interested choices while working toward a goal. The problem, says Assistant Professor Ian Larkin, is that the most powerful workplace motivator is our natural tendency to measure our own performance against the performance of others. Key concepts include: The most powerful workplace motivator is our natural tendency to measure our own performance against the performance of others. Salespeople will actually give up the chance to make extra money if doing so will garner positive recognition from their peers. In the age of social networking, employees are more likely than ever to share salary information with each other. Employers need to keep this fact in mind when designing compensation plans.HBS Faculty Member Ian I. Larkin is an assistant professor in the Negotiation, Organizations and Markets unit at Harvard Business School. Any parent can tell you that a surefire way to turn joy into rage is to offer your child a big candy bar—and then turn around and offer an even bigger one to his sister. Suddenly, a special treat turns into a great injustice. "Hey! How come she got more? That's not fair!"And any hiring manager can tell you that the world of business is not so different. "It really was all about the recognition of and comparison with their peers, and many of them were willing to pay for it.""This is why MBA programs send out lists of average salaries, and why students spend hours poring over those lists," says Ian Larkin, an assistant professor in the Negotiation, Organizations & Markets Unit at Harvard Business School. "You should see the angry e-mails I get from students when they find out that a job offer turns out to be $10,000 per year below the average. It's not that they really feel like an annual salary offer of $115,000 is unfair on its own. They might be perfectly happy with that salary if it weren't for the information that it's below average."And it's not just a matter of money. In several studies of social comparison in the workplace, Larkin has found that the most powerful workplace motivator is our natural tendency to measure our own performance against the performance of others."Traditionally, [the field of] economics has held a very rational view of people, and there's a gigantic amount of literature focusing on financial incentives and the idea that simply having financial incentives causes people to work harder," he says. "But my research suggests that in deciding how hard we work and how well we think we're performing, social comparisons matter just as much."The $30,000 gold starThe power of social comparison can lead to irrational financial decisions, according to Larkin's 2009 paper "Paying $30,000 for a Gold Star: An Empirical Investigation into the Value of Peer Recognition to Software Salespeople."The paper describes a field study at a large enterprise software firm, where salespeople's salaries are largely based on commissions. The firm also features another common sales incentive--a "president's club" membership for those employees who sell more software than 90 percent of their peers in a given year.The software firm uses a "commission accelerator" program over the course of each financial quarter, meaning that a salesperson expecting a high-volume sale at the beginning of a quarter would receive a higher commission on any additional sales in the same quarter. A salesperson expecting a large sale early in the first quarter of the year would rationally want to delay any other potential sales until later in that quarter, so as to take advantage of the accelerating commission schedule.However, making the sale right away, before the end of the year, could help the salesperson achieve special recognition as a member of the club. Thus, the salesperson faces a choice: delay the sale and garner eventual commission boosts, or make the sale right away and improve the chance of attaining club membership. In the paper, Larkin uses actual choices of hundreds of salespeople facing this decision to statistically estimate the average salesperson's "willingness to pay" for club induction—the point at which a salesperson is indifferent to waiting for greater commissions and closing the deal now and getting inducted into the club. The willingness-to-pay statistic at the software firm is calculated to be nearly $30,000, or approximately 5 percent of take-home pay."My research shows that salespeople who are right on the margin of club induction are actually willing to pay to get over the margin and into the club," Larkin says.Importantly, Larkin observed that there were no apparent financial benefits to attaining club membership. Recipients received a gold star on their name card, companywide recognition, an e-mail from the CEO, and a weekend trip to a tropical destination with the other club members. (Granted, the trip was worth several hundred dollars, but was far less financially valuable than a large commission.)Club members "were not more likely to be promoted, leave for a better job, or make higher commissions in the future," Larkin says. "It really was all about the recognition of and comparison with their peers, and many of them were willing to pay for it."Insecurity leads to dishonestySocial comparison also can lead to insecurity-driven cheating, as Larkin details in a 2009 paper co-written with HBS colleague Benjamin Edelman, Demographics, Career Concerns or Social Comparison: Who Games SSRN Download Counts? The paper addresses an issue near and dear to academics worldwide: the relative popularity of working papers in the Social Science Research Network (SSRN) repository.The SSRN is a huge academic paper repository, with more than 100,000 authors and 500,000 registered users who have the opportunity to view or download every paper on the site. For each paper, SSRN creates a web page that includes statistics on how many times the paper has been downloaded and viewed. The SSRN site also publishes various "top 10" lists in numerous fields, ranked according to how many times the paper has been viewed, downloaded, or cited elsewhere on SSRN.Some scholars paid a lot of attention to the reported download counts of their papers; Larkin reports that one prominent legal academic described the monitoring of his own paper's download counts as "like crack for me."Historically, SSRN allowed unlimited downloads of papers, and most of those downloads were reflected in the reported download count on each paper's web page. It became apparent that many authors were gaming the download count system by repeatedly downloading their own papers, so that others would see the high download count and assume that these particular papers were very popular. SSRN maintains detailed historical records of every paper download and is able to determine when papers appear to be downloaded over and over by the same person."It's like having a convenience store that's not manned, and everyone who comes in can either steal or pay, but there's a video camera that nobody knows about, and it's tracking everyone's every move," Larkin says. "For years, some academics got away with inflating their own download count numbers, but we were able to see exactly who was doing this, and in what circumstances."In their research, Larkin and Edelman teamed up with the SSRN and set out to determine the factors that would make academics inflate the download counts of their own papers."As economists, we thought, hmmm, it's probably people who are up for tenure soon, or maybe it's the people who just graduated, and they want to get their name out there," Larkin says. "We were thinking very much along the traditional economic model--people doing things for rational, career-promoting reasons."Larkin shared these hypotheses with HBS colleague and mentor Max Bazerman, a leading ethics scholar, who had a different theory. "Max told me, 'I'll bet people are doing this because they feel bad that their papers aren't being downloaded as much as their colleagues' papers,' " Larkin says. "So we looked at that."It turned out Bazerman was right. The researchers found that authors were more likely to download their own papers repeatedly when a colleague's paper was performing especially well on the site, or when a very similar paper to an author's was newly released and received significant downloads. Deceptive downloads also increased during times when a paper was close to gaining (or losing) placement on a top 10 list. (Ironically, one of the most downloaded SSRN papers of all time is 'I've Got Nothing to Hide' and Other Misunderstandings of Privacy.)"Again, what was surprising to us was how little we found in terms of the economic reasons for doing this," Larkin says. "By far, the biggest predictor of this behavior was fear of being socially inferior to one's peers."(Those tempted to boost a paper's usage stats should note that SSRN's terms of service now state that the attempted manipulation of download counts is against site rules, and that the organization retains the right to ban anyone caught abusing the system.)Ramifications for salary managersThe field evidence from the worlds of software sales and academia indicates that companies need to bear social comparison in mind when designing compensation plans. Larkin discusses the issue in The Psychological Costs of Pay-for-Performance: Implications for the Strategic Compensation of Employees, a paper he cowrote with HBS colleague Francesca Gino and Washington University's Lamar Pierce.The authors argue that paying each employee solely according to his or her performance is actually an inefficient strategy; it can lead to resentment or even sabotage on the part of employees who believe they are underpaid compared with their colleagues. Thus, a standardized salary scale, combined with ancillary incentive programs, may be the best way to motivate employees. "When deciding how much effort to exude, workers not only respond to their own compensation, but also respond to pay relative to their peers as they socially compare," the paper states.That's important food for thought, considering that Facebook, LinkedIn, and other such sites have made it de rigueur to share information that we used to keep to ourselves."It used to be that our salaries were very secret, but they're getting less and less secret because of social networking," Larkin says. "And people get upset quickly when they realize that there are large variances in how much other people are paid. Companies need to realize that with the overflow of information these days, paying peers differently is going to affect not only how those people feel but how their colleagues feel as well."About the authorCarmen Nobel is senior editor of HBS Working Knowledge.

Horrible Boss Workarounds

2011-11-03T05:20:00.000-07:00

October 27, 2011Author: Carmen NobelExecutive Summary:Bad bosses are generally more inept than evil, and often aren't purposefully bad, says Professor Rosabeth Moss Kanter. She discusses common bad-boss behaviors, and how good colleagues can mobilize to overcome the roadblocks. Key concepts include:Common traits of bad bosses include a failure to communicate goals effectively, if at all; a failure to realize that employees have more to offer than their job descriptions dictate, and a tendency to get caught up in the details to the detriment of the big picture. Employees can work around bad-boss roadblocks by proactively mobilizing their peers toward a common goal.About Faculty in this Article:HBS Faculty Member Rosabeth Moss Kanter is the Ernest L. Arbuckle Professor of Business Administration at Harvard Business School. On film, few characters are more obviously villainous than the extremely bad boss. There's Star Wars' Darth Vader (who manages a disrespectful underling by strangling him with his mind), Katharine Parker in Working Girl (who shamelessly steals ideas from the movie's hero), John Milton in The Devil's Advocate (who is literally the devil incarnate), the eponymous villains in the recent hit Horrible Bosses (whose infractions include cocaine abuse and sexual harassment) …the list goes on and on.Reality is more nebulous, of course. Bad bosses are generally more inept than they are evil, and often aren't purposefully bad, says Harvard Business School Professor Rosabeth Moss Kanter, who has authored several business management books, including Confidence: How Winning and Losing Streaks Begin and End and SuperCorp: How Vanguard Companies Create Innovation, Profits, Growth, and Social Good "What's horrible is often in the eye of the beholder," she says. "There are many people who complain about their bosses without taking a look at themselves, and vice versa."Kanter recently sat down with HBS Working Knowledge to discuss some of the factors that create bad bosses—and what employees can do to resist them. As she states in a recent column in Harvard Business Review, "The best cure for horrible bosses is wonderful colleagues."Bad boss behavior #1: failure to communicate. At any level of management, it's important that bosses effectively communicate company or team goals from the get-go. "Empowerment can happen only when there's a consensus on goals and an agreement that certain standards have to be met," Kanter says. "If there isn't agreement in the beginning, that's when certain situations start to unravel."But problems arise when bosses fail to realize that they're not communicating clearly. Kanter cites an old joke as an example:A man drives to a gas station to fill up his tank, and the attendant can't help noticing that there's a penguin in the backseat of the car. "Yes," the man says. "I found him there this morning, and I don't know what to do with him." The attendant suggests that the man take the penguin to the zoo right away, and the man agrees that this is an excellent idea. But the next day, when the man returns to the same gas station, the clerk notices that the penguin is still in the backseat of the car—only this time it's wearing sunglasses. "Hey," the clerk says. "I thought I told you to take the penguin to the zoo." The man nods and says, "I did take him to the zoo. He had such a great time that I decided to take him to the beach, too!"Miscommunication often leads to situations in which bosses throw up their hands in frustration, believing that their employees are incapable of delivering good ideas, when in fact the problem is that the employees just aren't clear on the mission."Sometimes [bosses] have it in their head that they know what they're driving at, but they don't always bother to tell everyone what's in their head, and if they do, the translation is not always clear," Kanter says. "So CEOs make speeches all the time and think everyone is interpreting their words in the exact same way, and they're not. And they're surprised later to find out that what they thought was going to happen didn't exactly happen. Constant, consistent communication is important."Bad boss behavior #2: pigeonholing. Another common bad-boss trait is the inability to accept the idea that employees' skills and talents probably exceed their job descriptions. Not only is this attitude demoralizing for employees, but it discourages collaboration and idea sharing as well. For example, "there was one CEO of a company in the IT industry who kept everyone on his executive team confined to narrow little boxes," Kanter says. "One member of the team had actually built several successful IT companies and so knew a lot about marketing. But because he had been hired for a technology job, the CEO would listen to him only on technology matters."Bad boss behavior #3: inability to zoom in and out. Kanter also stresses the importance of zooming—the ability to view the world through an adjustable lens as the situation demands, examining particular details in certain situations and maintaining a broad view of the mission in others. Talented bosses know how and when to adjust their lenses. But for those who can't or won't adjust, staying stuck on zoomed out is the lesser of two evils, Kanter says."If I had to choose between getting too close to the details or getting too far out and losing the situation in the clouds, I would always go for zooming out," Kanter says. "If employees are forced to stay too focused on the details, without thorough preparation, without clear goals, without a larger vision, without a sense of purpose, then they are left to be dependent on the daily moods or whims of a boss. Bosses who spend too much time zooming in on the details are more likely to lose sight of the big picture and the goals."In those cases, Kanter says, it's up to the employees to keep each other on track.Working around a bad-boss roadblockIn situations where the boss is obviously impeding progress or morale, Kanter recommends that employees try to mobilize their peers to create a course of action. She acknowledges that this is easier said than done, especially when a bad boss has created a culture of fear. But teaming up to effect change need not require a palace coup."If you test the waters in very small and diplomatic ways, you're more likely to get a hearing at higher levels when you come with a constructive solution—not one that is a demand, but rather one that has alternatives and options associated with it," she says. "Self-organizing is the new mode for getting things done in companies. Yes, you have a set area of responsibility in your job, but you also have the ability to see an issue or a problem, to find a few other people who see the issue or problem, and to try to find a constructive solution. If you start small, then you can overcome the courage gap. People are timid and scared that people are too set in their ways. But in fact the boss may not be sure what the solution should be and is just waiting for someone to come forward."In her classes, Kanter teaches the case of the upscale cookware retailer Williams-Sonoma, where the CEO repeatedly eschewed the idea of online sales. He wasn't a terrible boss, but he didn't use computers himself and didn't see the value in the strategy. So a group of self-starters went ahead and designed a small, low-risk e-commerce pilot anyway. It tested well, the CEO was at last impressed, and the project moved forward. "Williams-Sonoma ended up with one of the best e-commerce sites on the web in the early years of e-commerce," she says. "And it was a small group of believers that made that happen."Ideally, of course, collaboration is borne of shared excitement over a shared goal rather than shared frustration over a lousy boss. Kanter notes that many well-meaning companies attempt to encourage collaboration by assembling groups of employees with shared traits rather than shared goals."I've seen a lot of people try to form networks in companies: Let's get all the women together, let's get all the working parents together, let's get all the Asian Americans together. That's usually good for one or two lunches if there's no agenda. The secret of collaboration is that you have a task that you care about together."Carmen Nobel is senior editor of HBS Working Knowledge.http://hbswk.hbs.edu/item/6829.html?wknews=11022011

Four Ways Christians Can Influence the World

2011-11-03T05:06:00.000-07:00

DiscipleshipJohn Stott: Four Ways Christians Can Influence the WorldHow we can be salt and light.John R. W. Stott | posted 10/20/2011 10:15AMAlienation was originally a Marxist word, and Karl Marx meant by it the alienation of the worker from the product of his labors. When what he produces is sold by the factory owner, he is alienated from the fruits of his work. But nowadays the word alienation has a much broader meaning of powerlessness. Whenever you feel politically or economically powerless, you are feeling alienated.Jimmy Reid, the well-known Marxist counselor in Glasgow and leader of the Clydeside Ship Workers, when he was rector of Glasgow University, said, "Alienation is the cry of men who feel themselves to be the victims of blind economic forces beyond their control. Alienation is the frustration of ordinary people who are excluded from the processes of decision-making." Have we any influence? Have we any power? That's the question.The word influence can sometimes be used for a self-centered thirst for power, like in Dale Carnegie's famous book How to Make Friends and Influence People. But it can also be used in an unselfish way of the desire of Christians who refuse to acquiesce to the status quo, who are determined to see things changed in society and long to have some influence for Jesus Christ. Are we powerless? Is the quest for social change hopeless before we begin? Or can Christians exert some influence for Jesus Christ?There is a great deal of pessimism around today that grips and even paralyzes people. They wring their hands in a holy kind of dismay. Society is rotten to the core, they say. Everything is hopeless; there is no hope but the return of Jesus Christ. As Edward Norman, dean of Peter-house in Cambridge, once said in a radio interview, "People are rubbish."People are not rubbish. People are made in the image of God. Indeed they are fallen, but the image of God has not been destroyed. Are they capable of doing no good?But people are not rubbish. People are men and women made in the image of God. Indeed they are fallen, but the image of God has not been destroyed. Are they capable of doing no good? The doctrine of total depravity, which means that every part of our human being has been tainted by the Fall, does not mean that we're incapable of doing any good. Jesus himself said that although you are evil, you are able to do good things and give good gifts to your children. Now, of course we believe in the Fall. We believe that when Christ comes again he is going to put things right. If you develop a Christian mind, you don't concentrate exclusively on the fall of man and the return of Christ. You also think about the creation and about the redemption through Jesus Christ. And we have to allow the creation to be, as it were, qualified by the Fall, and the Fall by the Redemption, and the Redemption by the Consummation. And the Christian mind thinks in terms of this total purpose of God, which includes the Creation, the Fall, the Redemption, and the Consummation.If we are pessimists and think we are capable of doing nothing in human society today, I venture to say that we are theologically extremely unbalanced, if not actually heretical and harmful. It's ludicrous to say Christians can have no influence in society. It's biblically and historically mistaken. Christianity has had an enormous influence on society down through its long and checkered history. Look at this conclusion of Kenneth Latourette in his seven-volume work on the history of the expansion of Christianity:No life ever lived on this planet has been so influential in the affairs of men like the life of Jesus Christ. From that brief life and its apparent frustration has flowed a more powerful force for the triumphant waging of man's long battle than any other ever known by the human race. By it millions have been lifted from illiteracy and ignorance and have been placed upon the road of growing intellectual freedom and control over the physical environment. It has done more to allay the physical ills of disease and famine than any other impulse known to man. It's emancipated millions from chattel slavery and millions of others from addiction to vice. It has protected tens of millions in exploitation by their fellows. It's been the most fruitful source of movement to lessen the horrors of war and to put the relations of men and nations on the basis of justice and of peace.rest of article go to http://www.christianitytoday.com/ct/2011/october/saltlight.html

Should the Screening Age for Colorectal Cancer Be Lowered?

2011-11-01T23:24:00.000-07:00

Albert B. Lowenfels, MDPosted: 10/21/2011Is It Time to Lower the Recommended Screening Age for Colorectal Cancer?Davis DM, Marcet JE, Frattini JC, Prather AD, Mateka JJ, Nfonsam VNJ Am Coll Surg. 2011;213:352-361SummaryThe authors used cancer incidence data from the SEER database to analyze age-specific changes in the incidence of colorectal cancer in the United States. A marked increase in the incidence of colorectal cancer was found in the 40- to 44-year age group. In 1987, the incidence was 10.7 per 100,000; in 2006, the incidence had climbed to 17.9 per 100,000, an increase of 67%. The increase was even more pronounced for rectal cancer, amounting to over 3% per year. However, incidence rates for colorectal cancer in the > 50 age group decreased.ViewpointThe currently accepted screening age for colorectal cancer is 50 years. The authors of this report suggested that lowering the screening age may be appropriate on the basis of data that showed a significant increase in the incidence of colorectal cancer in younger individuals, especially in the rectum. Although sigmoidoscopy would be adequate for detecting rectal tumors, many tumors in the colon would escape detection. The authors pointed out that the incidence of colorectal cancer in younger individuals resembles the incidence rate of similarly aged patients with cervical cancer -- a group that is routinely screened. Estimates of the cost of lowering the screening age were not included and still need to be obtained.

Consistent Exercise Linked to Lower Risk for Death From Colon Cancer

2011-11-01T23:20:00.000-07:00

From Medscape Medical News > OncologyFran LowryJanuary 7, 2011 — Add another study to the body of literature that says exercise is good for you, especially with regard to modifying cancer risk and outcomes.The latest research, carried out by at the Siteman Cancer Center at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis, Missouri, shows that regular long-term physical activity is associated with a lower risk for colon cancer mortality.The study appears in the December issue of Cancer Epidemiology, Biomarkers & Prevention."This study is among the first to show that physical activity can make the disease less deadly," lead author Kathleen Y. Wolin, ScD, told Medscape Medical News. "It supports an existing body of research that suggests that physically active lifestyles have a host of benefits, both for cancer prevention and cancer-related death."However, an expert not involved in this research who was approached for comment said the study was negative, because it fails to show that exercise reduces the risk of getting colon cancer.Previous StudiesThere is already a body of literature showing the benefits of exercise on both physical and mental well-being, including several studies showing a reduction in the risk for cancer, as reported recently by Medscape Medical News.In November 2010, it was reported that women who exercised for at least 150 minutes a week might have a reduced risk for endometrial and postmenopausal breast cancer.In addition, new guidelines from the American College of Sports Medicine highlighted the benefits to cancer patients of exercise training both during and after cancer treatments to improve physical functioning, quality of life, and cancer-related fatigue.Effect on Colon CancerIn the latest study, Dr. Wolin and her colleagues sought to examine whether changes in physical activity alter the risk for colon cancer incidence and mortality."We know people will be active when they are younger, but then work or family obligations get in the way, and they tend to become less active. Others may not have been that active in young adulthood, but then in their 30s or 40s, when the pounds start creeping on, or when they start to be more concerned about their health and wanting to live longer, they become physically active," Dr. Wolin explained. "In this study, we were able to look at people's behaviors at multiple time points."The researchers used data from the American Cancer Society Cancer Prevention Study II (CPS-II) Nutrition Cohort to look at whether changes in physical activity influenced either the incidence of colon cancer diagnosis or the risk for death from the disease.CPS-II comprised more than 150,000 men and women. To determine how exercise affected colon cancer, the researchers compared levels of physical activity between 1982 and 1997, and linked those activity levels to the number of colon cancer diagnoses between 1998 and 2005 and to the number of colon cancer deaths that occurred between 1998 and 2006.Physical activity included walking, jogging/running, lap swimming, tennis, racquetball, bicycling, stationary biking, aerobics/calisthenics, and dancing.The study found that people who were consistently active for at least 10 years had a significantly lower risk of dying from their colon cancer than those who were consistently inactive (multivariable hazard ratio, 0.45; 95% confidence interval, 0.34 to 0.59). This held after adjustment for body mass index.People who were consistently active over 15 years had half the risk for colon cancer death as those who were more sedentary.However, being physically active did not appear to reduce their risk of getting colon cancer, Dr. Wolin said."Regular long-term physical activity was associated with a lower risk of colon cancer mortality," she said. "People often wonder around the start of a new year whether exercise really will help them stay healthy or whether it's already too late. It's never too late to start exercising, but it's also never too early to start being active. That's the message we hope people will take away from this study."A Negative Study That Fails to Show That Exercise Reduces RiskAsked to comment on this study for Medscape Medical News, Susan G. Fisher, MS, PhD, professor and chair of the Department of Community and Preventive Medicine at the University of Rochester in New York, said that it was well done, but because the data were not collected prospectively, it has limitations."It's a negative study. It fails to show that increasing physical activity over a 10- to 15-year period reduces an individual's risk of developing colon cancer," she said. "While this study does suggest that individuals who consistently participate in vigorous regular exercise throughout adulthood are less likely to die from colon cancer, the risk of developing colon cancer does not appear to be reduced," she said.Because these results are extracted from data that were previously collected, there are potential limitations in the methods used to measure the amount of physical exercise over a 10- to 15-year period, Dr. Fisher added. "These measurement difficulties may alter the study results. For instance, if I exercised 3 or 4 times a week and developed colon cancer, it's not unreasonable to think I would begin to have some symptoms, some indigestion or maybe fatigue, even before my diagnosis, and I would end up decreasing my exercise program. So people may be decreasing their exercise because they're feeling sick; I don't think they controlled for that perfectly," she said.Cancer Epidemiol Biomarkers Prev. 2010;19:3000-3004. Abstract

Bahrain Condemned Over Doctors' Jail Terms

2011-10-26T22:12:00.000-07:00

From Reuters Health InformationBy Stephanie NebehayGENEVA (Reuters) Oct 03 - Bahrain's handing down of harsh sentences to 20 doctors followed flawed trials that failed to meet international standards of transparency and due process, the United Nations human rights office said on Friday.The World Medical Association also condemned as "totally unacceptable" the jail terms imposed by a military court, while the World Health Organization said medical personnel should never be punished for doing their duty of treating all patients.A security court sentenced 20 doctors to jail on Thursday for between five and 15 years on theft and other charges, the state news agency said, in what critics claimed was reprisal for treating injured protesters during unrest in the Gulf kingdom this year."For such harsh sentences to be handed down to civilians in a military court with serious due process irregularities raises severe concerns," Rupert Colville, spokesman for U.N. High Commissioner for Human Rights Navi Pillay, told a news briefing.Defendants had limited access to lawyers and most lawyers did not have enough time to prepare properly, he said."We've even heard reports of detainees calling their families the day before their hearing asking them to appoint a lawyer," he said.The hearing itself had taken less than 10 minutes, according to a defense lawyer.The court -- whose three judges are appointed by the military -- "has also not been investigating torture allegations and has not permitted recordings of the proceedings," Colville said.The doctors denied the charges, saying they were invented by the authorities to punish medical staff for treating people who took part in anti-government protests. They were among dozens of medical staff arrested during protests led by the Shi'ite majority demanding an end to sectarian discrimination and a greater say in government.Bahrain's Sunni Muslim rulers quashed the protests in March, with the help of troops from fellow Sunni neighbors Saudi Arab and the United Arab Emirates. At least 30 people were killed, hundreds wounded and more than 1,000 detained -- mostly Shi'ites -- in the crackdown.On September 26th, Bahrain sentenced 32 men to 15 years in jail over violent protests and handed the head of a teachers' union a 10-year prison term for calling for the overthrow of the Gulf Arab monarchy.Two days later, a military court upheld life sentences against Shi'ite opposition leadersColville, referring to the doctors, said: "The charges have varied from illegal gatherings or expressing hatred of the government to what one normally consider actual crimes such as murder and destruction of property. So quite a lot of these charges related to freedom of expression and freedom of assembly."Bahrain's government had announced that all cases would be referred to civilian courts in October, but it was not clear how appeals by those convicted in military courts would be handled, he said."It is a sad day for medicine when physicians are incarcerated for treating patients. Physicians have an ethical duty to care for all patients in situations of conflict irrespective of the political circumstances," World Medical Association President Wonchat Subhachaturas said in a statement.The body links eight million physicians in 97 countries."In times of conflict, medical neutrality must be respected under the Geneva Conventions," Fadela Chaib, spokeswoman of the WHO, a United Nations agency, said."This means that injured people must be allowed to receive treatment regardless of their affiliation, health care workers must be allowed to access them and treat them and medical facilities including transport and personnel must all be protected," she told reporters.

Smoking Set to Cause 40 Million Extra Tuberculosis Deaths

2011-10-26T22:02:00.001-07:00

From Medscape Medical NewsKate JohnsonOctober, 4, 2011 — If worldwide smoking trends continue to 2050, tuberculosis (TB) mortality rates could jump by 40 million, according to a study published online today in the British Medical Journal."Aggressive tobacco control measures could avert millions of deaths from tuberculosis over the next four decades if these predictions are correct," write Sanjay Basu, MD, from the University of California, San Francisco, and colleagues."In the past, multinational tobacco companies have attempted to persuade health organisations to focus on infectious diseases rather than tobacco control. Our results show that this is a false dichotomy: tobacco control is tuberculosis control," they note.Smoking increases the rate of latent TB by a factor of 1.9, active TB by 2.0, and death from TB by 2.6, after adjustment for socioeconomic status, they explain.The researchers used a mathematical model to predict the effect of various worldwide smoking scenarios on the rates of TB and death between 2010 and 2050.The model predicted that if smoking rates continue along the same trajectory as they did between 2005 and 2010, there will be a 7% increase, or 18 million excess cases of TB, by 2050 (from 256 million to 274 million) and a 66% increase, or 40 million excess deaths (from 61 million to 101 million), compared to a nonsmoking model.This would translate to a 20-year delay in meeting the Millennium Development Goal target of reducing TB mortality by half between 1990 and 2015, they reported.In a more pessimistic scenario, the model predicted that if smoking rates were to increase at twice the current rate (to a maximum of 50% prevalence), there would be a 6% increase in TB cases (reaching a total of 290 million) and a 12% increase in TB deaths (to a total of 114 million) compared to the impact of current smoking trends.If aggressive tobacco control efforts were to reduce smoking prevalence by 1% per year until eradication, the TB infection and mortality rate could be reduced by 13% and 27%, respectively, from the current trajectory, they added.The authors have disclosed no relevant financial relationships.BMJ. Published online October 4, 2011.

The Year's Best Medical Practice Management Tips: 2011

2011-10-26T18:55:00.000-07:00

From Medscape Business of MedicineLeslie Kane, MAPosted: 10/24/2011Medical practices are going through seismic changes, and physicians are looking for ways to increase revenue or lower costs. There are many tactics that address the myriad ways to do both of those: by changing practice strategy; adding services; solving patient-flow and workflow problems that have been ignored; and focusing more on getting money that is owed to you.Throughout the year, Medscape has offered expert advice on ways to build a more successful practice. Here are some of the tips that physician readers found most helpful.1. Offer Your Patients One-Stop ShoppingFor your patients' convenience, do everything possible in-house: Draw blood, conduct urinalyses and stool guaiac tests, and so forth on your own. You should be able to bill for these items, and your patients won't have to wait at an outside lab to get the services that they need.When your patients need outpatient procedures that you cannot offer in-house, help them schedule appointments while they are in your office so that they won't have to hassle with the bureaucracy. Make their lives easier and they will reward you for it.2. Get New Patients by Creating a NicheYou'll go broke if you wait for sick patients to walk through the door. There aren't enough of them to go around. Consider doing wellness medicine, which widens the scope of potential patients to include everyone.Develop a subspecialty such as in dermatology, thyroid disorders, diabetes, or geriatrics. Get into occupational health -- pre-employment physicals, drivers' physicals, flight physicals, workers' compensation for minor injuries, drug screening, etc -- and advertise that you offer these services. A river of money may run by lawyers, but it doesn't run by physicians. We have only rivulets, but add them up and you will have a mighty stream.3. Avoid Gaps in the Schedule Due to No-ShowsStart with the basics: Have a no-show policy that charges patients either for the first or the second no-show appointment. It may be difficult to collect, but if patients wish to return to the practice, collect it via credit card when booking an appointment. Communicate the no-show policy to patients.Confirm all new patient visits 36 hours prior to the visit. If a patient cancels, that gives the practice time to fill the slot. Develop a cancellation list of patients who want to be seen sooner, and call them for cancellations. Track no-show patient characteristics. Are they emergency department referrals? Follow-ups? Is the no-show rate so high that the group needs to book extra patients to keep gaps from the schedule?Monitor the number of no-shows at baseline, implement changes, and set a goal that reduces the number. Graph your progress, and involve all staff members in meeting this goal.4. Try to Get Paid on the Basis of RVUs Rather Than Collections, if You're in a Hospital or Large GroupMany hospital billing services are really bad. Relative-value units (RVUs) are directly tied to the coding. It's a better measure of patient acuity than collections, and it eliminates contractual discounts.One problem for doctors starting a new job is that they may not get a productivity bonus in the first year if their incentive is based on collections that are measured annually. Because there's typically a 3-month lag before their charges are collected, the extra revenue that they generated through hard work won't show up in the first year.In contrast, they can get a productivity bonus in the first year if they're rewarded for hitting RVU targets, notes Tommy Bohannon, Senior Director of Recruiting and Development Training for Merritt Hawkins & Associates in Dallas, Texas.If a hospital or group includes quality metrics in its payment calculation, that will usually constitute about 10% of compensation. Sometimes a contract will specify that various percentages of the potential productivity bonus be paid to doctors, depending on how well they score on the quality measures.Intangible factors may account for another 10%. Among those factors are patient satisfaction, participating in committees, doing community service or community education, and public speaking, he says. In some cases, physicians who work harder and see more patients can earn more than those who spend a lot of time being good citizens.5. Make Sure That All Physicians Are Pulling Their Own Weight, and Deal With Those Who Aren'tThough a daunting prospect, you must have a frank discussion with the physicians who are dodging a share of the duties, regardless of seniority. "The senior doctor shouldn't carry more weight than the other partners. We should all be even stakeholders who are looking out for the common good of the practice," says Practice Management Expert Judy Capko, of Capko & Company, in Thousand Oaks, California.Advance preparation is essential. "There's a certain baseline cost for carrying a doctor, whether 10 or 20 patients are being seen. You need to gather a lot of data to see what the financial impact of this physician's routine is on the practice," Capko says. Determine what you need an underperforming physician to do; discuss the best way to lay out your position; and present it as a united group.The group spokesman should be someone who this physician greatly respects. Although some practices engage a management consultant as a facilitator, "you have a much better chance of succeeding if a physician expresses the group's viewpoint than if the consultant is given the role of dealing with this. Otherwise, the doctor who feels challenged is just going to attack the consultant. He or she is not going to see that the doctors agree with that consultant unless that's voiced," Capko says.Steer the discussion away from the physician's behavior and focus on the long-term health of the practice. Capko recommends: "You have been the foundation of this practice. We owe you a lot, but this practice -- your practice -- is struggling with some issues, and we need to address these for the future." Then you can delineate your concerns.6. Get Payment Even if Your Patient's Check BouncesYour practice's financial policy needs to include your policy on bounced checks and what steps the practice will take to recover that payment. If there are bank charges, stipulate that the patient will be charged for those fees. If you're in a state that allows you to collect a processing fee above the bank charges, that needs to be stipulated in the financial policy that a patient signs.For example, in Illinois the value of what can be collected is 3 times the face value of the check plus court costs if litigated. In North Carolina it is the cash amount of the check, bank fees, plus $35 for the handling fees. In Florida, you're only allowed to charge $20 above the check value and bank fees. The National Check Fraud Center lists the bad-check laws for each state. It is helpful to publish or reference the consumer credit laws in your financial policy. These simple steps will keep everyone on the same page and establish the financial component of the medical care relationship.Successful practices will make every method available for patients to pay bills. Cash, checks, postdated checks, credit cards, debit cards, and online services such as PayPal are all viable means for patients to settle their debts. Postdated checks are a good collection tool unless they bounce. Postdated checks are considered "promissory notes" rather than checks unless they are truly held until the date written on the check by the debtor before deposit.Consider using a check-scanning system from a company that guarantees the check if it clears. This will protect the practice as well. The monies are immediately deposited into your practice's bank account without the added burden of a trip to the bank.Almost all of these payment methods have some amount of service fee attached to them. However, the fees paid are a small price to pay for the general practice's cash flow. The smart practice will shop around for the bank with the best small-business service package available or will look to build a hybrid system with a couple of different vendors for the various services needed. No matter how you build your financial recovery process, you're wise to make as many methods available as possible as long as those methods protect the practice.7. Be Money Smart When You Move to an EHRTake a closer look at application service provider (ASP) technology. ASP technology means that the electronic health record (EHR) program and data are housed securely at a vendor's or an institution's location; you don't need to have expensive servers and tech support in your office if you have high-speed Internet access.The ASP EHR model will range from about $350 to $650 per month, plus training. Billing software will be an additional cost. The other option is buying an EHR that requires an in-house server and software. Systems like this that I reviewed averaged between $40,000 and $60,000 depending on the amount of bells and whistles added.With ASP models, benefit changes and software improvements are continually updated on your site so that your practice is always using the most recent data and advanced software. You don't need proprietary hardware or additional servers. You do not need to house your own server, and many systems have a minimal cost up front. You also will be able to log in from home to view patient data and reports.The downside to ASP technology is that when the Internet is down, so are you. Make sure that you have good, stable Internet service before considering this option.8. Think About a Professional Services Agreement if You're Considering EmploymentProfessional services agreements (PSAs) have been around for many years but are now growing in popularity. Physicians may view a PSA as a way to get the advantages of employment without selling their practices, and hospitals see it as a mechanism for controlling doctors without employing them directly."In a PSA, the physicians maintain their own professional corporation," explains Alice Gosfield, a Philadelphia, Pennsylvania, healthcare attorney. "The physicians assign the right to payment to the hospital; the hospital bills for them; and the physicians receive a base salary, usually with productivity bonuses. In more and more PSAs, the physicians also get bonuses that are based on quality metrics."Despite doctors' retention of practice ownership, Gray Tuttle, a practice management consultant in Lansing, Michigan, says that a PSA "is very similar to an employment relationship. The end results financially are close to identical. The difference is that the physicians are employed by a practice that they own. Typically the hospital will employ everybody else including the receptionists, nurses, and technicians. The providers -- physicians and even midlevels -- retain their relationship with the professional corporation."The physicians still own the practice assets including ancillary services, which, notes Tuttle, they lease to the hospital. The hospital must factor revenues from those ancillaries into the amount that it agrees to pay the physicians or the doctors won't sign up, he adds."Typically the hospitals provide reasonably long guarantees with no pay cuts and, in many cases, enhanced reimbursement," says Tuttle, adding that the guarantees may last up to 5 years for specialists and 3 years for primary care doctors.One reason why PSA reimbursement may be higher than what the doctors previously earned is that the hospital can often negotiate higher rates than most practices could on their own. In addition, some hospitals will pay doctors extra for quality and efficiency.9. Be Aware of Which Aspects of Prevention Care Are Now ReimbursedThe Patient Protection and Affordable Care Act has given physicians new tools to offer patients easier access to preventive care. Starting in January 2012, Medicare will eliminate its Part B deductible and copayments for a host of proven preventive services including bone mass measurement; some cancer screenings; diabetes and cholesterol tests; and flu, pneumonia, and hepatitis B vaccinations -- among other services.Medicare now covers annual wellness visits. It covers smoking cessation counseling. It began paying a 50% rebate for the brand-name medications that seniors need to manage chronic conditions when they reach the coverage gap known as the "doughnut hole."Your patients in new private insurance plans also won't pay out of pocket for many preventive services including screening blood pressure, diabetes, cholesterol, and for certain cancer screenings; counseling to quit smoking or cut alcohol consumption; routine vaccinations; and regular well-baby and well-child visits from birth to 21 years of age.The Centers for Medicare & Medicaid Services is working to make sure that you and your patients have the support that you need to achieve better health. Our investment in prevention takes a big step in that direction. If you or your patients are looking for more detailed information, go to healthcare.gov and click on "Learn About Prevention" at the top.

10 Lessons I Learned From Steve Jobs

2011-10-20T21:02:00.000-07:00

Jason ScharzAuthors the popular investment newsletter, Economic Weather Station, which is available at www.economictiming.comDuring this time of reflection I think we all feel a profound sense of gratitude for the life of Steve Jobs. He was exemplary in so many ways. For me, it’s about so much more than the iUniverse he created. It’s the way he did it. Some of the priceless pearls of wisdom that he left behind include the following life lessons:1- Don’t be afraid to fail.“I didn’t see it then, but it turned out that getting fired from Apple (AAPL) was the best thing that could have ever happened to me. The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.” Steve Jobs, June 12, 2005.2- Stay in the game. The real breakthrough moments in Steve’s career happened after 25 years of struggle.“Sometimes when you’re in the middle of one of these crises, you’re not sure you’re going to make it to the other end. But we’ve always made it, and so we have a certain degree of confidence, although sometimes you wonder.” Steve Jobs, March 7, 2008.“I’m convinced that about half of what separates the successful entrepreneurs from the non-successful ones is pure perseverance.” Steve Jobs interview, 1995.3- Follow your passion wherever it leads.“Being the richest man in the cemetery doesn’t matter to me … Going to bed at night saying we’ve done something wonderful… that’s what matters to me.” Steve Jobs, May 25, 1993.“Almost everything–all external expectations, all pride, all fear of embarrassment or failure–these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.” Steve Jobs, June 12, 2005.4- Just say no.“People think focus means saying yes to the thing you’ve got to focus on. But that’s not what it means at all. It means saying no to the hundred other good ideas that there are. You have to pick carefully.” Steve Jobs, June 2003.“I’m as proud of what we don’t do as I am of what we do.” Steve Jobs, February 6, 2006.5- Expect excellence. No company innovates on a regular schedule like Apple.“My job is to not be easy on people. My job is to make them better.” “Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.”6- A master architect builds a platform upon which others are given the capacity to thrive. Apple’s ecosystem and especially its App Store enabled creativity to flourish.7- Love and passion come first. Everything else will take care of itself.“My job is to make the whole executive team good enough to be successors, so that’s what I try to do.” “When I hire somebody really senior, competence is the ante. They have to be really smart. But the real issue for me is, Are they going to fall in love with Apple? Because if they fall in love with Apple, everything else will take care of itself. They’ll want to do what’s best for Apple, not what’s best for them, what’s best for Steve, or anybody else.” Steve Jobs, March 7, 2008.8- Too many of us fail to reach our potential because of the bureaucracy that binds us.“Why join the navy if you can be a pirate?” Steve Jobs, September 1982.9- Quality vs. quantity? Steve understands it.“Quality is more important than quantity. One home run is much better than two doubles.” Steve Jobs, February 6, 2006.10- Progress comes from within.“The cure for Apple is not cost-cutting. The cure for Apple is to innovate its way out of its current predicament.” Steve Jobs, 2004.There will never be another Steve Jobs. It has been a pleasure covering Apple with him at the helm and I look forward to continued greatness coming from the innovative company that he built. The scope of the Information Age and the evolution of the mobile revolution is still in its infancy.To honor Steve, we have organized an event that will include a who’s who of Apple investors, analysts, and commentators to provide hedge fund style research for individual investors. It is the first event of its kind. We’re calling it the AAPL Investor Summit and we hope it will provide you with profitable investment strategies for the years to come. For more information, please visit www.aaplinvestorsummit.com. A portion of the proceeds will be donated to the Huntsman Cancer Research Foundation. RIP Steve Jobs. http://seekingalpha.com/author/jason-schwarz

Monday Morning Atheist

2011-10-20T20:52:00.000-07:00

Source: Book Monday Morning Atheist by Doug Spada & Dave Scott ISBN978-0-9839628-0-9www.WorkLife.orgMonday Morning Atheist: Someone who believes in God but who works like He does not existSix Life in Work PrinciplesThe work of the righteous leads to life ... Proverbs 10 v16The personal objective is to have:1. Clarity – awareness of God’s original purpose for work that helps you live your whole life with greater clarity Genesis 2, Exodus 20 : 8 -112. Calling – affirmation of your unique design and how God has strategically placed you at work to fulfill his calling Eph 2 v 10, Psalm 1393. Balance - alignment with the role of work that allows you to pursue biblical priorities and life balance Colossians 3 v 17 – 4 v14. Skills – ability to please God and serve others through the development and excellence of your work skills Proverbs 22v29, 1 Cor 10v315. Influence – authenticity in personal character at work as u experience purposeful faith conversations and grow your influence titus 2 v 9 – 10, Matt 5 v166. Relationship – alliance with Christ helping you effectively navigate work issues and develop healthy relationships Heb 3v13, James 2v15-17Action ideas1. Pray for 3 people you work with – pray privately for his blessings n intervention2. Begin your day with God – read bible, begin with few verses – may use devotional, or a chapter of proverbs a day over one month (there are 31 chapters)3. Commit to a higher standard of work – decide to glorify god with your work, better attitude, better service or product4. Cut out complaints – Complaining is not part of God’s will. Talk to God about the area u want to complain about, seek his help to develop better response5. Go the extra mile –if u are used to doing the bare minimum – take it one step further – higher than what others require of u – do it every day for one week6. Cultivate gratitude – be thankful for whatever blessings. At the end of the day, say aloud what u are thankful for each hour of the working day7. Be slow to anger – when u are frustrated or angry – try reciting a bible verse e.g. Micah 6v8 tells what God expects of u – to do justice, love mercy and walk humbly with your God8. Work with friends, family or a spiritual mentor to help u identify specific habits or attitudes in your work life god may want to change – commit prayerfully to a small action u can do each day.

How 'Hybrid' Nonprofits Can Stay on Mission

2011-10-19T19:37:00.000-07:00

Published: October 17, 2011Author: Carmen NobelExecutive Summary:As nonprofits add more for-profit elements to their business models, they can suffer mission drift. Associate Professor Julie Battilana says hybrid organizations can stay on target if they focus on two factors: the employees they hire and the way they socialize those employees. Key concepts include: In order to avoid mission drift, hybrid organizations need to focus on whom they hire and whether their employees are open to socialization. Because early socialization is so important, hybrid firms may be better off hiring new college graduates with no work background rather than a mix of seasoned bankers and social workers. The longer their tenure in a hybrid organization, the more likely top managers may be to hire junior people.HBS Faculty Member Julie BattilanaJulie Battilana is an associate professor in the Organizational Behavior unit at Harvard Business School.For those who like to view things in black and white, it's tempting to divide the working world into two camps. There is the for-profit sector, primarily driven by the prospect of financial success. And then there's the not-for-profit world, which eschews the almighty dollar in the pursuit of curing societal ills. In reality, though, the line between the two is growing blurrier."In the not-for-profit sector, a number of organizations are trying to be less dependent on donations and grants," says Julie Battilana, an associate professor at Harvard Business School. "In the meantime, facing increased public pressure to help address societal problems, for-profit firms have adopted social responsibility policies, which have pushed them to focus more on social initiatives." "Some of them have been accused of losing sight of their social mission, or even having a negative impact on the populations they were trying to help"In the wake of this evolution over the past decade, more organizations have adopted a hybrid business model in which a social mission is the primary goal, but they still aim to generate enough commercial revenue so they can survive and thrive without depending on charitable donations like a typical nonprofit would. Commercial microfinance organizations often adopt a hybrid model, for example: they provide business loans to poor people who wouldn't traditionally qualify, but they still depend on the loan recipients paying them back with interest.The main problem with the model is that hybrid organizations run the risk of suffering from so-called mission drift—meaning that they stray from their original goals—usually by focusing on profits to the detriment of the social good, but sometimes vice versa."Mission drift has been identified as a potential problem among microfinance organizations," says Battilana, who has been studying hybrid organizations for several years. "Some of them have been accused of losing sight of their social mission, or even having a negative impact on the populations they were trying to help."According to Battilana, there are two key questions that leaders must address to keep the mission on course while still making enough money to sustain that mission: One, whom should you hire to strike a healthy balance between idealism and the bottom line? And two, what's the best way to socialize new hires to stay focused?Lessons from BoliviaIn a recent Academy of Management Journal article, Battilana and Silvia Dorado from the University of Rhode Island tell the true tale of two Bolivian microfinancing organizations, Banco Solidario and Caja de Ahorro y Préstamo Los Andes. Both were hybrid orgs created in the early 1990s as spin-offs from existing NGOs. Both set out to avoid mission drift. But each took a different tack in hiring new employees.BancoSol hired employees based on their previous experience and proven capabilities. Because the mission required know-how in both profit making and social work, the organization ended up hiring a mix of social workers, sociologists, anthropologists, bankers, and economists. The idea was that these seasoned employees would complement each other with their disparate backgrounds, after training them to work together toward the common good.But the reality was that their single-purpose backgrounds made it hard for them to adjust to the hybrid model. Those with social work experience and those with a financial background ended up resenting each other to the point of constant fighting, such that the organization could hardly operate. Loan officers quit left and right, the number of active borrowers plummeted, and the profit margin dropped, too."They basically had to deal with conflict that became intractable," Battilana says.Los Andes's launch in 1995 came three years after that of BancoSol's, meaning that Los Andes would learn from BancoSol's hiring woes. Los Andes took what Battilana and Dorado call a "socializability-focused" approach to hiring. Rather than looking for job candidates with experience in either social welfare work or finance, Los Andes hired people with essentially no work experience at all—recent college graduates—and then trained them specifically to be microfinance loan officers. The idea was that it would be easier for the employees to adhere to the hybrid mission if they were not hampered by their preexisting work logics, be they either social-based or profit-based. Whereas BancoSol was more focused on the dual end-goal of helping loan applicants while still making a profit, Los Andes was more concentrated on the means to an end—the process of training and managing the novice employees.Because it took longer to train newbies than it would take to coach seasoned professionals, measurable progress was slow, but steady at Los Andes. "Instead of relying on commitment to the end pursued by the organization (i.e., its mission), Los Andes's approach to socialization thus relied on commitment to the means used to achieve this end," Battilana and Dorado write. "You might be better off hiring blanker slates"In the end, in addition to avoiding interpersonal strife, Los Andes was more successful than BancoSol in avoiding mission drift. By the turn of the century, Los Andes had both lower average loans and a lower percentage of delinquent loans than its predecessor. (Higher values on either are signs of mission drift.)"So what we found was that in the early days, you might be better off hiring blanker slates and then try to socialize them in the way that you want them to work in the hybrid organization," Battilana saysManagers have baggage, tooBe that as it may, top managers at hybrid organizations may find it difficult to make the best hiring decisions because of their own preexisting biases.Battilana explains the problem in a yet-to-be-published paper, tentatively titled "Neither Corporations Nor Not-For-Profits…But a Combination of the Two: The Challenges of Sustaining Hybrid Work Contexts.""In the same way as new hires' work habitus influences the way in which they will enact the market and social welfare logics within hybrids, the work habitus of top managers influences the way in which they enact both logics in their daily practices," the paper states. Thus, even knowing the importance of the hybrid mission, a manager with a strong background in the nonprofit social sector is likely to be drawn toward candidates who also have a social sector background. And a manager with a background in finance is more likely to hire a financier over a social worker, all else being equal.Firms can address this inherent bias problem by enacting strict and scientific hiring mechanisms. For instance, rather than vetting possible hires via job interviews, Los Andes both hired and promoted its employees almost solely on the basis of how the candidates performed on written exams. This prevented the possibility that hiring managers would be swayed by their own backgrounds, meaning that sporting either a finance degree or a social work degree didn't result in preferential treatment for a potential candidate.But Battilana's research also suggests that managers are likely to learn from experience; the longer their tenure at a hybrid organization, the more probable it is that top managers hire junior employees."What we expect is that the more time they spend in a hybrid context, the more likely the managers are to become familiar with the problem of hiring, say, both bankers and socially minded employees," Battilana says. "The more experienced they are, the more likely they may be to hire blanker slates, especially in the early days of the organization when its hybrid culture is not yet strongly established."About the authorCarmen Nobel is senior editor of HBS Working Knowledge.http://hbswk.hbs.edu/item/6795.html

Keeping Older Drivers Safe

2011-10-18T20:46:00.000-07:00

Medscape Medical News from the Gerontological Advanced Practice Nurses Association (GAPNA) 30th Annual ConferenceAn Expert Interview With David Carr, MDElizabeth McGann, DNSc, RNSeptember 30, 2011 — Editor's note: Older drivers are generally considered safe drivers, in contrast to drivers who have specific medical impairments. More education geared toward older drivers and healthcare professionals is needed. Attention must be directed toward proper assessment and interventions to promote driver safety among older Americans. A podium presentation, entitled Driving the Older Adult: State of the Science, was featured at the Gerontological Advanced Practice Nurses Association (GAPNA) 30th Annual Conference, held September 14 to 17 in Washington, DC.To find out more about older driver safety, Medscape Medical News interviewed David Carr, MD, who is associate professor in the Department of Medicine and Neurology at Washington University at St. Louis, Missouri. He is a board-certified internist and geriatrician, and medical director of The Rehabilitation Institute of St. Louis. He has assisted in the development and operations of the driving connections clinic there. His research interests are in medical conditions that affect driving, especially issues of assessing driving safety and cessation in the older drivers with dementia and stroke.Medscape:What are the data for national crash and injuries in older drivers?Dr. Carr: Older drivers have the lowest rate of crasher per year, compared with any other age group. However, they have an increased crash rate per miles driven, which approaches that of the teenaged driver. Therefore, for the amount of time they are on the road, they are at an elevated risk, compared with middle-aged drivers. They are at increased risk for injury and death regardless, when you look at this statistic per licensed driver or based on exposure.Medscape: What is the current state of the science related to older drivers?Dr. Carr: Older drivers are, in general, a very good risk behind the wheel. Age should not be an indicator for driving retirement, nor for mandatory testing during licensure. The focus should be on the medically impaired drivers. We need more education for all types of health professionals to be comfortable discussing, evaluating, and counseling older drivers who have age-related medical diseases.Medscape: What are the best approaches to assess impaired older drivers?Dr. Carr: The best approaches will use a good history of driving behavior and any changes in driving habits that may have occurred related to a chronic medical illness. The physical examination should focus on visual acuity, visual fields, muscle testing, joint range of motion, and various cognitive abilities such as processing speed, reaction time, attention, judgment, and visuo-spatial ability.Medscape: What are some of the instruments used to assess risk?Dr. Carr: Some of the commonly used instruments are the clock drawing task, Trail Making Test A and B, maze completion tests, the useful field of view measure, the motor-free visual perceptual test, and a measure of contrast sensitivity.Medscape: What resources are available to older drivers and healthcare professionals?Dr. Carr: There is a variety of online resources for providers and older drivers. The American Medical Association has an online resource called the Physician's Guide to Assessing and Counseling Older Drivers, developed in cooperation with the National Highway Traffic Safety Administration. The American Automobile Association offers an online program called Roadwise Review, designed to allow senior drivers to test their functional abilities related to driving. There is also an online driver safety program sponsored by the American Association of Retired Persons.Medscape: What major challenges do providers and families face when getting the older driver to give up driving?Dr. Carr: There may be resistance because of a lack of insight from an underlying dementing illness. In general, many older adults will give up driving voluntarily if they believe they are putting themselves or others at risk while driving. Of course, this depends on viable alternatives to driving, which may not be readily available or accessible to older adults, especially in rural communities.Medscape: What are the 2 most significant aspects of your presentation?Dr. Carr: The 2 most important take-home messages are that older adults, in general, are safe drivers, and the focus should be on medically impaired drivers; and that instruments are being developed for the clinician to use in the office that can be useful in determining driving safety.Dr. Carr reports relationships with the National Institute on Aging, the Missouri Department of Transportation, the American Medical Association, and Advanced Drivers Education Products & Training, Inc. (ADEPT).

Social media: What parents should know

2011-10-11T19:31:00.001-07:00

Children and teens are creating and sharing information more than ever using digital media such as cell phones, smart phones, and computers. They send text messages, use Facebook and Twitter, write blogs, share photos and video to stay in touch with friends and family and to make new friends.Social media offers lots of opportunity to help your child and teen be creative and stay connected and informed. But it’s important to learn about the different technologies and how your children use them so you can help keep them safe online.The social media landscape changes quickly. Because this document is only an introduction, we’ve included links to other websites you might find helpful.What is social media?Social media refers to the online tools that connect people with common interests on the Internet. Unlike traditional media (TV, radio, newspapers and so on), social media allow users to interact with each other. Popular social networking websites include Facebook, Twitter, YouTube, Flickr, and MySpace.There are many different ways that people use social media: Online profiles: Most social media sites require users to set up a profile. A profile usually includes a name, e-mail address, birth date, interests and a photo. Friends: Depending on the kind of social media, users “follow” or “request friends” from people they know such as classmates or family. They may also use social media sites to find and meet new friends. Messaging: Sending short text messages over the Internet, using instant messaging and between cell phones. Walls and boards: Social media sites allow people to post or send messages in many different ways. On Facebook, for example, information is posted to a “wall”. Some messages are visible to a wider audience, while others can be sent privately like e-mail. Photo and video sharing: Social networking sites allow users to upload personal photos and videos. Some sites, such as Flickr for photos and YouTube for videos, are used solely to share images. Blogs: A blog is a website kept by an individual who updates it with regular entries of text or photos and videos. It is a lot like a journal, only on the web. People who read blogs can comment and share published content among their own online networks. Joining groups: Many kinds of social media allow users to create groups. People join, “like” or follow these groups to get access to information and have conversations with other members. To play games: Children and teens visit online sites to play games, alone or with their friends. Some, like Facebook, include free online gambling applications.How can I keep my children safe using social media? Learn about the technologies your children and teens are using. Ask how they communicate with friends online. Tell them that you are willing and interested to learn about it. Keep computers in common areas where you can watch while your children use them. Be clear about the rules for using the computer and set limits on the amount of time and how they can be used. Set limits on cell and smart phone use. Talk about when it’s a good time to use a cell phone. Your child or teen’s school, for example, likely has rules about where and when they can or can’t be used. Teach them the value of “unplugging” from devices and computers for technology free time. Reinforce that no e-mail or message is so important that it can’t wait until the morning. Get online protection for your family. Programs that provide parental controls can block websites, enforce time limits, monitor the websites your child visits, and their online conversations. Tell your children and teens that you are monitoring their online activity. Be aware that some parent control programs will block information about puberty and sexuality that you might want your teen to look for. Ask your children and teens about the people they “meet” online. Showing genuine interest will help them feel comfortable talking about it. Explain that it’s easy for someone on the Internet to pretend to be someone they are not. Discuss what’s okay and safe to post online and what isn’t. People can’t always control the information others post about them. Explain that information and photos available online can turn up again years later. Ask your children and teens where else they access the Internet. Talk to teachers, caregivers and other parents about your rules for social media. Because people are not always who they pretend to be online, talk about the importance of keeping online friendships in the virtual world and how it can be dangerous to meet online friends face-to-face. Make it clear that if your child wants to meet a virtual friend in person, it must be with a trusted adult. If your child or teen is playing online games, join them (even if only to sit and watch) so you can see exactly what they are doing and talk to them about it.What should I know about online privacy?Social media websites have privacy policies and settings, but they are all different. Some sites are completely public, meaning that anyone can read or look at anything, anytime. Other sites let you control who has access to your information.Read a website’s privacy policy before providing any personal information. Some social media websites, like Facebook for example, don’t allow children under 13 to joint their site. Check your child’s privacy policy settings to make sure he isn’t sharing more information than you want.The following suggestions will help your children protect their online privacy: For some social media sites it is a good idea to choose an online nickname, instead of using a real name. Keep everything password protected, and change passwords often. Don’t accept friend requests from people you don’t know in real life. Think carefully about what you post online. Remember: things that are posted online stay online forever. As a general rule, don’t post anything you wouldn’t want a parent or teacher to see or read. Remember to protect a friend’s privacy too. Ask permission before posting something about a friend, a photo or a video. Be aware of what your friends are posting about you. If you use a GPS-enabled smart phone or a digital camera, you could be posting status updates, photos and videos with geotags. Geotags provide the exact location of where your photo was taken. Make sure these are turned off on your device. What is cyber-bullying?Just as some people are bullied in real life, people are bullied online. It happens many ways: by sending mean messages by e-mail or posting them in an online forum or by sharing photos and videos without permission.Talk to your children about cyber-bullying. If it isn’t too serious, suggest that they ignore it at first. If it doesn’t stop, is violent or sexually explicit or your child gets scared, encourage them to talk to you or another trusted adult.The Media Awareness Network has some more information on cyber-bulling at: http://www.bewebaware.ca/english/cyberbullying.htmlWhat is sexting?Sexting is a term used to describe sending sexually explicit messages, photos or videos between cell phones. It can also happen using e-mail or on social media websites. Ask your teen what she knows about sexting. Talk about the dangers of sexting. Remind her that words and photos posted online can easily be shared among many different people. Remind your teen that nothing is ever really deleted online. Friends, enemies, parents, teachers, coaches, strangers, and potential employers can find past postings.Posted: July 2011This information should not be used as a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances.Canadian Paediatric Society2305 St. Laurent Blvd.,Ottawa, Ont. K1G 4J8Phone: 613-526-9397, fax: 613-526-3332

The Role of Obesity, Salt and Exercise on Blood Pressure in Children and Adolescents

2011-08-24T22:14:00.000-07:00

From Expert Review of Cardiovascular TherapyStella Stabouli; Sofia Papakatsika; Vasilios KotsisPosted: 08/16/2011; Expert Rev Cardiovasc Ther. 2011;9(6):753-761. © 2011 Expert Reviews Ltd. Abstract and Introduction Definition of Pediatric HTN Childhood Obesity & BP Regulation Dietary Salt Intake & BP in Childhood Exercise & Prevention of HTN in Children & Adolescents Expert Commentary Five-year ViewAbstractThe increasing trends of blood pressure (BP) in children and adolescents pose great concern for the burden of hypertension-related cardiovascular disease. Although primary hypertension in childhood is commonly associated with obesity, it seems that other factors, such as dietary sodium and exercise, also influence BP levels in children and adolescents. Several studies support that sympathetic nervous system imbalance, impairment of the physiological mechanism of pressure natriuresis, hyperinsulinemia and early vascular changes are involved in the mechanisms causing elevated BP in obese children and adolescents. Under the current evidence on the association of salt intake and BP, dietary sodium restriction appears to be a rational step in the prevention of hypertension in genetically predisposed children and adolescents. Finally, interventional studies show that regular aerobic exercise can significantly reduce BP and restore vascular changes in obese with hypertensive pediatric patients. This article aims to summarize previous studies on the role of obesity, salt intake and exercise on BP in children and adolescents.IntroductionThe prevalence of primary hypertension (HTN) in children and adolescents has been reported to have increased during the last few decades. HTN awareness is currently increased, due to the easier detection and improved classification of HTN in the young. Despite the difficulty in estimating the exact percentage of children with elevated blood pressure (BP), pediatric primary HTN is present in 1–5% of children and adolescents of all age groups. Differences in race/ethnicity, variance in secondary HTN, sex-related changes, environmental and nutritional influences are all confounding factors in the estimation of prevalence.The most important aspect of identifying HTN in the pediatric population is 'BP tracking', that means the association of high BP in childhood with elevated BP in adulthood. With this concept, factors that affect BP in childhood, are likely to further influence the burden of HTN and cardiovascular disease in adults. The documented increasing prevalence of childhood obesity has accounted for the trends of elevated BP in children and adolescents. However, in the recent National Health and Nutrition Examination Survey (NHANES; 1988/1994 and 1999/2000), adjustment for obesity explain only 29% of the increase in systolic BP (SBP) and 12% in diastolic BP (DBP), suggesting that other factors, such as increased salt intake and low physical activity, may also affect BP trends over time.This article aims to summarize previous studies on the role of obesity, salt intake and exercise on BP in children and adolescents.http://www.medscape.com/viewarticle/746947_4

US Gets Less for Its Healthcare Buck Than Other Nations

2011-08-12T20:46:00.000-07:00

From Medscape Medical News

Robert Lowes

August 11, 2011 — Despite outspending 18 other developed nations on healthcare as a percentage of gross domestic product (GDP) in 2005, the United States posted the highest mortality rate among its peers, according to a study published online last month in the Journal of the Royal Society of Medicine Short Reports.
Although the United States reduced its mortality rate from 1979 to 2005, 15 of the other developed countries, including the United Kingdom, did the same thing at a faster clip.
In short, the American healthcare system is one of the least cost-effective, whereas the system in the United Kingdom is the second most cost-effective, doing more with less, write Colin Pritchard, PhD, a professor of psychiatric social work at Bournemouth University in Bournemouth, United Kingdom; and Mark Wallace, BSc, who teaches economics, politics, and philosophy at the Latymer School in London.
Pritchard and Wallace paid particular attention to the United Kingdom's performance because they conducted their study in response to frequent references to the "apparent failings" of the National Health Service during the ongoing healthcare reform debate in the United States.
The other countries in the study are Austria, Australia, Canada, Finland, France, Germany, Greece, Ireland, Italy, Japan, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, and Switzerland.

In 1980, public and private healthcare expenditures in the United States as a percent of GDP amounted to 8.8%, ranking it second behind Sweden at 9%. By 2005, the United States had vaulted to first place with 15.3%, Switzerland placing a distant second at 11.6%.
The United States also ranked number 1 in average GDP healthcare expenditures — 12.2% — during the entire 25-year time frame.
The authors extrapolated mortality rates per million (PM) from data compiled by the World Health Organization for 2 time frames — 1979 to 1981, and 2003 to 2005 — with separate rates for individuals aged 15 to 74 years, 15 to 34 years, 35 to 54 years, and 55 to 74 years.
The mortality rate in the United States for the comprehensive 15- to 74-year-old age group decreased from 9158 deaths PM to 6660 PM, or by 27% during the roughly quarter-century span, but the nation nevertheless posted the highest mortality rate in 2005 among the 19 developed nations.
All but Portugal, Spain, and Switzerland saw their mortality rate decrease at a slower pace.
The United Kingdom had the fifth highest mortality rate — 5471 PM.
Likewise, the United States topped the mortality-rate list for the 55- to 74-year-old age groups, whereas the United Kingdom came in at number 6.

Too Many Guns in the United States?
The authors calculated a cost-effectiveness ratio for each country by dividing the level of reduced mortality rates — in the case of the United States, 9158 PM minus 6660 PM or 2498 PM — by average GDP healthcare spending from 1980 to 2005. According to this measure, the United States ranked third from the bottom for the 15- to 74-year-old age group with a ratio of 1:205 vs 1:557 for the United Kingdom, which ranked second behind Ireland. The same pecking order for the 3 countries held true in the 55- to 74-year-old age group.
Several characteristics of the United States might help explain the country's high mortality rate among the 19 nations, according to Pritchard and Wallace. They point to the country's "considerable variation" on a range of socioeconomic and health factors, especially regarding ethnic groups. In addition, the availability of firearms here "impacts upon mortality rates such as homicide and suicide, far more than any other Western country."
The authors attempt to answer the question of why the United States performs so poorly on healthcare cost-effectiveness when the market forces of a largely private healthcare system are assumed to foster efficiency. The US system, Pritchard and Wallace write, has "inherent market failures" such as adverse selection, in which individuals with greater health risks are more likely to obtain coverage from private insurers than individuals with lesser risks, driving premiums upward and discouraging the "better bets" from getting coverage in the first place. Another market failure stems from private insurers charging everyone higher premiums to hedge against "a few individuals that require unexpectedly very expensive medical treatment."
Nations with mostly public healthcare systems, such as the United Kingdom, avoid these pitfalls, according to the authors.
The study authors have disclosed no relevant financial relationships.

J R Soc Med Sh Rep. 2011;2:60. Full text

How Can I Remember All That I've Learned in Preclinical Classes?

2011-08-10T19:58:00.000-07:00

From Medscape Med Students > Ask the Experts

Alex Millman, MD

Posted: 12/15/2010

Do you have any tips for remembering all the stuff I learned in the first 2 years, and for integrating it into clinical practice?

Response from Alex Millman, MD
Resident Physician, University of California, San Francisco

Trying to remember the material learned during the preclinical years of medical school is a perennial challenge for physicians in training. The quantity of information is daunting, and it can certainly feel as though your brain is overflowing with facts that are difficult to relate to clinical practice. If you find yourself in this situation, remember these 2 important points: (1) everyone in medicine has confronted this issue at some point in his or her career; and (2) you know more than you think you do.
The transition from the preclinical to the clinical years presents a new set of challenges for all medical students. Not only are you confronted with the complexities of functioning on a team, navigating long hours, and caring for patients, you also are learning new aspects of clinical medicine while simultaneously trying to preserve your "book knowledge." How does one do this effectively?
The first 2 years of medical school provide a foundation -- a starting place from which clinical knowledge will grow. Although it may be difficult to find time to review old material during clerkships, clinical practice provides an important tool for learning: the patient.
Learning from the context of patient care is truly the most effective way for reviewing topics and expanding your knowledge base. I find it easiest to remember things when related to an experience with a patient. Caring for patients provides necessary opportunities for experiential learning by actually demonstrating the pathophysiology learned during the preclinical years.
For example, I have read about the different physical exam maneuvers that accentuate the murmur of aortic stenosis compared with that of outflow tract obstruction. However, it was not until I treated a patient with aortic stenosis that I was able to truly commit the difference to memory. Moreover, caring for patients motivates you to read more about their diseases and treatments. Associating one's learning with an actual patient provides a considerably stronger framework for remembering facts than simply sitting down and reading about random topics for 2 hours.
Medical student presentations can also serve as excellent mechanisms for reviewing preclinical material and for expanding your knowledge base. As a medical student on a clinical team, you will likely be expected to make at least 1 presentation on a particular disease topic during the course of your rotation. This gives you a chance to become a "mini-expert" on a topic while reviewing material you might have forgotten.
For example, if you have a patient with a type of renal tubular acidosis (RTA), it would behoove you to refresh yourself on the mechanisms behind different types of RTAs. Discussing the pathophysiology behind the disease and pairing it with additional information about diagnosis and therapeutics will help you review and expand your knowledge base simultaneously. In fact, these types of topic reviews also allow you to educate other members of the medical team (so be sure to listen to others' presentations as well). Remember, medical students are closest to the basic science years. Other members of the team appreciate a chance to refresh their own knowledge as well.
Although it may seem daunting to remember and apply knowledge from the first 2 years of medical school to the clinical arena, there are methods for effectively doing so. By continuously revisiting old topics in the context of patient care, you will be able to review your basic science foundation while concurrently learning more about clinical medicine. Although clinical practices are consistently in flux, developing the skills to build upon your understanding of the basic mechanisms of disease is essential to becoming a successful physician.

Five Discovery Skills that Distinguish Great Innovators

2011-08-10T19:02:00.000-07:00

Published:	July 20, 2011
Authors:	Jeff Dyer , Hal Gergersen, and Clayton M. Christensen

Executive Summary:

In The Innovator's DNA, authors Jeff Dyer , Hal Gergersen, and Clayton M. Christensen build on the idea of disruptive innovation to outline the five discovery skills that distinguish the Steve Jobses and Jeff Bezoses of the world from the run-of-the-mill corporate managers. Key concepts include:

Academic and medical research supports the idea that innovative tendencies are not genetic. Rather, they can be developed.
The authors identify five discovery skills that distinguish successful innovators: associating, questioning, observing, networking, and experimenting.

Clayton M. Christensen is the Robert and Jane Cizik Professor of Business Administration at Harvard Business School.

In their new book, The Innovator's DNA, authors Jeff Dyer, Hal Gergersen, and Clayton M. Christensen build on the idea of disruptive innovation to explain how and why the Steve Jobses and Jeff Bezoses of the world are so successful. This excerpt from Chapter One summarizes the five discovery skills that distinguish innovative entrepreneurs and executives from run-of-the-mill managers.

What Makes Innovators Different?

So what makes innovators different from the rest of us? Most of us believe this question has been answered. It's a genetic endowment. Some people are right brained, which allows them to be more intuitive and divergent thinkers. Either you have it or you don't.
But does research really support this idea? Our research confirms others' work that creativity skills are not simply genetic traits endowed at birth, but that they can be developed. In fact, the most comprehensive study confirming this was done by a group of researchers, Merton Reznikoff, George Domino, Carolyn Bridges, and Merton Honeymon, who studied creative abilities in 117 pairs of identical and fraternal twins. Testing twins aged fifteen to twenty-two, they found that only about 30 percent of the performance of identical twins on a battery of ten creativity tests could be attributed to genetics. In contrast, roughly 80 percent to 85 percent of the twins' performance on general intelligence (IQ) tests could be attributed to genetics.
So general intelligence (at least the way scientists measure it) is basically a genetic endowment, but creativity is not.
Nurture trumps nature as far as creativity goes.
Six other creativity studies of identical twins confirm the Reznikoff et al. result: roughly 25 percent to 40 percent of what we do innovatively stems from genetics. That means that roughly two-thirds of our innovation skills still come through learning—from first understanding the skill, then practicing it, and ultimately gaining confidence in our capacity to create.
This is one reason that individuals who grow up in societies that promote community versus individualism and hierarchy over merit—such as Japan, China, Korea, and many Arab nations—are less likely to creatively challenge the status quo and turn out innovations (or win Nobel prizes).
To be sure, many innovators in our study seemed genetically gifted. But more importantly, they often described how they acquired innovation skills from role models who made it "safe" as well as exciting to discover new ways of doing things.
If innovators can be made and not just born, how then do they come up with great new ideas?
Our research on roughly five hundred innovators compared to roughly five thousand executives led us to identify five discovery skills that distinguish innovators from typical executives.

First and foremost, innovators count on a cognitive skill that we call "associational thinking" or simply "associating." Associating happens as the brain tries to synthesize and make sense of novel inputs. It helps innovators discover new directions by making connections across seemingly unrelated questions, problems, or ideas. Innovative breakthroughs often happen at the intersection of diverse disciplines and fields. Author Frans Johanssen described this phenomenon as "the Medici effect," referring to the creative explosion in Florence when the Medici family brought together creators from a wide range of disciplines—sculptors, scientist, poets, philosophers, painters, and architects. As these individuals connected, they created new ideas at the intersection of their respective fields, thereby spawning the Renaissance, one of the most innovative eras in history. Put simply, innovative thinkers connect fields, problems, or ideas that others find unrelated.
The other four discovery skills trigger associational thinking by helping innovators increase their stock of building-block ideas from which innovative ideas spring. Specifically, innovators engage the following behavioral skills more frequently:

Questioning. Innovators are consummate questioners who show a passion for inquiry. Their queries frequently challenge the status quo, just as [Apple Inc. co-founder Steve] Jobs did when he asked, "Why does a computer need a fan?" They love to ask, "If we tried this, what would happen?" Innovators, like Jobs, ask questions to understand how things really are today, why they are that way, and how they might be changed or disrupted.
Collectively, their questions provoke new insights, connections, possibilities, and directions.
We found that innovators consistently demonstrate a high Q/A ratio, where questions (Q) not only outnumber answers (A) in a typical conversation, but are valued at least as highly as good answers.

Observing. Innovators are also intense observers. They carefully watch the world around them—including customers, products, services, technologies, and companies—and the observations help them gain insights into and ideas for new ways of doing things. Jobs's observation trip to Xerox PARC provided the germ of insight that was the catalyst for both the Macintosh's innovative operating system and mouse, and Apple's current OSX operating system.

Networking. Innovators spend a lot of time and energy finding and testing ideas through a diverse network of individuals who vary wildly in their backgrounds and perspectives. Rather than simply doing social networking or networking for resources, they actively search for new ideas by talking to people who may offer a radically different view of things.
For example, Jobs talked with an Apple Fellow named Alan Kay, who told him to "go visit these crazy guys up in San Rafael, California." The crazy guys were Ed Catmull and Alvy Ray, who headed up a small computer graphics operation called Industrial Light & Magic (the group created special effects for George Lucas's movies). Fascinated by their operation,Jobs bought Industrial Light & Magic for $10 million, renamed it Pixar, and eventually took it public for $1 billion. Had he never chatted with Kay, he would never have wound up purchasing Pixar, and the world might never have thrilled to wonderful animated films like Toy Story,WALL-E, and Up.

Experimenting. Finally, innovators are constantly trying out new experiences and piloting new ideas. Experimenters unceasingly explore the world intellectually and experientially, holding convictions at bay and testing hypotheses along the way.
They visit new places, try new things, seek new information, and experiment to learn new things.
Jobs, for example, has tried new experiences all his life—from meditation and living in an ashram in India to dropping in on a calligraphy class at Reed College.
All these varied experiences would later trigger ideas for innovations at Apple Computer.

Collectively, these discovery skills—the cognitive skill of associating and the behavioral skills of questioning, observing, networking, and experimenting—constitute what we call the innovator's DNA, or the code for generating innovative business ideas.

AHA/ASA Issue Scientific Statement on Vascular Dementia

2011-08-08T19:23:00.000-07:00

From Medscape Education Clinical Briefs

News Author: Megan Brooks
CME Author: Désirée Lie, MD, MSEd

07/28/2011Stroke. Published online July 21, 2011.

Study Highlights

The overall prevalence of dementia in developed countries is 5% to 10% in persons 65 years and older. The prevalence of Alzheimer's disease doubles every 4.3 years, with vascular dementia doubling every 5.3 years.
VCI embraces the spectrum of severity from prodrome to full-blown manifestations of cognitive impairment including stroke, and from pure Alzheimer's disease to vascular dementia.
Criteria for a diagnosis of VCI should be based on the presence of 2 factors: demonstrated cognitive disorder (such as dementia) by neuropsychological testing, and a history of stroke or evidence of vascular disease by neuroimaging testing.
It is often difficult to determine if the cognitive impairment is the result of vascular factors or deterioration in Alzheimer's disease.
Magnetic resonance imaging and other neuroimaging techniques are useful for detection of VCI and provide evidence that subcortical forms with white matter hyperintensities and small deep infarcts are common.
Risk factors for vascular dementia and VCI can be nonmodifiable and modifiable.
Nonmodifiable factors include increasing age. There is a suggestion that ethnicity may be a risk factor, with a higher incidence in blacks and Hispanics vs whites.
Genetic factors are involved in Alzheimer's disease, but their role in VCI is unclear at present.
Modifiable risk factors include education, diet, physical activity, body mass index, and social support.
Although lower education has been cited as a risk for VCI, there may be confounders explaining the link.
Antioxidants have been suggested as being protective for VCI, but prospective randomized trials do not support a benefit.
High intake of fish has been found to be inversely related to the risk for VCI.
The role of vitamin D, folic acid, and the B vitamins remains unclear. However, antioxidants and B vitamins are not considered useful in the prevention of VCI, even when homocysteine levels are improved.
Long-term physical activity has been shown to be protective for VCI and for preservation of brain health.
Obesity and smoking have both been implicated in the risk for VCI.
The current recommendations to reduce the risk for VCI are smoking cessation, moderate alcohol intake, weight control, and moderate physical activity.
The Mediterranean diet has been found to be helpful in the prevention of cognitive decline.
In persons at risk for VCI, other recommendations to reduce risk include treatment of atrial fibrillation, hypertension, hyperglycemia, and hypercholesterolemia, but it is unclear if treatment of inflammation would affect risk.
The longer the treatment of hypertension, the greater the benefit in the prevention of VCI. Compared with the oldest old, the youngest old experience the greatest benefits.
In general, prevention of chronic vascular disease may help to reduce the burden of VCI, dementia, and recurrent stroke.
For treatment, donepezil can be useful for cognitive enhancement in patients with vascular dementia.
Galantamine may be beneficial for mixed Alzheimer's disease and vascular dementia.
Rivastigmine and memantine are not considered useful in vascular dementia at present.
Antiaggregant therapy has not been found to be effective.
Cognitive rehabilitation and cognitive stimulation have not been proven to be useful so far; more studies are needed.
Acupuncture was found to be useful in 1 rodent study, but a Cochrane review found inconclusive results in human studies.
Recent recommendations for stroke prevention from the AHA are a useful guide for VCI prevention in risk management.
The authors concluded that early detection of VCI with use of neuropsychological batteries, neuroimaging, and preventive strategies — especially prevention of cardiovascular disease — were important approaches to improve outcomes.

Clinical Implications

Risk factors for VCI are similar to those for cardiovascular disease, and risk reduction involves similar approaches.
Donepezil and galantamine may be beneficial for VCI, but rivastigmine and memantine, cognitive stimulation, and cognitive rehabilitation have not been found to be helpful.

The Three Foundations of a Great Life, Great Leadership, and a Great Organization

2011-08-07T18:29:00.000-07:00

Published:	July 28, 2011

Author:	Michael C. Jensen

Michael C. Jensen is the Jesse Isidor Straus Professor of Business Administration, Emeritus, at Harvard Business School.

Executive Summary:

This is the commencement speech that HBS professor Michael Jensen delivered to the 2011 graduates of the McDonough School of Business at Georgetown University. Drawing from his own experiences, he discusses the three foundations of a great personal life, great leadership, and a great organization.
Those three foundations are integrity, authenticity, and being committed to something bigger than oneself.
Key concepts include:

As integrity declines, workability declines. As workability declines, value (or more generally, the opportunity for performance) declines.
The actionable pathway to authenticity is to be authentic about your inauthenticities.
Being committed to something bigger than oneself is the source of both personal and corporate passion and energy.

Abstract

I argue here that the three factors my co-authors and I identify as constituting the foundation for being a leader and the effective exercise of leadership can also be seen as the foundations not only for great leadership, but also for a high quality personal life and an extraordinary organization.
One can see this as a "value free" approach to values because,
1) integrity as we define it (being whole and complete) is a purely positive proposition,
2) authenticity is also a purely positive proposition (being and acting consistent with who you hold yourself out to be for others and who you hold yourself to be for yourself), and
3) being committed to something bigger than oneself is also a purely positive proposition (that says nothing about what that commitment should be other than it be bigger than oneself).

full video is available at http://www.georgetown.edu/video/1242670572193.html

Air Cleaners Do Not Thwart Most Effects of Secondhand Smoke

2011-08-05T21:49:00.000-07:00

From Medscape Medical News

Emma Hitt, PhD

August 4, 2011 — Air cleaners significantly reduce particulate matter (PM) levels but are not enough to reduce exposure to secondhand smoke in inner-city children with asthma residing with a smoker, a new study has found.
Arlene M. Butz, ScD, MSN, CPNP, with the Division of General Pediatrics at The Johns Hopkins University School of Medicine, in Baltimore, Maryland, and colleagues reported the findings in the August issue of the Archives of Pediatrics & Adolescent Medicine.
"Despite parental awareness that second-hand smoke exacerbates asthma, 40% to 67% of inner-city children with asthma reside in a household with at least 1 smoker," the study authors note.
According to the researchers, PM concentrations of secondhand smoke exposures have previously been found to be reduced with the use of air cleaners.
The current study sought to test the ability of an air cleaner only (n = 41), an air cleaner plus a health coach (n = 41), or delayed air cleaners (control; n = 44) in reducing PM, air nicotine, and urine cotinine concentrations. The number of symptom-free days was also evaluated.
Eligible children were aged 6 to 12 years, with clinician-diagnosed asthma, symptom frequency, and/or controller medication use signifying persistent asthma. A smoker, who smoked more than 5 cigarettes per day and resided in the home at least 4 days per week, was also present.
Reductions in mean fine and coarse PM (PM_2.5 and PM_2.5-10) concentrations from baseline to 6 months were significantly higher in both air cleaner groups vs the control group (PM_2.5concentrations, P = .003; and PM_2.5-10 concentrations, P = .02 for differences between both air cleaner groups and control).

However, the presence of secondhand smoke, as measured by air nicotine and urine cotinine concentrations, was comparable among the groups.
Use of a health coach did not further reduce PM concentrations.
Air cleaner groups, when combined, had a significant increase in symptom-free days during the past 2 weeks (1.36 vs 0.24 symptom-free days for control group children from baseline to follow-up), representing an increase of 14% to 18% symptom-free days, and yielding an additional 33 symptom-free days per year.
"Use of air cleaners in homes of children with asthma was associated with a significant reduction in indoor PM concentrations and increase in symptom-free days," the study authors note. "However, the reduced indoor PM levels were not sufficiently decreased to meet EPA [Environmental Protection Agency] standards for outdoor air quality," they add.

Arch Pediatr Adolesc Med. 2011;165:741-748.

Burned Out? How Doctors Recover Their Spark

2011-08-03T21:46:00.000-07:00

From Medscape Business of Medicine

Shelly M. Reese

Introduction

When Steve Hyman, MD, from Nashville, Tennessee, looks back, he doesn't like the person he used to be.
"I was a lot meaner then," says Hyman, an anesthesiologist. "I was a lot less tolerant. I had a chronic depression and I didn't know what the problem was." Attributing his malaise to his workplace, he switched practices. It didn't help.

It wasn't until Dr. Hyman cut back his work schedule to 3 days a week and started using his new found spare time to indulge a forgotten passion for piano that he was able to pinpoint the root of his problem: burnout.
Today Dr. Hyman happily splits his time between medicine and music. Three days a week he is in the operating room. The rest of the time he is a concert pianist performing recitals and playing with regional orchestras.

Dr. Hyman wasn't able to avoid burnout, but he was fortunate to find a way out of the abyss. It's something that other doctors can do as well.

Burnout: "A Loss of Ideals and Hope"
Stress and burnout are often lumped together, but they are distinct processes.
Unlike stress, which is associated with overengagement, burnout is characterized by disengagement, blunted emotions, depression, exhaustion that affects motivation and drive, and demoralization.
Stress produces a sense of urgency and hyperactivity.
Burnout produces a sense of helplessness and hopelessness.

Archibald Hart, PhD, psychologist, author, and Dean Emeritus of the Fuller Theological Seminary School of Psychology in Pasadena, California, noted that "Burnout can best be understood as a loss of ideals and hope."
Stress is omnipresent. Underwater mortgages, the economy, job losses, and the mundane stressors of daily living affect many people. Every industry has its own cache of challenges. Doctors may have to contend with healthcare reform, EMRs, reduced rates, medical school loans, and pressure to see more patients.

What puts physicians at greater risk for burnout isn't necessarily the work-a-day stresses they face but the nature of their role as caregivers, says Neelum Aggarwal, MD, a Chicago neurologist who frequently lectures on stress and burnout. "We have to interact with many people many times a day," she says, "and the element of having to provide care for someone -- the personal responsibility for someone else's health -- that's an unconscious element that feeds into everything."
It's a role that many physicians -- unlike professionals in most other fields -- internalize, notes John-Henry Pfifferling, PhD, director of the Center for Professional Well-Being in Durham, North Carolina. "The greatest risk for burnout comes when the doctor identifies being a doctor as who they are."

"Delayed Gratification" Puts Doctors at Risk

Part of the problem, Dr. Aggarwal says, is that doctors are in constant motion. They're also very purposeful and, thanks to their protracted medical training, masters when it comes to delayed gratification.
Those qualities, especially if they're mixed with characteristics such as perfectionism, conscientiousness, a need to be in control, and difficulty relaxing, can put physicians at risk, she says.
"When you are always doing, you can't step back and see the big picture," she says. "Often people know something is wrong. They sense it. But the way they try to work through it is, 'Maybe I'm not productive enough or efficient enough' and they go back and try to do more. Figuring out what's wrong really requires stepping back."
The workplace often exacerbates the problem. It's not just long work hours, demanding post call schedules, and administrative demands, notes Pfifferling.
Physicians aren't taught how to work in teams and support each other, and there's a stigma associated with reaching out for help.
What's more, although they're very good about preaching self-care to their patients, they often don't internalize those messages.
"When I talk about burnout I used to start with the medical aspects -- diet and exercise -- for preventing it," says Dr. Aggarwal. "But I realized that just put them back into 'doing' mode.
Now I start with, 'You have to learn to sit and be at peace with yourself.' That hits home with people because most doctors can't just sit quietly."
Dr. Aggarwal herself spends an hour in quiet each morning. Quiet sitting might involve meditation, inspirational reading, listening to relaxing music, or just doing nothing, she says, and it's a skill that doctors need to master before they can move on to more active tactics for combating burnout, such as breathing exercises, walking, improving their diet and -- most important -- adding joyful pursuits back into their lives.

The Importance of Meaningful Pursuits

In February 2008 LocumTenens.com asked 1200 physicians how they avoid burnout.
The answer: They aren't couch potatoes. Respondents listed participating in sports, travel, and outdoor activities as their top 3 burnout busters .
Many mentioned volunteer and humanitarian commitments as well.
A recent posting on the Medscape discussion board posed the same question. "Exercise every day," advised one physician. "I'm not a gym rat or fitness freak. I'm just talking about a 20-minute walk. Leave the cell phone at home." Another advised, "Buy a small vacation house in Sarasota and go there for 5 days every 4-6 weeks. I did, starting 4 years ago before I sold my practice, and I came back refreshed and recharged."

Diet, exercise, and rest are important components to health, but wellness is a holistic pursuit with physical, emotional, psychological, and spiritual components.

Physicians need to remember -- or discover -- what brings them joy and fulfillment. It might be making dinner with family or friends, listening to music, bowling, traveling, volunteering, or participating in spiritual or religious activities. Whatever pastime they find fulfilling, Dr. Aggarwal says, doctors need to purposefully reintroduce it into their lives.

As easy as it sounds, it can be very difficult to break out of the cycle of perpetual motion, Dr. Hyman says.
"When you have a really strong work ethic and take time off for yourself, you feel guilty about the free time. It takes you a while to get over that," he says. It was only when he brought music back into his life that he was able to accept and embrace the difference between "what I want to be doing and what I do for a living."
Although it definitely falls in the "doing" category, finding a long-term way to deal with burnout means addressing workplace issues as well, says Gabriela Cora, MD, a psychiatrist and author of Leading Under Pressure: Strategies to Avoid Burnout, Increase Energy, and Improve Your Well-Being. That means finding a way to take control over your environment and workload and learning to say "no."

"Don't just look at yourself," she advises, "Look at your practice. Is your nurse practitioner or your office manager stressed out? Look at your turnover. What's the mood? Burnout often happens when there is a lack of processes but also a lack of lifestyle balance. You need a combination of organizational skills and lifestyle strategy to tackle it."

The Cost of Stoicism

Finally, Dr. Hyman says, doctors need to understand that in ignoring the symptoms of burnout, they aren't being stoic; rather, they are doing a disservice to themselves, to the people around them, and to their patients.
"In the field of medicine, particularly for people who trained 20 or 30 years ago, the mindset was that you really needed to forego everything to practice medicine. But when you feel so bad about yourself and your workplace, to go there and be cheerful and give 100% is very difficult," he says.
Fortunately, he says, that's not a problem for him anymore.
"Now when I go to work I'm ready to be there. I like my work and I do a really good job. I don't think the fact that I have other interests and that I don't love my work makes me a bad physician. It doesn't make me less empathetic to my patients. You have to take care of yourself."

Looking in the Mirror: Questions Every Leader Must Ask

2011-07-20T23:28:00.000-07:00

Published:	July 18, 2011
Author:	Carmen Nobel

Executive Summary:

"Show me a company or nonprofit or government in trouble, and I will almost invariably show you a set of leaders who are asking absolutely the wrong questions," says professor Robert Steven Kaplan. He discusses his new book, What to Ask the Person in the Mirror. Plus: book excerpt. Key concepts include:

Leaders need to address critical issues including: vision and priorities, time management, giving and getting feedback, succession planning and delegation, evaluation and alignment, being a role model, and reaching true potential.
Leaders must have a clear vision and a set of priorities for the organization, and must ensure that their key subordinates know what those priorities are.
Because CEOs don't have the benefit of feedback from their superiors, it's crucial that they solicit feedback about their leadership style from subordinates.

Robert Kaplan is a Professor of Management Practice at Harvard Business School.

When CEOs speak with Rob Kaplan looking for answers, he usually focuses them instead on figuring out and discussing the right questions.
"Show me a company, nonprofit, or a government leader that is struggling, and almost invariably you'll see someone who isn't sufficiently focused on asking the right questions," says Kaplan, a Professor of Management Practice at Harvard Business School. "Most leaders spend a lot of their time looking for answers. Very often, they may feel isolated and alone. I want to help them refocus their attention on framing and then discussing the key questions that will help them regroup, mobilize their team, formulate a plan of action, and move forward."
In his new book, What to Ask the Person in the Mirror , Kaplan argues against the notion that great leadership is about having all the answers. He believes that leadership skills can be learned--and that many of these skills require executives to rethink their conception of what a superb leader actually does. Developing and practicing these skills requires hard work and may demand that talented executives overcome some degree of discomfort and even anxiety in order to raise their game.
The book discusses several key areas of inquiry that can help leaders improve the success of their companies and nonprofit organizations including: vision and priorities, managing your time, giving and getting feedback, succession planning and delegation, evaluation and alignment, being a role model, and reaching your potential. "My objective is to help leaders reach their potential by helping them realize that they don't need to have all the answers or do this alone. I hope they will see that framing a question and listening can be enormously powerful in leading to excellent decisions. A leader needs to master the use of inquiry and reflection as well as advocacy in order to build his or her organization and career."

Have you developed a clear vision and key priorities for your enterprise?

"When I see a problem with a business or nonprofit, it often starts with a lack of clarity about the organization's aspirations," Kaplan says. The leader may have a clear vision in his or her head but has not communicated it effectively throughout the organization. "When there is not a clearly articulated vision along with a manageable set of key priorities, you may see an organization where employees are expending their energies in a number of divergent and uncoordinated directions."
Leaders need to ask whether they articulate a clear vision and, just as importantly, whether their key employees can rearticulate this vision in a consistent manner. For instance, DuPont's vision is "to be the world's most dynamic science company, creating sustainable solutions essential to a better, safer and healthier life for people everywhere." This vision helps DuPont employees better understand what (and why) they are spending their professional energies trying to accomplish.
Once the vision is established, Kaplan advises leaders to come up with and communicate a list of no more than three to five priorities that are critical to the organization in order to achieve the vision. In his book, Kaplan describes various approaches to formulating and adapting these priorities to each department and geographic region in order to better achieve overall organization objectives. "When a leadership has this discipline, they focus much more intently on what tasks they need to do superbly well in order to achieve their goals. This also can help them to question certain activities where they are spending substantial time and money yet not contributing to organizational goals and maybe they shouldn't be pursuing."

Does the way you spend your time match your key priorities?

Many CEOs tell Kaplan that they don't have time to figure out their vision and priorities--they're working 80-hour weeks! In his book, Kaplan discusses techniques for matching available hours with key priorities, so executives can learn to do much more effective work and better manage their time.
He recommends that executives track their time for a couple of weeks and then analyze how it is being spent. If substantial time allocations do not match top priorities, he discusses how these tasks should be either delegated or eliminated.
"When someone asks you to spend time on work that doesn't match your key priorities, the right action is probably to say no," Kaplan says. "Once you have a better matching of your time with priorities, you'll want to encourage your direct reports to do the same."

Do you coach and also solicit feedback from your key subordinates?

Most good leaders understand they need to coach key employees, but fewer realize the importance of asking subordinates for coaching. The more senior you are in a company, the fewer senior executives and peers are able to effectively observe and coach you. Kaplan gives advice on several techniques that leaders can use to solicit coaching from their direct reports.
"Ironically, the executives most in need of feedback in many organizations are very senior," he says. "They may have become isolated or not realize that their direct reports have constructive advice regarding specific changes they need to make to improve their leadership effectiveness."
The book describes various approaches for giving and receiving feedback. In particular, it offers various techniques that should be implemented in advance of the year-end review, which typically arrives too late for professionals to make changes that would improve their compensation and/or promotion prospects in that year.
When senior leaders ultimately do cultivate junior coaches, they find that the criticism can feel "devastating at first because you realize it is accurate and that it is probably a widespread view within the organization. You have to thank the junior coach, and then go out and work on what they've told you." Not sure the assessment is accurate? Call a few close friends or loved ones and see what they think. Most likely, Kaplan says, they'll agree with your subordinates.
"Leadership is a team game," he says. "You have to solicit help from others or you're likely to under-achieve your potential."

Do you have a succession-planning process in place?

Kaplan stresses the importance of developing potential successors for key positions in your company-including your own-and creating a confidential list. "Many great companies do this but a surprising number don't," he says.
Senior leaders should leverage this depth chart information about up-and-comers by delegating to them more extensively. This also allows senior leaders more time to achieve a better match between their own time and key priorities. Leaders who fail to train successors risk not only doing too much themselves but also losing these valuable employees, who can become frustrated that they aren't being challenged to build their skills and careers at the company.

If you had to design your company today with a clean sheet of paper, what would you change?

The world doesn't stand still and it's natural for companies to fall out of alignment with achievement of key objectives. Too often, leaders don't realize how off-track they are until serious damage has been done to the business or the firm's reputation. Kaplan likens the situation to realizing your health is at risk only after you're stricken with a heart attack.
He describes various approaches for reviewing your organization with a clean sheet of paper. For example, one approach involves creating a task force of younger emerging company leaders. "Emerging leaders, organized and mandated properly, can give you fabulous strategic recommendations," he says. "Looking to up-and-comers is not only quite effective in getting great strategic advice but also in motivating these future leaders."

Do you act as a role model?

Leaders don't always realize that their actions set an example for the people who work for them, especially if they have risen through the ranks of a company so quickly that they fail to realize their influence as role models. Kaplan learned this from personal experience during his tenure at the Goldman Sachs Group, where he worked in several capacities, eventually serving as vice chairman before leaving the firm in 2005.
"I went from being a junior person to running a large business in what seemed like a nanosecond," he says. "And suddenly more people were watching what I did, and I had to adjust my actions because I wasn't quite ready for that." In his book, he discusses various approaches that leaders should take in order to connect their behaviors with the messages they want to be sending.

Are you reaching your potential and being true to yourself?

While much of this book is about tangible "blocking and tackling" to become a more effective executive, Kaplan dedicates the last two chapters to methods of gaining perspective and managing oneself more effectively.
"In the end, it's not about meeting everyone else's expectations," he says. "It's about reaching your unique potential and developing your own leadership style.

Rupert Murdoch and the Seeds of Moral Hazard

2011-07-20T23:25:00.000-07:00

Published:	July 19, 2011
Author:	Michel Anteby

Executive Summary:

Many companies today operate like Russian nesting dolls, relying heavily on other companies or external individuals to conduct many of their activities. The result can lead to moral hazard, such as we are seeing in the News of the World fiasco, says professor Michel Anteby.

Michel Anteby is an associate professor in the Organizational Behavior unit at Harvard Business School.

The News Corporation/News of the World scandal has been described as a case study in bad management. What was there about the company's organizational culture that led to "Murdoch's Mess"? Professor Michel Anteby, who studies how meaning is built at work and how moral orders are sustained, provides an answer. He is the author of, among other publications, Moral Gray Zones, published by the Princeton University Press in 2008.

Many companies today operate like Russian nesting dolls, where one large figure is actually made up of many smaller ones. These organizations present a unified face to the outside world, but rely heavily on other, usually smaller, companies or external individuals to conduct many of their activities.

What part of your iPad is made by Apple? Is the Verizon customer representative you're talking with really part of that company? How many parts of the Airbus or Boeing plane you're flying on are actually built by these firms? Many would argue that answers to these questions are irrelevant. As long as services are performed and products manufactured, they say, such organizational configurations are beneficial. They allow companies to remain lean and react to shifting demands. Yet the associated moral hazard often goes unnoticed. Such a risk can prove even greater when the various elements of the "delegation chain" obey different standards.

What does this have to do with the ongoing Rupert Murdoch case? Journalists at News of the World apparently hired people outside the company to illegally hack into the phones of select individuals. That these hackers seem not to be News of the World employees illustrates the Russian nesting doll model, which contains the seeds of moral hazard, since it allows for the plausibility of denial. While we readily recognize such a hazard in the food and apparel industries and the need to "secure" all elements of their production chain, most other industries have yet to recognize such a hazard.

In the media business, news items require fair and secure sourcing, despite the fact that a freelancer—or small doll—may be crafting the story. But at the News of the World, the people who were asked to hack the phones were apparently hired by journalists, but were not journalists themselves. This gave them the freedom to obey norms different from those of their employers. Needless to say, journalists are not supposed to act illegally. The 1993 Council of Europe's Resolution 1003 on the ethics of journalism clearly states that "In the journalist's profession the end does not justify the means; therefore information must be obtained by legal and ethical means." The hired hands at News of the World, however, did not have to respect this code of ethics.
When media groups employ external private investigators, health-maintenance organizations hire outside medical doctors, and governments occasionally rely on private mercenaries, people can plausibly deny knowledge of illegal activities. In addition, each professional group's distinct standards can create a false impression that all is well. Yet the Murdoch case teaches us that nesting dolls require our full attention. Although these configurations may seem nimble, they can also be highly problematic. Because professional groups are working separately for a common cause does not mean that the production line is secure. In fact, the nesting dolls model may be the best way to go wrong while seemingly doing the right thing.

Lessons from Champions of Freedom

2011-07-19T23:20:00.000-07:00

Allow me to share the thoughts of leaders,who in their life-time, were uncommon champions of human liberty and changedthe destiny of their nations forever.

Asour country (Malaysia) goes through the cantankerous tantrums of its teenage years, let usponder on the words of Abraham Lincoln (1809 -1865), the 16^th USpresident.

His heroic efforts during theCivil War helped preserve the Union, preventing the southern states fromsecession. He conceived the Proclamationof Emancipation which ended slavery, years after his assassination.

The shepherddrives the wolf from the sheep for which the sheep thanks the shepherd as hisliberator, while the wolf denounces him for the same act as the destroyer of liberty.

Plainly, the sheep and the wolf are not agreed upon a definition of liberty.

How many legs does a dog have, if you call the tail a leg? Four.

Calling a tail a leg does not make it aleg.

This country with its institutions belongs to the people who inhabit it. Wheneverthey shall grow weary of the existing government, they can exercise theirconstitutional right of amending it, or exercise their revolutionary right to overthrow it.

We the people are the rightful masters of both congress and the courts, not toover throw the constitution but to overthrow the men who pervert theconstitution.

To sin by silence when they should protest, makes cowards of men.

He has a rightto criticise, who has a heart to help.

“With malice tonone, with charity for all, with firmness in the right, as God gives us to seethe right,
let us strive on to finish the work we are in, to bind up our nations'wounds...”

Winston Churchill (1874-1965) had this to say about criticisms,fanatics and lies.

Criticism maynot be agreeable, but it is necessary.
It fulfils the same function as pain inthe human body.
It calls attention to an unhealthy state of things.

A fanatic is onewho can’t change his mind and won’t change the subject

A lie getshalfway round the world before the truth has a chance to get its pants on

A man does whathe must, in spite of personal consequences, in spite of obstacles and dangersand pressures – and that is the basis of all human morality

John F Kennedy (1917 -1963)

I have justreceived the following wire from my generous daddy: “Dear Jack, don’t buy asingle vote more than is necessary. I’ll be damned if I’m going to pay for alandslide.”

Let us not seekthe Republican answer or the Democratic answer, but the right answer. Let usnot seek to fix the blame for the past. Let us accept our own responsibilityfor the future.

We want to builda world of peace, where the weak are secure and the strong are just.

Those who makepeaceful revolution impossible will make violent revolution inevitable

NelsonMandela (1918 - )

I detestracialism, because I regard it as a barbaric thing, whether it comes from ablack man or a white man.

It always seemsimpossible until it is done

source : www.brainyquote.com

Should Christians be involved in street rallies

2011-07-19T23:13:00.000-07:00

UNDERSTANDING WHY WE MARCHED

One question is agitating the minds of theconservative arm of the church at this hour.

Should Christians or their leaders participate incivil disobedience, street marches and rallies to protest against governmental arrogance,tyranny, oppression and corruption?

What is the accurate Biblical standpoint on thisissue?

Is there a place for proclamationand outcry in the streets or does the Bible forbid it?

Let the Bible speak foritself:

1. The first time the word ‘street’ occurs in theBible is in Genesis 19:1&2 (KJV) when the angels of God refused to enterthe house of misguided but righteous Lot and preferred to abide in the streetall night before destroying Sodom. That in itself was an indictment and aprotest.

2. From the lamentation of David after King Sauldied, it appears that when certain types of news are proclaimed on the streetsof a city or nation, a sense of joy and triumph envelops the people therein.(See

2 Samuel: 1:17-20)

3. Oftentimes, when a people and their leaderspersistently disobey God, He sends His prophets to the streets. (Jeremiah11:1-6)

4. Outcry in the streets will only stop when anation is rescued from the hands of strange men in government whose mouthsspeak lying words and whose right hands are right hands of falsehood. (Psalm

144:11-15)

Are we there yet? NO. But someone may quote theprophecy of Isaiah out of context to confuse and

mislead religious minds from taking to the streets. Isaiah42:1-4

If this scripture relates to Jesus Christ, how comeany of His servants will take to the street and not be in rebellion?

Saints and strangers, scripture is not capable ofprivate interpretation – it takes scripture to interpret scripture.

Let the Bible speak again:

i. In His earthly ministry, Jesus spoke in thestreets. (Luke 13:22-27)

ii. Not only did Jesus teach in the streets, hecommanded His disciples to take to the street and make proclamations against everycity that rejected the message of the gospel. (Luke 10:1-12)

iii. What then is the concealed message in Isaiah42? What is it that Jesus would not say in the street? Let scripture interpretscripture again: Matthew 12:9-21, verses 16&17 are key – “yet He warned themnot to make Him known that it might be fulfilled which was spoken by theprophet Isaiah.”

iv. It is in the same vein that charitable deeds andprayers are forbidden in the streets, not strong protests against injustice,crass hypocrisy and corruption. (Matthew 6:1-6)

v. Whenever truth is fallen in the street and equitycannot enter, the voice of wisdom will cry aloud in the streets.

(a) Isaiah 59:1-15

(b) Proverbs 1:10-33.

vi. Even in troubled times, prophetic fulfillmentdoes not happen except the street and the wall of a city are rebuilt. (Daniel9:20-25)

Brothers and sisters, we have locked ourselves inthe sanctuary for too long a time, fasting, praying and preaching for goodgovernance in our nation.

That in itself is not evil, but we need to do morethan that as the salt of the earth and the light of the world.

We need to spearhead effective social mobilization,rebuild the spiritual streets and the walls of our nation and influence what ishappening there.

IT IS TIME FOR THE TRUE CHURCH TO COME OUT OF THECLOSET AND REBUILD ANCIENT RUINS.

PASTOR ‘TUNDE BAKARE FOR SAVE NIGERIA GROUP

Part of TEXT OF LIVE RADIO BROADCAST FROM THEAUDITORIUM

OF THE LATTER RAIN ASSEMBLY,LAGOS, NIGERIA ON SUNDAY, JANUARY 17, 2010

Fame, Faith, and Social Activism: Business Lessons from Bono

2011-07-14T21:52:00.000-07:00

Published: June 20, 2011
Author: Kim Girard
http://hbswk.hbs.edu/item/6700.html

Bono on business

The business takeaways from U2's story, according to Koehn, are universal and ring true whether she's teaching the case to advertising execs or second-year students in the MBA program.

They include:

Take smart (and onging) stock of how you are using your people, your authority, and your resources. Bono became interested in Africa in the mid 1980s when he and his wife, Ali Hewson, worked at an Ethiopian feeding station.
He used his growing celebrity status to forge a crucial longtime relationships with Eunice Kennedy Shriver (U2 recorded a song for her Special Olympics cause), and then Bobby Shriver, who connected him to the Kennedys and other influential politicians. Bono and Bobby Shriver helped form the political advocacy organizations DATA (Debt, AIDS, Trade, Africa) and ONE, and the fundraising group (RED) to fight disease, poverty, and hunger in Africa.

He also used his fame and understanding of Christianity to convince North Carolina Senator Jesse Helms to change his position on government funding for AIDS. As Koehn points out, Bono chose to use his authority as a rock star for social ends, recognizing that his own status has been critical to his ability to make a difference: "Bono doesn't get to meet with Bill Clinton and shake hands with the Pope John Paul II if he's not a rock-and-roll roll star."

A leader's mission is not static; it evolves.
Bono continuously sets new goals around several related global challenges. For example, he started advocating for famine relief in Africa in the mid-1980s, and then in the early 1990s began raising awareness of the conflict in Sarajevo, playing live footage of the war during U2's Zooropa tour. After working to get eight industrialized nations in 1999 to agree to $100 million in African debt relief, he continued with a campaign to cancel debt owed by Third World nations to the World Bank and the International Monetary Fund. Then he began lobbying the administration of George W. Bush for additional funding to fight AIDS (in 2003, the US government pledged $15 billion toward the disease). Like Bono, Koehn says, leaders "must take a hard look at (their missions) on an ongoing basis."

The mission of the CEO should align with the organization's performance.
The band's mission is to make fulfilling music that comes from the four members' heads, hearts, and souls, and that connects to many audiences.
Koehn says the band would not have been as successful if its members had not remained true to themselves and this larger purpose.
For example, at various moments, Bono's commitment to the band was questioned by his colleagues because of all of the time he devoted to political causes.
In Koehn's case study, manager Paul McGuinness says Bono "takes far too much on but it is hard to criticize him because his political achievements are very real." Ultimately, the other members believed in what he was doing. "There was a sense that (the political activism) could demystify and devalue U2," Bono has commented. "It wasn't very glamorous work...It should have damaged us…but it didn't."

Who you are and what you stand for as an organization have great relevance to the people who buy your product. Many of U2's supporters embrace the band because the causes the four members work to address—from social injustice to hunger—are issues the fans themselves are concerned about.
By participating in Live Aid, Band Aid, and the Amnesty International Conspiracy of Hope tour, U2 also refuses to sell out creatively, which keeps fans loyal.
"People don't just buy (the single) "Walk On" or (album) No Line on the Horizon," Koehn says, "they are buying the backstory to that music, just like grocery shoppers buying organic milk or fair trade coffee."

This lesson applies across all businesses. "We think this is only true for artists and entertainers, but it's true for making tennis shoes and semiconductors, and for how you create limited partners at an investment bank," she says. "The backstory of organizations is now part of the value proposition for consumers. The lads from Dublin understood that early on and they still understand it."

Koehn says the U2 case remains a work in progress and she believes she will someday interview Bono for her work—just as Oprah showed up at her classroom to answer student questions during a case discussion about the talk show icon.. "Stay tuned," Koehn says. "I am meant to meet this restless, devoted, and inspiring leader."

Are You a Level-Six Leader?

2011-07-14T21:40:00.000-07:00

Published: July 6, 2011
Author: Mitch Maidique

Executive Summary:

Asking the question, whom do you serve? is a powerful vector on which to build a useful typology of leadership.
Visiting professor Modesto Maidique offers a six-level Purpose-Driven Model of Leadership ranging from Sociopath to Transcendent.
Key concepts include:

The most telling question to ask a leader is, whom do you serve? Yourself? Your group? Society?
The answer to this question often reveals more about leaders than knowing their personality traits, level of achievement, or whether they were "transformational" or "transactional" leaders.
The six levels of leadership are Sociopath, Opportunist, Chameleon, Achiever, Builder, and Transcendent.

The central, most telling question to ask a leader is, whom do you serve?

Some leaders will tell you, using a popular descriptor, that they aspire to be "servant leaders." The question still remains, however, a servant to whom: to yourself, to your group, or to society (to cite three of several options)?

"Opportunists are the people who always ask, 'What's in it for me?'"

Asking the question whom do you serve? is a powerful vector on which to build a useful typology of leadership. Based on this idea, I have constructed a six-level Purpose-Driven Model of Leadership informed by the work of Jean Piaget, Lawrence Kohlberg, and his colleague, Robert Kegan (see table 1).
The answer to the question whom do you serve often reveals more about leaders than knowing their personality traits, level of achievement, or whether they were "transformational" or "transactional" leaders.

Level One: Sociopath

At the base of the model is the person who literally serves no one: the Sociopath. The Sociopath, afflicted with what the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) describes as antisocial personality disorder, exhibits abnormally low empathy and destroys value, himself, and, ultimately, those who surround him as well. (I use the male pronoun because the vast majority of Sociopaths and psychopaths are male.) Fortunately, Sociopaths comprise less than 1 percent of the population. An excellent current example is Muammar Gaddafi, who is destroying his country, his tribe, his family, and, in time, himself. Indeed, he serves no one. The same was true of Adolf Hitler and Saddam Hussein.

Level Two: Opportunist

The second level is the leader who serves only himself or herself, often at the expense of others: the Opportunist. These are the people who always ask, "What's in it for me?"
Their moral compass is guided primarily by the accumulation of wealth and power, all else be damned.
Bernie Madoff, now in prison, is a poster boy for the Opportunists. While Madoff enjoyed the luxuries of a life of wealth and power, hundreds if not thousands of retirees saw their nest eggs evaporate because of their unwitting participation in a deliberately contrived Ponzi scheme that, in time, became the largest ($50 billion) in Wall Street history. By this measure, or in terms of the families brought to financial ruin, Madoff remains one of the modern world's greatest Opportunists. Also of this genre, although somewhat lesser known, is Jeffrey Skilling, the Enron CEO who sold off tens of millions of dollars of stock just before Enron filed for bankruptcy, claiming he had no knowledge of the scandal that would engulf his company. He was sentenced to 24 years and four months in prison.

Level Three: Chameleon

At the next level sits Chameleons. These are the "leaders" who bend with the wind and strive to please as many people as possible at all times.
In some cases this could be the group they work with; in other cases, the regional or national electorate. It is difficult to find renowned corporate leaders who fit this category because in business, typically, the Chameleons are weeded out before they reach the top. The world of politics is another matter.
Many politicians fall into this category. Those who follow presidential politics will remember Senator John Kerry (D-MA), who was pilloried as a "flip-flopper" after explaining a vote regarding the Iraq war: "I actually did vote for the [authorization bill] before I voted against it."
In Florida, former governor Charlie Crist changed colors so often that it was difficult to know with precision where he stood on any given issue, from climate change to which party, if any, he really belonged to.

There is a natural cleavage between the model's first three levels described above and the next three levels. There is not much to celebrate about the first three levels, although certainly levels two and three abound in organizations. There's much more to admire in levels four, five, and six.

Level Four: Achiever

"Achievers often substitute the needs of the whole with their personal striving to succeed."

The level-four leader, the Achiever, fills the senior executive ranks. These leaders rarely fail to achieve their goals and often exceed sales quotas, create generous profits, and are frequent stars at merit-award dinners. The Achiever, to use Peter Drucker's felicitous phrase, is often a "monomaniac with a mission" and is focused, energetic, results-oriented, and highly prized by top management. Achievers pursue goals established by their bosses or by themselves, in a single-minded manner. Therein lies the Achilles' heel of Achievers: They drive toward a goal without giving much consideration to the broader mission.
Former Hewlett-Packard CEO Mark Hurd is an excellent example of a level-four leader. Under his watch HP's stock price more than doubled, but he decimated the infrastructure and intellectual seed corn (R&D) of the company to do so. By simply cutting R&D to a level of about 2.5 percent of revenue, down from 6 percent during the 1990s, the Carly Fiorina/Mark Hurd team "saved" HP about $4 billion—about the equivalent of half the profits earned during Hurd's last year. HP's once formidable technological and product strength was slowly sapped away. When I asked Dave Packard in the early 1980s what accounted for HP's extraordinary run he modestly replied, "I guess we found a way to make a better product." Where are those better products today? Referring to one of HP's most visible new product initiatives, the TouchPad, a late entry into the iPad dominated tablet space, a senior HP executive reportedly told the Wall Street Journal, "We know we're the fifth man in a four-man race." In their drive towards a goal, Achievers often substitute the needs of the whole with their personal striving to succeed.

Level Five: Builder

The level-five leader, the Builder, strives not to reach a goal but to build an institution. Builders are legendary leaders such as IBM's Tom Watson Jr., GM's Alfred P. Sloan, and Harpo's Oprah Winfrey.
These people serve their institutions by managing for the long term and not allowing themselves to be seduced by the twin mirages of short-term profit or stock market valuations.
They have a grand vision for the future of their organizations, and they infect others with their energy, enthusiasm, and integrity. These are the leaders we write books about, study, try to understand, and lionize.

Level Six: Transcendent

Builders are few and far between, but there is an even rarer type of leader who transcends the Builder: the Transcendent.
Level-six leaders transcend their political party, their ethnic or racial group, and even their institutions. They focus on how to benefit all of society.
These are "global citizens," in the words of Howard Gardner's recent book, Truth, Beauty, and Goodness Reframed, who watch out not only for numero uno but for the wider public as well.
There is no better example of what it really takes to be a Transcendent than the first black president of South Africa, Nelson Mandela.
He was able to soar above hatred for his white jailers, the political tug of the African National Congress, the pull of his racial and tribal group, and the rejection by the Afrikaners to build a South Africa for all South Africans. Now in his 90s, he is perhaps the world's greatest living leader.

"Nelson Mandela is perhaps the world's greatest living leader."

Like Martin Luther King Jr., Mandela wanted people to be judged by the "content of their character rather than the color of their skin."
The Dalai Lama, another Transcendent, told me that the first thing he does in the morning after he finishes his prayers is to ask himself, "How can I help to make the world better today?"
Imagine if our senior political and business leaders started their day by asking that question and acting on the answer.

Portfolio mix

No one is a pure Transcendent or a pure Opportunist. Rather, we are all a portfolio of the different types with one type being dominant. Even the Dalai Lama has to deal with the pull of his emotions when he makes decisions. And Madoff did his best to shield his wife and sons when he confessed his grand scheme to the FBI.

Figure 1 graphically illustrates what the portfolio of levels might look like for a 35-year-old executive. This picture, however, is not static. Man is capable, though not always assured, of continuing moral development. The sense or the meaning we give to our life at 60 may be considerably different than how we see life at 30.

The levels we propose, though not linear, are in a general way a path to what Erik Erickson calls generativity and integrity. Helping leaders to find their own path and follow it should be the ultimate goal of a leadership development program.

Figure 1: Profile of a Young Professional (35)

Table 1: A Purpose-Driven Model of Leadership

About the author
http://hbswk.hbs.edu/item/6752.html

Modesto A. Maidique is a visiting professor at Harvard Business School. He is Professor of Management and executive director of the Center for Leadership in the College of Business Administration at Florida International University. He developed and serves as director of the university's Leading Decisions Executive Leadership Development Program.

Why Leaders Lose Their Way

2011-07-14T20:20:00.000-07:00

June 6, 2011
Bill George
Professor of Management Practice, Henry B. Arthur Fellow of Ethics, at Harvard Business School.

Executive Summary:

Dominique Strauss-Kahn is just the latest in a string of high-profile leaders making the perp walk. What went wrong, and how can we learn from it?
Professor Bill George discusses how powerful people lose their moral bearings.
To stay grounded executives must prepare themselves to confront enormous complexities and pressures.
Key concepts include:

Leaders who move up have greater freedom to control their destinies, but also experience increased pressure and seduction.
Leaders can avoid these pitfalls by devoting themselves to personal development that cultivates their inner compass, or True North.
This requires reframing their leadership from being heroes to being servants of the people they lead.

In recent months several high-level leaders have mysteriously lost their way. Dominique Strauss-Kahn, former head of the International Monetary Fund and a leading French politician, was arraigned on charges of sexual assault.
Before that David Sokol, rumored to be Warren Buffett's successor, was forced to resign for trading in Lubrizol stock prior to recommending that Berkshire Hathaway purchase the company.
Examples abound of other recent failures:
Hewlett-Packard CEO Mark Hurd resigned for submitting false expense reports concerning his relationship with a contractor.
US Senator John Ensign (R-NV) resigned after covering up an extramarital affair with monetary payoffs.
Lee B. Farkas, former chairman of giant mortgage lender Taylor, Bean & Whitaker, in April was found guilty for his role in one of the largest bank fraud schemes in American history.

These talented leaders were highly successful in their respective fields and at the peak of their careers. This makes their behavior especially perplexing, raising questions about what caused them to lose their way:

Why do leaders known for integrity and leadership engage in unethical activities?
Why do they risk great careers and unblemished reputations for such ephemeral gains?
Do they think they won't get caught or believe their elevated status puts them above the law?
Was this the first time they did something inappropriate, or have they been on the slippery slope for years?

In these ongoing revelations, the media, politicians, and the general public frequently characterize these leaders as bad people, even calling them evil. Simplistic notions of good and bad only cloud our understanding of why good leaders lose their way, and how this could happen to any of us.

Leaders who lose their way are not necessarily bad people; rather, they lose their moral bearings, often yielding to seductions in their paths. Very few people go into leadership roles to cheat or do evil, yet we all have the capacity for actions we deeply regret unless we stay grounded.

Self-reflection: a path to leadership development

Before anyone takes on a leadership role, they should ask themselves, "Why do I want to lead?" and "What's the purpose of my leadership?"
These questions are simple to ask, but finding the real answers may take decades. If the honest answers are power, prestige, and money, leaders are at risk of relying on external gratification for fulfillment. There is nothing wrong with desiring these outward symbols as long as they are combined with a deeper desire to serve something greater than oneself.

Leaders whose goal is the quest for power over others, unlimited wealth, or the fame that comes with success tend to look to others to gain satisfaction, and often appear self-centered and egotistical. They start to believe their own press. As leaders of institutions, they eventually believe the institution cannot succeed without them.

The leadership trap

While most people value fair compensation for their accomplishments, few leaders start out seeking only money, power, and prestige. Along the way, the rewards—bonus checks, newspaper articles, perks, and stock appreciation—fuel increasing desires for more.

This creates a deep desire to keep it going, often driven by desires to overcome narcissistic wounds from childhood. Many times, this desire is so strong that leaders breach the ethical standards that previously governed their conduct, which can be bizarre and even illegal.

Very few people go into leadership to cheat or do evil.

As Novartis chairman Daniel Vasella (HBS PMD 57) told Fortune magazine, "for many of us the idea of being a successful manager—leading the company from peak to peak, delivering the goods quarter by quarter—is an intoxicating one.
It is a pattern of celebration leading to belief, leading to distortion.
When you achieve good results… you are typically celebrated, and you begin to believe that the figure at the center of all that champagne-toasting is yourself."

When leaders focus on external gratification instead of inner satisfaction, they lose their grounding. Often they reject the honest critic who speaks truth to power. Instead, they surround themselves with sycophants who tell them what they want to hear. Over time, they are unable to engage in honest dialogue; others learn not to confront them with reality.

The dark side of leadership

Many leaders get to the top by imposing their will on others, even destroying people standing in their way.
When they reach the top, they may be paranoid that others are trying to knock them off their pedestal.
Sometimes they develop an impostor complex, caused by deep insecurities that they aren't good enough and may be unmasked.

To prove they aren't impostors, they drive so hard for perfection that they are incapable of acknowledging their failures. When confronted by them, they convince themselves and others that these problems are neither their fault nor their responsibility. Or they look for scapegoats to blame for their problems. Using their power, charisma, and communications skills, they force people to accept these distortions, causing entire organizations to lose touch with reality.

At this stage leaders are vulnerable to making big mistakes, such as violating the law or putting their organizations' existence at risk. Their distortions convince them they are doing nothing wrong, or they rationalize that their deviations are acceptable to achieve a greater good.

During the financial crisis, Lehman CEO Richard Fuld refused to recognize that Lehman was undercapitalized. His denial turned balance sheet misjudgments into catastrophe for the entire financial system.
Fuld persistently rejected advice to seek added capital, deluding himself into thinking the federal government would bail him out.
When the crisis hit, he had run out of options other than bankruptcy.

It's lonely at the top, because leaders know they are ultimately responsible for the lives and fortunes of people. If they fail, many get deeply hurt. They often deny the burdens and loneliness, becoming incapable of facing reality. They shut down their inner voice, because it is too painful to confront or even acknowledge; it may, however, appear in their dreams as they try to resolve conflicts rustling around inside their heads.

Meanwhile, their work lives and personal lives get out of balance. They lose touch with those closest to them̬their spouses, children, and best friends—or co-opt them with their points of view. Eventually, they lose their capacity to think logically about important issues.

Values-centered leadership

Leading is high stress work. There is no way to avoid the constant challenges of being responsible for people, organizations, outcomes, and uncertainties in the environment. Leaders who move up have greater freedom to control their destinies, but also experience increased pressure and seduction.

Leaders can avoid these pitfalls by devoting themselves to personal development that cultivates their inner compass, or True North. This requires reframing their leadership from being heroes to being servants of the people they lead.
This process requires thought and introspection because many people get into leadership roles in response to their ego needs.
It enables them to transition from seeking external gratification to finding internal satisfaction by making meaningful contributions through their leadership.

Maintaining their equilibrium amid this stress requires discipline. Some people practice meditation or yoga to relieve stress, while others find solace in prayer or taking long runs or walks.
Still others find relief through laughter, music, television, sporting events, and reading. Their choices don't matter, as long as they relieve stress and enable them to think clearly about work and personal issues.

A system to support values-centered leadership

The reality is that people cannot stay grounded by themselves. Leaders depend on people closest to them to stay centered. They should seek out people who influence them in profound ways and stay connected to them. Often their spouse or partner knows them best. They aren't impressed by titles, prestige, or wealth accumulation; instead, they worry that these outward symbols may be causing the loss of authenticity.

Spouses and partners can't carry this entire burden though. We need mentors to advise us when facing difficult decisions. Reliable mentors are entirely honest and straight with us, defining reality and developing action plans.

In addition, intimate support groups like the True North Groups, with whom people can share their life experiences, hopes, fears, and challenges, are invaluable. Members of our True North Group aren't impressed by external success, but care enough about us as human beings and as leaders to confront us when we aren't being honest with ourselves.

As Senator Ensign told his fellow senators in a farewell speech in May, "When one takes a position of leadership, there is a very real danger of getting caught up in the hype surrounding that status … Surround yourselves with people who will be honest with you about how you really are and what you are becoming, and then make them promise to not hold back… from telling you the truth."

Brief Protective Gear List for street demos

2011-07-04T23:27:00.000-07:00

by LA Activist Doc Thursday, Mar. 20, 2003 at 9:23 AM

This list of gear describes the tools which can help protect you and enable you to make your voice heard in the coming days. The list describes some basic tools which will protect you against tear gas/pepper spray, as well as a bit of first aid gear.

I. Basic Gear For Street Demos:

(choices arranged in order of increasing cost)

(1) Eye protection:

Shatterproof eye protection is very useful in case of "less than lethal" weapons used for crowd control (plastic bullets, tear gas [aka 'CS' or 'CN'] canisters, pepper spray [aka 'OC'] "paintballs", etc.)

Possibilities include:

shop "goggles" - plastic shatterproof material - sold at any hardware stores. If you tape up the air holes, gives some protection against tear gas/pepper spray.

shatterproof swim goggles - sold at swim stores.

shatterproof face shield - sold at most hardware stores - is suspended off head band over front of face. Good protection (with a broadbrimmed hat) against pepper spray squirted into crowds. If you combine with goggles/simple respirator, good against tear gas [note - check to see that respirator/goggles fit under face shield]

shatterproof glasses (sold at gun shops, etc) -

full face respirator with shatterproof shield - gives good protetion against tear gas/pepper spray - sold at some big hardware/industrial supply houses [call first]

military surplus gas mask - best are full face transparent shields with detahable (replaceable) filters. Second best have partial transparent shields over upper face. Least good have two separate transpartent areas over each eye.
AVOID Israeli masks (from Gulf War I), old WW II/Korean/Vietnam masks - they didn't work in Seattle or any of the later protests.
AVOID any masks with glass lenses. AVOID any masks unless you know face shield/eye shields are shatterproof.

(2) Breathing protection -

NOTE: Tear "gas" is actually a petrochemical based solid which has to be heated to become a gas. If the heated molecules pass through water (especially water acidified with lemon juice or - less good - vinegar) some of the molecules will become trapped in the water...so you can't breathe them.

Tear "gas" molecules also revert to their solid state when they cool off. When tear gas (CS or CN) molecules encounter a solid surface (like the ventilation ducts of an office building, your skin, your eyes, the lining of your nose/mouth, the inside of a sturdy 5 gal plastic bucket) the gas molecules cool off and become solid.

If they cool off on your body, you hurt - the wetter the part of your body, the more you hurt! If they cool off somewhere off your body, then they wont cause you pain (unless you handle the object they cooled off upon).

So, breathing protection involves trapping the tear gas:

Possibilities include:

bandanas with water - only work for a few minutes. Hard to seal to nose mouth.

bandanas with lemon juice (or vinegar) - last for more minutes. Still hard to seal to nose/mouth. Vinegar really stinks and can cause skin irritation - lemon juice is better! You can fold up a lot of moistened bandanas and keep in Ziploc bags - this worked well in other big demos.

"respirator" from paint/hardware stores - covers nose/mouth - has replaceable filters (screw on/off). Very effective - make sure you get filters for "organic chemicals" or "methylene choride". Usual cost - about $20 to $30.

military surplus full face (or nose/mouth) gas mask - see info above. Only gas masks with replaceable (screw on/off) filters are likely to work. The old fashioned masks with long tubes leading to a separate filter apparatus are nearly useless. Usual cost: $40 - 100.

full face respirators with shatterproof face shields and replaceable filter(s). Excellent protection. Usual cost: > $100

(3) Skin protection:

NOTE: Pepper spray ("OC") is usually delivered as a liquid (sometimes fired into crowds as "paintballs") - it may be squirted from small, hand held canisters, backpak size canisters, or water cannon. Pepper spray causes an immediate burning sensation.

Tear "gas" ( "CS" or "CN") is a solid which must be heated to become a "gas". When tear "gas" settles on you, it causes a chemical reaction which produces pain. The wetter the place the tear "gas" lands, the greater the chemical reaction and - therefore - the greater the pain. For most people, tear "gas" will produce the greatest discomfort in eyes/nose/mouth.

The primary goal in skin protection is to keep pepper spray off your skin.....

Bringing an extra set of basic clothing (including socks!) wrapped securely inside a heavyweight plastic trash bag will make your day much better if you have been sprayed or gassed......

Protective possibilities include:

(a) face:

- broad brimmed hat. Helps shield pepper spray from above. (Pepper spray on the ears hurts!) Useless for "straight-on" spray.

- bandana. Very limited

- "face shield" (see above). Together with hat, gives good protection

- full face respirator/gas mask . Together with hat, gives best protection.

(b) feet:

- closed toe footwear is much better than sandals/open toed footwear.

(c body/arms/legs:

- Heavy duty 40 gal plastic trashbags with torn out holes for head/neck

- loose fitting, long sleeved lightweight (in LA) windbreakers/ rain jackets/ "warm-up" pants made of waterproof material. These will "shed" pepper spray for a while (if they get soaked, they will then act like a big wick on your skin - if this happens, dump them)

- loose fitting, long sleeved lightweight (in LA) windbreakers/ rain jackets/ "warm-up" pants made of cotton (or other absorbent fabric).

- lightweight "jumpsuits" made of synthetic fabric. Very DEVO....

II. Basic First Aid Gear.

Please take any prescription/non-prescription meds you take (especially inhalers!) on a regular or as needed basis. Take in original, lablelled containers from pharmacy. If you are worried about losinng the meds, store the bulk of the pills (safely) at home in marked containers (out of reach of children/pets/roomates) and take a few days worth to demo with you.......

A. Spray bottle (new!) with hand squeeze action - from 1 pt to 1 qt is best. Fill with 1/2 liquid maalox and 1/2 water. Use for pepper spray in eyes. (If you don't have spray bottle, plastic "bottled" water with "sports top" is better than nothing).

B. Water in plastic "bottles" with "sports top" - figure at least 4 to 6 pints per person per day - more if you have to wash eyes/skin from chemical weapons.

C. 4x4 (nonsterile) pads or clean squares of torn fabric for soaking up pepper spray. DO NOT wipe pepper spray so it spreads over a larger area - you'll just increase the size of the chemical burn!
Mineral Oil/Rubbing Alcohol (both - in separate original containers!) - ONLY if you know how to use them for pepper spray on skin. If you don't know how to use them, please don't experiment on self/others - it will make the pain worse.....

D. Band-AIds, moleskin (synthetic!) are always good - as are any other basic supplies you know how to use....

Asthma Prevalence Up 12% in Last Decade: CDC

2011-05-08T22:32:00.000-07:00

From Medscape Medical News

Alison McCook

May 3, 2011 — Asthma now affects 1 in 12 Americans — an increase of 12% during the last decade — but only one third are using long-term control therapies such as inhaled corticosteroids, according to the US Centers for Disease Control and Prevention (CDC).

The findings reinforce clinicians' vital role in preventing asthma's potentially deadly consequences, said Ileana Arias, PhD, principal deputy director of the CDC, including prescribing long-term control medicine and teaching patients how to monitor and manage their condition. "Asthma attacks are not inevitable," Dr. Arias told reporters during a press conference today. "Asthma can be controlled."

The analyses were published today in "Vital Signs," a monthly edition of the CDC's Morbidity and Mortality Weekly Report, in honor of World Asthma Day.

The findings are based on data collected during the National Health Interview Survey, in which people provide health information during household interviews, and the Behavioral Risk Factor Surveillance System, an ongoing state-based telephone health survey of US adults.

The authors found that the overall prevalence of asthma in adults and children increased from 7.3% in 2001 to 8.2% in 2009, or from 20.3 million to 24.6 million people.

The rate of asthma increased among all subgroups, but asthma is currently more common in children (9.6%) than adults (7.7%).
The most significant increase in prevalence occurred in black children, who saw an almost 50% rise in diagnoses from 2001 to 2009.
Now, nearly 1 in 6 black children has asthma.

The rate of asthma appeared highest in low-income people, affecting 10.6% and 13.5% of poor adults and children, respectively.

Most people with asthma (89%) had health insurance, but among those who did not, more than 40% said they could not afford their prescription medications — a problem that affected only 11.5% of those who had health insurance. People without health insurance were also less likely to say they had consulted a primary care physician or specialist.

Only 34.2% of people with asthma said they had received a written asthma action plan, and only 68.1% said they had been taught how to respond appropriately when they experience symptoms of an asthma attack.
Finally, only one third of adults and children said they were using long-term control medicine such as inhaled corticosteroids.

Action Plan Needed for All Patients With Asthma

In a conference call with reporters, Paul Garbe, DVM, MPH, chief of the CDC's Air Pollution and Respiratory Health Branch, reinforced the importance of a written asthma action plan, in which physicians and patients work together to develop a detailed, personalized description of how to control asthma and handle symptoms when they arise.

The CDC recommends that all patients with asthma receive a written action plan; it is not clear why most have not done so, Dr. Garbe told Medscape Medical News in response to a question asked during the press conference. A good plan takes time, he said, and it is possible that physicians believe that developing one "would possibly prevent them from providing care to other patients that day."

It is also not clear why more patients are being diagnosed with asthma — and therefore need a written action plan — than in previous decades, he added, particularly as outdoor air quality has improved and exposure to smoking has decreased in recent years. "We don't know exactly why the rate is going up," said Dr. Arias.

As the rate of asthma increases, so do its costs: In 2007, expenses related to asthma totaled approximately $56 billion, an increase of 6% since 2002, equaling roughly $3300 per person with asthma.

In 2008, approximately one half of people with asthma said they had experienced an asthma attack in the last 12 months, more than 40% of whom said their asthma had caused them to miss at least 1 day of school or work. Although the number of deaths from asthma has declined, almost 3500 people still die every year from the condition, said Dr. Garbe.

"Asthma is a serious, lifelong disease that unfortunately kills thousands of people each year and adds billions to our nation's healthcare costs," CDC Director Thomas R. Frieden, MD, MPH, said in a statement. "We have to do a better job educating people about managing their symptoms and how to correctly use medicines to control asthma so they can live longer more productive lives while saving healthcare costs."

Morb Mortal Wkly Rep. Published online May 3, 2011.

Allah - The Name of God

2011-04-11T23:09:00.000-07:00

Al’lah is simply defined by the New American Webster Dictionary as “(Moslem) God”. The Encyclopedia Britannica defines Allāh (Arabic: “God”) as the one and only God in the religion of Islam.

There are 129 million references on Google Search for the word “Allah”.
This paper is a compilation of information gleaned from some of them and internet webnews.

Most scholars agree that allah is the Arabic word that shares the same ancestral root as the biblical Aramaic elah and Hebrew eloah, which is the singular of elohim, a generic word for God used throughout the Old Testament.
The name’s origin may be traced to the earliest Semitic writings in which the word for “God” was “Il” or “El”, the latter being the Old Testament synonym for YHWH.
Western scholars are fairly unanimous that the source of the word is probably Aramaic from the Syriac word alāh (“the god”).
It has its root in the word ’l, which in Syriac was pronounced as alâhâ (“the god”), which has the same meaning as ha-’elôah in Hebrew, ho theos in Greek and Allâh (= al-ilâh) in Arabic.
The word allah also appears in other Semitic languages such as Assyrian, Babylonian, Aramaic and Phoenician Ugarit languages.
In the Semitic languages, this word refers to a power which is beyond the reach of human beings, a power that belongs to the gods.

The Arabic translation of the Bible, along with the holy books of other religions (Torah, Sikh) uses it based on a common treasury of the Arabic language.

There are controversies about the pre Islamic origin of the word allah, which most sources claim to have been previously used by pagan Meccans as a reference to the creator deity, possibly the supreme deity, in pre-Islamic Arabia.

Inscriptions with the word “allah”, dated from as early as 5th century BC, have been discovered in archeological findings in the region, lending support to the fact that the word was already in general use before Islam and Prophet Mohammad (570-632 AD).
His father, who died several months before Mohammad’s birth, was called Abd Allah ibn Abd al-Muṭṭalib (545-570AD).
Abd Allah, which means "servant of God", "slave of God" or "worshipper of God" was once a common name among Arabic-speaking Jews as well.

The term Allāh is derived from a contraction of the Arabic definite article “al-“ "the" and “ilāh "deity, god" to al-lāh meaning "the [sole] deity, God".
In Islamic tradition, there are 99 names of God each of which evoke a distinctive characteristic of Allah.
All these names refer to Allah, the supreme and all comprehensive divine name. Muslims insist that the name “Allah" must be used in every language and cannot be translated to “Dios” in Spanish, “Dieu” in French, or “God” in English.
Muslims thus regard "Allah" not as a generic word for god, but as the proper name of “the God” as revealed to the Prophet Mohammad (?610AD).

Shared usage of the word Allâh was acknowleged in the Qur’an by Prophet Mohammad. The Madinah Covenant drawn up by the Prophet after the Hijrah 622 AD acknowledged that while the Jews and Christians had different religions (dîn), they were still part of the people of the one Allâh (God), meaning that they were people who worshipped the true Allâh (God)

This view was reiterated in the Hadith which recorded the incident when the Christians from Najran met with the prophet in Madinah to discuss matters relating to dogmas where they differed from the prophet.
The Christians were invited by Muhammad to use the prayer room in his house to conduct their worship, because there was no church in Madinah.
The prophet acknowledged that the Christians worshipped the same Allâh (God) although their religion (dîn) was different.

The Wikipedia Bahasa Indonesia summarizes it as follows: Allāh adalah kata dalam bahasa arab yang merujuk pada nama Tuhan. Perkataan tuhan dalam bahasa arab adalah Ilah sebagaimana dalam dua kalimah sahadah Islam. Kata Allah ini lebih banyak dikenal sebagai sebutan tuhan oleh penganut agama Islam. Kata ini sendiri di kalangan para penutur bahasa arab, adalah kata yang umum untuk menyebut tuhan terlepas dari agama mereka, termasuk penganut Yahudi dan Kristen Arab. Konsekuensinya, kata ini digunakan dalam terjemahan kitab suci agama Kristen dan Yahudi yang berbahasa arab, sebagaimana pula terjemahan Alkitab dalam bahasa Indonesia dan Turki.

Allah in Bible Translations

The oldest Arabic translation of the Bible (manuscripts dated 867 AD) by Bishr Ibn Al Sirri, a Nestorian Christian living in Damascus, was discovered in the 19th century in the Saint Catherine's Monastery, Mount Sinai.
Since the ninth century AD, Arab Christians have continued to translate “elohim” and “theos” (the primary terms for god in Hebrew and Greek) as “allah” in the Arabic Bible and Muslim writers have used Allah in their quotations of the Christian Bible.
Jewish scholars have also been translating elohim and elah as Allah since the earliest known Arabic translations of the Torah in the ninth century until today.

As of July 2010, translations of the books in the Bible have been made into 3,168+ languages, one of the two Testaments in 1,668 languages, and the complete Bible in 457 languages.

Albert Cornelius Ruyl, a Protestant Dutch merchant in Indonesia, translated the book of Matthew into Malay in 1612, which was printed in the Netherlands in 1629. He then translated Mark which was published in 1638.
The Malay (Indonesian) New Testament was printed in 1731 and the complete Al Kitab in 1733.
The Malay translation of Matthew has the distinction of being the first non European language translation of any book of the bible.

Both the terms Allah and Tuhan are used in the Malay and Indonesian Bible. Mainstream Bible translations in both languages use Allah as the translation of Hebrew Elohim (translated in English Bibles as "God").
This goes back to early translation work by Francis Xavier in the 16th century. Following the precedence set by the Arab Christians, Allah is used to translate el/elohim and Tuhan (TUHAN) is used to translate Yahweh (YHWH).

The word Tuhan is also applied to Jesus Christ in the New Testament. Thus we read of the Lord Jesus as Tuhan Yesus.
The word Lord was used to translate the word kurios 8400 times in the Greek version of the Old Testament. It refers to human beings only 400 times and to God 8000 times. Of these 8000 times, 6700 are substitutes for the word YHWH.
The transference of the title kurios LORD/YHWH to Jesus Christ is testimony to the belief in the deity of Christ right at the beginning of Christianity.

The Indonesian (BIS) bible (Alkitab Kabar Baik dalam Bahasa Indonesia Sehari-hari) uses the word “Allah” 4192 times, “Tuhan” 6871 times and “TUHAN Allah” 977 times.
In the first book of the bible, Genesis there are over 180 verses containing this word “Allah” translated in the English version as “God”.

This simple statistical survey shows clearly that the demand by Muslims that Christians simply substitute the word Allah with Tuhan is untenable since it will render many Biblical references to God and Jesus Christ incoherent.

What is the translator’s job when handling the Scriptures?
It is to communicate as faithfully as possible, taking a word that is used in the source language, and utilizing its equivalent (if there is one) in the target language.
The principle is this: that when referring to God, you may use the generic cultural word for “god”, but not the proper name of a specific god from that culture (e.g. Baal, Zeus, Thor, etc.).

In the Arabian, Malay, Indonesian or Iban translation of the Bible, the word allah has been used in the generic sense for god, not referring to the Allah professed by Muslims.

The Malay language is a member of the Austronesian language family spoken as a native language by more than 33 million over Malaya, Sumatra and Borneo and the national language of Malaysia and Indonesia. 20 million Indonesian Christians use the Alkitab in Indonesia (90% Muslim).

Lifetime Exposure to Cigarette Smoking and the Development of Adult-onset Atopic Dermatitis

2011-04-06T20:10:00.000-07:00

From The British Journal of Dermatology

C.H. Lee; H.Y. Chuang; C.H. Hong; S.K. Huang; Y.C. Chang; Y.C. Ko; and H.S. Yu
Abstract

Adult-onset atopic dermatitis (AD) has recently been recognized as a distinct disease entity, but its risk factors have not yet been clearly defined.
Although gestational and perinatal exposure to tobacco smoking may be associated with the development of classic AD, the association between active/passive smoking and adult-onset AD remains controversial.
Objectives
To determine if exposure to smoking, including environmental tobacco smoke (ETS), is associated with the risk of adult-onset AD.
Methods
Tobacco smoking and exposure to ETS were measured in a case–control association analysis in 83 patients with physician-diagnosed adult-onset AD and 142 age- and sex-matched controls.
Results
Multiple logistic regression analyses showed that, among the potential environmental risk factors, both current and ever smoking were significant risk factors for adult-onset AD [odds ratio (OR) 4·994 and 3·619, respectively], compared with never smoking. Also, packs per year was significantly associated with adult-onset AD (OR 1·058, 95% confidence interval 1·028–1·089), suggesting a lifelong cumulative risk in current smokers. Moreover, nonsmokers with adult-onset AD reported significantly more exposure to ETS.
Conclusions
Early and/or current exposure to cigarette smoking may contribute cumulatively to the development of adult-onset AD.
Exposure to ETS in childhood is associated with the development of adult-onset AD. Adults should be discouraged from smoking to prevent adult-onset AD in themselves and their family members.

Introduction

Atopic dermatitis (AD) is characterized by chronic relapses of dermatitis in patients with a personal or family history of atopic disease.
The onset of AD commonly occurs in early childhood, although symptoms can persist or begin in adulthood.
Depending on the age of onset, AD preferentially affects specific locations on the skin. For example, AD usually affects flexural areas with lichenification in children, while adult-onset AD preferentially affects the face and hands.
Taking into consideration the familial tendency towards specific antigen sensitization to AD, a complex interplay of genetic and environmental factors may play an important role in the pathogenesis of AD.
Several important environmental factors are considered risks for AD, including food allergens, aeroallergens and infectious agents such as Staphylococcus aureus
This study focuses on tobacco smoking and its possible contribution to AD.

Although the development of AD was thought to occur in very early childhood, recently several groups from Japan, Australia and the U.S.A. have described adult-onset AD. Both classical AD and adult-onset AD cases present with intensive itching. However, adult-onset AD differs from classical AD by preferentially affecting the face, hands and nonflexural areas and a prurigo-like pattern occurs more frequently in adult-onset AD. Except for a study in Italy demonstrating the outcome of patch tests in patients,no risk factors have been defined for adult-onset AD.

Although there is an increased risk of asthma from gestational and perinatal exposure to smoking,studies investigating the influence of such exposure on the development of AD show mixed results.Wang et al. reported that exposure to smoke during pregnancy might increase the risk of childhood AD, but results from other reports are inconsistent with these findings. A molecular investigation found blood IgE to be elevated in infants born to mothers who smoked, and there are reports that active smoking might increase IgE in asthmatic patients.Evidence that exposure to environmental tobacco smoke (ETS) during early childhood predisposes the child to later AD has been documented,[12,13] but the association between current smoking and the development of AD remains unclear. Using mail-in questionnaires from a study population of 40 888 subjects, Bo et al. reported an association between active smoking and the development of AD in Norway [odds ratio (OR) 1·31], but the association did not reach significance. In the U.K., self-reported mail-in questionnaires from 150 patients with AD also suggested a similar but insignificant association with smoking (OR 1·1).
In France, an analysis of 14 578 subjects reported a significant association between active smoking and AD in adolescents (OR 1·8).
Although the approaches varied considerably, from very large surveys with no clinical data to smaller clinical studies, these studies consistently indicate an association of active smoking with AD.
The studies, however, did not specifically address the association of active smoking and adult-onset AD, probably because they were studying cases of classical AD in which the age of onset precedes the onset of smoking behaviour.
Moreover, self-reported questionnaire surveys are subject to inaccurate diagnosis for AD and a low response rate, and they lack a physician diagnosis.
Smoking more than 10 cigarettes per day is reported to increase the risk of hand eczema, also suggesting a potential link between smoking and adult-onset AD.
Thus, the current evidence consistently suggests a link between tobacco smoking and AD, but a more thorough investigation is required to support the link. Moreover, how adult-onset AD is associated with smoking has never been addressed.
In this hospital-based, case–control study we investigated whether exposure to tobacco smoke, including current smoking, ever smoking and ETS, is associated with the risk of adult-onset AD. It represents the first study to investigate directly the possible association between ETS exposure and adult-onset AD.

Yoga Found to Reduce AF Episodes

2011-04-04T20:58:00.000-07:00

From Heartwire

Sue Hughes

April 2, 2011 (New Orleans, LA) – Taking a 45-minute yoga class three times a week was associated with a halving of episodes of atrial fibrillation (AF) in a new small study.

The study, presented today at the opening press conference of the American College of Cardiology 2011 Scientific Sessions , was conducted by a team led by Dr Dhanunjaya Lakkireddy (University of Kansas Hospital, Kansas City).

He said he started the study after a patient had reported a great improvement in her AF after having started practicing yoga.
For the study, 49 patients with paroxysmal AF underwent a three-month control phase in which they could engage in any type of physical activity they were previously accustomed to doing.
They then underwent a three-month study phase where they participated in a supervised yoga program consisting of breathing exercises, yoga postures, meditation, and relaxation.
They were also encouraged to practice the exercises at home on a daily basis. All participants were new to the practice of yoga, and the program was designed to allow beginners to progress safely from basic movements to more advanced practice over the course of the study.

Results showed that during the yoga-intervention phase, the number of episodes of AF was significantly reduced--from a mean of 3.8 to 2.1. The number of phantom episodes was also reduced, from a mean of 2.6 to 1.4. In addition, 22% of patients did not have any AF episodes during the yoga phase.

Lakkireddy reported that there was also a "drastic" improvement in quality of life, with significant reductions in anxiety and depression scores.

He said: "It appears yoga has a significant impact on helping to regulate patients' heartbeat and improves their overall quality of life.
Any intervention that helps in reducing or controlling the arrhythmia burden in atrial fibrillation can have a huge impact on public health."

He recommended that yoga be used as a supplemental therapy in AF. "I am not suggesting that patients should stop taking their medication, but if used as a supplement to medication, yoga could really make a dramatic difference," he added. He also stressed that yoga cannot prevent stroke, and patients definitely need to continue on their anticoagulant treatment.

He said he did not know how the yoga was working but suggested that it might prevent the peaks in sympathetic and parasympathetic tone that precede AF episodes. "It looks as if yoga is reducing the triggers of AF, but we would like to do more studies to look into the mechanisms further," Lakkireddy added.
He suggested that yoga may also bring about this effect by reducing systemic inflammation and endothelial dysfunction.

He commented to heartwire : "Yoga also helps reduce blood pressure, cholesterol, and stress, so it is a comprehensive lifestyle change that can have a broad effect."

Asked if clinical recommendations could be made on the basis of a 49-patient study, Lakkireddy said: "We're not claiming yoga fixes everything in AF, and we are advising patients to continue taking their medication, but we have shown some impressive effects. Everything has to start somewhere."

Radiation From Airport Scanners Very Low: Study

2011-04-04T20:48:00.000-07:00

From Reuters Health Information

By Julie Steenhuysen

CHICAGO (Reuters) Mar 29 - Airport scanners are an "extremely low" source of radiation exposure that poses virtually no health risk, not even to frequent air travelers, U.S. researchers said on Monday.

The study may help ease fears of uneasy travelers already spooked by reports of radiation leaking from the crippled nuclear plants in Japan.

"There is such a vast difference between super-low doses of radiation and the really high doses that happen if you are in the middle of a nuclear accident," said Dr. Rebecca Smith-Bindman, a radiology professor at the University of California, San Francisco, whose study appeared online March 28th in the Archives of Internal Medicine.

"Because they are all called radiation, we are tempted to put them all in the same category. That is a mistake."

She said the nuclear crisis in Japan has heightened fear about radiation, but she said a person would have to get more than 50 airport scans to get as much radiation exposure as one gets from a dental X-ray.

"When used properly, the doses from these machines are extremely low," Dr. Smith-Bindman said in a telephone interview.

Some travelers and airline crews have expressed concerns about being repeatedly exposed to radiation from the body scanners, which the Transportation Security Administration has deployed to detect banned items on passengers.

Only one type of full-body airport scanner - the backscatter X-ray machine - expose individuals to ionizing radiation such as that used in common medical X-rays.

To estimate the risk from these machines, Dr. Smith-Bindman and co-author Pratik Mehta estimated radiation exposure for three different groups: all flyers, very frequent fliers, and 5-year-old girls who are frequent fliers, because children are more sensitive to the effects of radiation.

They said of the total 750 million flights taken per year by 100 million passengers, there would be an additional six cancers over the course of the travelers' lifetimes. That is in addition to the 40 million cancers that would normally develop among people in a group this size.

For very frequent fliers -- people who fly 60 hours a week -- there might be four extra cancers on top of the 600 extra cancers just from so much flying - which exposes people to more solar radiation - and 400,000 cancers that normally would occur over their lifetime.

And for every 2 million 5-year-old girls who travel one round-trip a week, going through the scanners would cause one additional cancer out of the 250,000 breast cancers that are set to occur in this group over their lifetimes.

Dr. Stephen Machnicki of Lenox Hill Hospital in New York, who was not involved in the study, said the radiation from one of these scanners is less than what someone would get just by taking a cross-country flight.

He said he hopes the new data will help people "to overcome their fears of going through the scanners."

Dr. Smith-Bindman - who has published several studies on cancer risks from overuse of medical imaging - said the risk from airport scanners is trivial.

"If you compare it to a CT scan, you need to go through an airport scanner 200,000 times to be equivalent to the dose of one CT," she said.

"I'd rather focus on getting rid of some of those CTs."

SOURCE: http://bit.ly/hY9TQP
Arch Intern Med 2011.

Regular Exercise Can Help Preserve/Build Heart Mass

2011-04-04T20:34:00.000-07:00

From Heartwire
Exercise and heart mass

Sue Hughes

April 2, 2011 (New Orleans, LA) – Another benefit of regular exercise has been discovered--preventing the reduction in heart mass normally seen with aging.

Speaking at a press conference on the opening day of the American College of Cardiology (ACC) 2011 Scientific Sessions , Dr Paul Bhella (John Peter Smith Hospital, Fort Worth, TX) explained that heart muscle size--typically measured by left ventricular (LV) mass--peaks early in life and diminishes with sedentary aging.

Bhella conducted a study to look at the effect of regular exercise on this process and found that being physically active over the course of a lifetime can "preserve the heart's youthful elasticity." He noted that as the heart muscle atrophies with age, the heart becomes weaker, less capable of responding to increasing demands such as those associated with physical activity, and, in many circumstances, this leads to a stiffening of the heart by increasing the relative proportion of connective tissue compared with cardiac muscle.

In the study, Bhella and his colleagues compared two groups of people: 81 healthy but sedentary individuals aged 21 to 82 years; and 67 people aged 65 or older who had exercised regularly throughout their lives. The second group was subdivided into those who had exercised two to three times per week, four to five times week, and six to seven times per week. Exercise was defined as a period of at least 20 to 25 minutes of aerobic activity. Study participants underwent cardiac MRI to estimate cardiac mass and LV mass.

Results showed that in the sedentary group, LV mass reduced with age from an average of 55 g/m2 in those in their 30s to 24 g/m2 to those in their 60s. In contrast, in those older individuals who had done regular exercise, LV mass either stayed stable or actually increased, and there was a clear dose-dependent effect with the amount of exercise taken. Those who had did exercise two to three times were per week, had an average LV mass of around 53 g/m2, and this increased to about 62 g/m2 in those exercising four to times a week and to about 68 g/m2 in the six-to-seven-times/week group.

Similar results were seen with peak oxygen uptake. This decreased steadily with age in the sedentary group but increased with increasing exercise levels in the active group. Those individuals aged over 65 who exercised four to five times a week had a higher level of peak oxygen uptake than those aged under 34 who were sedentary.

"Use it or lose it"

To heartwire , Bhella commented: "You have to use it or lose it. It is never too late to start exercising. Exercising twice a week can prevent age-related loss of cardiac mass, while exercising four to five times a week can rebuild cardiac mass. This is the first time anybody has shown this."

He explained that while higher cardiac mass has not directly been shown to cause better outcomes, it is associated with increased levels of fitness, which has been shown to be associated with better outcomes. He stressed that all the increases were in the healthy range and that cardiac mass did not start to become pathologic until levels of around 130 g/m2, which happens in left ventricular dysfunction. "The increase we are seeing is a healthy remodeling of the heart, associated with delivering more blood effectively to the body. So oxygen uptake increases, and in turn fitness increases," he explained.

Lead investigator of the study, Dr Benjamin Levine, said in an ACC press release: "The data suggest that if we can identify people in middle age and get them to exercise four to five times a week, this may go a very long way in preventing some of the major heart conditions of old age, including heart failure. Defining how to intervene at the right time and with the right dose [of physical activity] are critical questions we need to answer from a public-health standpoint, but also as cardiologists we want our patients to remain healthy and forestall heart problems."

Should the HPV Vaccine Be Recommended for Boys and Young Men?

2011-03-30T21:02:00.000-07:00

From Medscape Infectious Diseases > Offit on Vaccines

Paul A. Offit, MD

for audio go to - http://www.medscape.com/viewarticle/739017?src=mp&spon=9

Hi. My name is Paul Offit, and I'm talking to you today from the Division of Infectious Diseases at the Children's Hospital of Philadelphia.
What I thought we could talk about is something that's going to be coming up soon at the June Advisory Committee for Immunization Practices (ACIP) meeting at the Centers for Disease Control, which is whether to make the HPV, or human papillomavirus vaccine a routine recommendation for boys and young men. We'll see what happens, but there are certainly a few reasons that one could do that.

Let's go back to the beginning though.
The first HPV vaccine, which contained types 6, 11, 16, and 18, was licensed in the United States in June 2006.
Another vaccine was licensed 2 years later that contained types 16 and 18.
Now, 16 and 18 prevent cervical cancer in girls and prevent about 70% of those strains that do cause cervical cancer.
Types 6 and 11 would prevent about 90% of the strains that cause anal and genital warts.

So we'll see what comes up in this June meeting, but I would argue that there are 3 reasons for why this vaccine should be routinely recommended for boys and young men.
One is that boys and young men get anal and genital warts, and there are hundreds of thousands of cases every year of those warts.Although they aren't fatal, they certainly are emotionally crippling and disfiguring.
The second reason is that boys and young men get anal and genital cancers. There are several thousand cancers every year, both anal and genital cancers, as well as head and neck cancers that could be prevented by an HPV vaccine.
The third reason is that girls get HPV from boys, so at the very least, there's social responsibility to protect girls from getting that disease, which is really the reason that we recommend the rubella vaccine (ie, the German measles vaccine) for boys as well.
I think these are certainly very compelling reasons to make the HPV vaccine a routine recommendation for boys and young men.

Rear seats for kids

2011-03-30T20:54:00.001-07:00

From Reuters Health Information

By Frederik Joelving

NEW YORK (Reuters Health) Mar 21 - Kids should sit in rear-facing car seats as long as they fit into them, or until age two, pediatricians urged Monday.

After that, they should ride in booster seats up to age eight or if they're still too small to fit correctly in seat belts.

"The best possible thing you can do is keep your child rear-facing as long as possible," said Dr. Benjamin Hoffman of the American Academy of Pediatrics, which issued the policy statement.
"We hope we will be able to convince parents to keep their children rear-facing longer."

The new recommendations update a 2002 statement, which had advised parents to follow car seat manufacturer limits, but also mentioned one year and 20 pounds as a minimum.

That led to some confusion among some parents, who would use the one-year cut-off as a milestone for when to make their child ride forward-facing, Dr. Hoffman told Reuters Health.

"The message, while it's been consistent, has not been as clear as it could have been for parents," he added.

According to the new statement, published online in Pediatrics, 1,500 kids under 16 die every year in car crashes in the U.S.

Child safety seats have been shown to cut the risk of death by 28% compared with seatbelts, and they also reduce non-fatal injuries.

That's because they distribute the energy of a collision over a bigger area, instead of concentrating it on the points where the seatbelt touches the body -- the shoulders, the belly and the hips.

Specifically, the AAP recommends:

- Infants should ride in rear-facing car safety seats until age two or until they reach the height and weight limits specified by the manufacturer.

- After that, they should ride in forward-facing car seats with a harness until age four or until they have outgrown the seat.

- Then they should be switched to a belt-positioning booster seat until they can use the seatbelt alone (typically between eight and 12 years, or when they've reached 4 feet 9 inches).

- Kids who are big enough to use the seatbelt alone should sit in the rear of the car until age 13.

The complete guidelines can be downloaded as a pdf file, at the URL given below.

SOURCE: http://bit.ly/hpFWdm

Pediatrics 2011.

Radiation From Japan's Nuclear Plant Now Poses Health Risk

2011-03-15T20:01:00.000-07:00

From Medscape Medical News

Zosia Chustecka

March 15, 2011 — A third explosion at the Japanese nuclear plant damaged by the earthquake and tsunami, as well as a fire at another reactor, has resulted in fresh release of radiation that is now considered to be harmful and has increased fears over a catastrophic meltdown.

Radiation levels around the Fukushima Daiichi plant rose to 8 times the legal limit, according to the Tokyo Electric Power Company (TEPCO) as reported by BBC News. After the third explosion (on Tuesday morning in Japan), the radiation reading rose to 8217 microsieverts an hour, having stood at 1941 just an hour earlier. The annual legal limit is 1000 microsieverts.

"Now we are talking about levels that can damage human health," said Japan's Chief Cabinet Secretary Yukio Edano. He instructed local residents to stay indoors and make their homes airtight.

The exclusion zone around the Fukushima Daiichi nuclear plant has been increased again, this time to a radius of 19 miles (up from 12 miles yesterday, after the second explosion). In addition, around 800 workers at the plant have been evacuated, with only 50 workers now remaining.

The spike in radiation released after this latest explosion, in the third reactor that was operational when the earthquake and tsunami struck on March 11, has led to fears that this time there has been damage to the reactor containment vessels that houses the nuclear fuel rods.

Unlike in the previous 2 explosions at 2 other similar reactors, this time the roof did not blow off, and it is thought that the trapped pressure cracked the containment vessel around the reactor's core, allowing radioactive material to seep out, according to an ABC News Report.

High Risk of More Radiation

The Japanese government has not commented on the state of this containment vessel, but in a nationally televised address, Prime Minister Naoto Kan warned, "There is still a very high risk of more radiation coming out."

Other reports from Japan say that radiation levels have varied wildly. A Reuters report of a briefing given by TEPCO and the Japanese government on Tuesday, after the third explosion, noted that radiation levels as high as 400,000 microsieverts (400 millisieverts) an hour were measured at some places within the plant complex.

The radiation levels of up to 400 millisieverts per hour recorded at the Fukushima plant "are levels that you have to take very seriously indeed to ensure you avoid immediate health effects," Professor Richard Wakeford, PhD, from the Dalton Nuclear Institute at the University of Manchester, United Kingdom, told the BBC World Service. He said that Japanese authorities will be imposing a ban on food and drink from the area and issuing potassium iodide tablets to block the intake of radioactive iodine to the thyroid. In fact, even before the latest explosion took place, potassium iodide was being distributed by the Japanese government.

In addition to the third explosion, there has been a fire at another reactor (reactor number 4), which was operational when the earthquake struck because it was undergoing maintenance. The fire occurred in that reactor's cooling pool, where the spent nuclear fuel is stored. TEPCO said that pool may still be boiling and the water levels may be falling, but it cannot check at the sites or determine what has burned because radioactivity at the cooling pool is high. Radiation leakage from the complex is likely to spread, the company warned.

According to a report from the Associated Press, the incidents at the nuclear plant to date have injured 15 workers and military personnel and exposed up to 190 people to elevated levels of radiation.

That report also quoted Chief Cabinet Secretary Yukio Edano as saying that fuel rods appear to be melting in all 3 of the reactors that were operational when the earthquake struck — all 3 of which have since exploded.

"Although we cannot directly check it, it's highly likely happening," he said.

This has increased fears of the nightmare scenario of a meltdown, which would trigger a massive build-up of pressure inside the containment units. If they then crack, radioactive dusts and gas would spew out into the air.

However, the latest reports from Japan (as of noon EST) are that radiation levels have fallen around the Fukushima Daiichi nuclear plant.

International Atomic Energy Agency "Remains Concerned"

The International Atomic Energy Agency says it "remains concerned" over the status of the Fukushima Daiichi nuclear power plant. Workers are continuing to inject seawater into all 3 reactors to cool them, and attempts to return power to the site are ongoing.

After the explosions at reactors 1 and 3, the primary containment vessels of both units were reported to be intact. However, the third explosion in reactor 2 may have affected the integrity of its primary containment vessels, the IAEA said in a statement.

The agency also notes that iodide tablets have been distributed to people at evacuation centers, but no decision has been taken yet about their administration.

Worst-Case Scenario

Whether radiation exposure becomes a major risk depends fundamentally on what happens to the 3 reactors at Fukushima Daiichi, commented Nathan Hultman, PhD, an energy policy expert and assistant professor at the University of Maryland School of Public Policy, College Park.

"All 3 of these reactors are suspected of having at least a partial meltdown, and therefore stabilizing them will require at minimum a venting of radioactive steam," he said. "The worse the meltdown has been the higher the radiation levels in the steam."

"This is at least moderate concern," Dr. Hultman said. "A full core meltdown would be far more worrisome, leading to molten fuel in the bottom of the containment unit and increasing the likelihood of highly radioactive substances escaping."

"The worst case scenario is if such molten material would breach the containment unit en masse," he commented. "The containment vessels are designed to withstand this scenario, and if we were to face a complete meltdown, we can only hope that they were well built and not damaged by the earthquake."

Radiation Risks of Reactor Meltdown Both Short and Long Term

2011-03-15T19:50:00.000-07:00

From Medscape Medical News

Robert Lowes

March 14, 2011 — The distribution of potassium iodide tablets in northern Japan underlines the fear of a catastrophic meltdown at the Fukushima Daiichi nuclear plant and the massive dispersion of deadly radioactive materials, with health implications for not only that country but also its neighbors.

Earlier in the crisis, radiation emitted by the plant's 3 overheating reactors was said to be at low, nonhazardous levels. However, radiation levels would skyrocket if the nuclear fuel in any of the reactors manages to escape its thick steel container. That possibility further worried Japanese authorities Monday evening EDT (Tuesday morning in Japan) when an explosion rocked reactor 2, the last of the units to blow. Kyodo News of Japan reported a spike in radiation, raising suspicions of a container breach.

"Each reactor has the radioactivity of 1000 Hiroshima bombs," said Ira Helfand, MD, an expert on radiation exposure in Leeds, Massachusetts, and a board member of the group Physicians for Social Responsibility, referring to the atomic bomb dropped on Hiroshima, Japan, during World War II.

The potassium iodide tablets were given out as protection against iodine-131, a radioisotope of iodine that can cause thyroid cancer. Iodine normally accumulates in the thyroid, so saturating the organ with a safe version by means of the tablets blocks the uptake of the radioactive version.

However, a busted nuclear reactor can throw off other dangerous particles, each with its own adverse effects on the body, Dr. Helfand told Medscape Medical News. "Strontium-90 is absorbed by bone, which leads to bone cancer and leukemia," he said. "Cesium-137 spreads throughout the body but favors muscle tissue. Plutonium is primarily toxic when inhaled and causes lung cancer."

Each particle’s half-life also calibrates risk. For iodine-131, it is a mercifully short 8 days; for strontium-90, it is an agonizingly long 29 years.

Symptoms of Acute Radiation Syndrome Subside, Return

In addition to long-term risks such as cancer, radioactivity can pose short-term risks. When most or all of the human body is exposed to a massive dose of radiation in a matter of minutes — a possibility with a nuclear reactor meltdown — the result is acute radiation syndrome (ARS).

The first symptoms of ARS — typically nausea, vomiting, and diarrhea — hit immediately, subside, and then come back strong, accompanied by loss of appetite, fatigue, fever, and possibly seizures and coma. Most people who do not recover die within several months, according to the US Centers for Disease Control and Prevention. In most cases, death results from the destruction of bone marrow, which leads to infections and internal bleeding.

A corollary to ARS is acute radiation damage to the skin, or cutaneous radiation injury (CRI). Symptoms such as transient itching, tingling, erythema, or edema can emerge within hours, days, or week. As with ARS, people with CRI usually experience a latent period of weeks to months. When skin lesions return, they can be debilitating or even life-threatening.

Shifting Winds a Factor

As a precaution, Japanese authorities have evacuated roughly 180,000 people from towns near the Fukushima Daiichi nuclear plant, even though radiation levels outside it as of Monday afternoon EDT were thousands of times below those considered dangerous. Japan also has benefited from westerly winds that have blown the small amounts of radioactive material east toward the Pacific Ocean. That drifting contamination does not pose a health threat to Hawaii, Alaska, or the West Coast, given the thousands of miles between Japan and the United States, according to the US Nuclear Regulatory Commission.

Rick Morin, PhD, chair of the safety committee of the American College of Radiology, explained that airborne radioactive material from the Japanese reactors is like smoke from a smokestack, diffusing and becoming less harmful the farther it travels. Traveling eastward, much of it would fall into the sea.

However, weather forecasts predict that winds in northern Japan will reverse direction tomorrow, which means any radioactive material from the reactors would be blown inland.

If a reactor meltdown spewed enormous quantities of radioactive particles in that weather scenario, Japan would have to worry about it coming down to earth and poisoning the food chain. Dr. Morin said thyroid cancer broke out among children after the meltdown of the nuclear reactor in Chernobyl, Ukraine, because they drank milk from cows that had eaten grass contaminated with iodine-131.

American Red Cross response to "Triangle of Life"

2011-03-14T20:46:00.000-07:00

Rocky Lopes, PhD
Manager, Community Disaster Education
American Red Cross National Headquarters

Recently it has been brought to my attention that an email from Doug Copp, titled "Triangle of Life," is making its rounds again on the Internet. "Drop, Cover, and Hold On" is CORRECT, accurate, and APPROPRIATE for use in the United States for Earthquake safety. Mr. Copp's assertions in his message that everyone is always crushed if they get under something is incorrect.

Recently, the American Red Cross became aware of a challenge to the earthquake safety advice "Drop, Cover, and Hold On." This is according to information from Mr. Doug Copp, the Rescue Chief and Disaster Manager of American Rescue Team International (a private company not affiliated with the U.S. Government or other agency.) He says that going underneath objects during an earthquake [as in children being told to get under their desks at school] is very dangerous, and fatal should the building collapse in a strong earthquake. He also states that "everyone who gets under a doorway when a building collapses is killed." He further states that "if you are in bed when an earthquake happens, to roll out of bed next to it," and he also says that "If an earthquake happens while you are watching television and you cannot easily escape by getting out the door or window, then lie down and curl up in the fetal position next to a sofa, or large chair."

These recommendations are inaccurate for application in the United States and inconsistent with information developed through earthquake research.
Mr. Copp based his statements on observations of damage to buildings after an earthquake in Turkey. It is like "apples and oranges" to compare building construction standards, techniques, engineering principles, and construction materials between Turkey and the United States.

We at the American Red Cross have studied the research on the topic of earthquake safety for many years. We have benefited from extensive research done by the California Office of Emergency Services, California Seismic Safety Commission, professional and academic research organizations, and emergency management agencies, who have also studied the recommendation to "drop, cover, and hold on!" during the shaking of an earthquake. Personally, I have also benefited from those who preceded me in doing earthquake education in California since the Field Act was passed in 1933.

What the claims made by Mr. Copp of ARTI, Inc., does not seem to distinguish is that the recommendation to "drop, cover, and hold on!" is a U.S.-based recommendation based on U.S. Building Codes and construction standards. Much research in the United States has confirmed that "Drop, Cover, and Hold On!" has saved lives in the United States. Engineering researchers have demonstrated that very few buildings collapse or "pancake" in the U.S. as they might do in other countries. Using a web site to show one picture of one U.S. building that had a partial collapse after a major quake in an area with thousands of buildings that did not collapse during the same quake is inappropriate and misleading.

According to the Centers for Disease Control and Prevention (CDC), which collects data on injuries and deaths from all reportable causes in the U.S., as well as data from three University-based studies performed after the Loma Prieta (September, 1989) and Northridge (January, 1994) earthquakes in California, the following data are indicated: Loma Prieta: 63 deaths, approximately 3,700 people were injured. Most injuries happened as a result of the collapse of the Cypress Street section of I-880 in Oakland. Northridge: 57 deaths, 1,500 serious injuries. Most injuries were from falls caused by people trying to get out of their homes, or serious cuts and broken bones when people ran, barefooted, over broken glass (the earthquake happened in the early morning on a federal holiday when many people were still in bed.) There were millions of people in each of these earthquake-affected areas, and of those millions, many of them reported to have "dropped, covered, and held on" during the shaking of the earthquake.

We contend that "Drop, Cover, and Hold On" indeed SAVED lives, not killed people. Because the research continues to demonstrate that, in the U.S., "Drop, Cover, and Hold On!" works, the American Red Cross remains behind that recommendation. It is the simplest, reliable, and easiest method to teach people, including children.

The American Red Cross has not recommended use of a doorway for earthquake protection for more than a decade. The problem is that many doorways are not built into the structural integrity of a building, and may not offer protection. Also, simply put, doorways are not suitable for more than one person at a time.

The Red Cross, remaining consistent with the information published in "Talking About Disaster: Guide for Standard Messages," (visit http://www.disastereducation.org/guide.html ) states that if you are in bed when an earthquake happens, remain there. Rolling out of bed may lead to being injured by debris on the floor next to the bed. If you have done a good job of earthquake mitigation (that is, removing pictures or mirrors that could fall on a bed; anchoring tall bedroom furniture to wall studs, and the like), then you are safer to stay in bed rather than roll out of it during the shaking of an earthquake.

Also, the Red Cross strongly advises not try to move (that is, escape) during the shaking of an earthquake. The more and the longer distance that someone tries to move, the more likely they are to become injured by falling or flying debris, or by tripping, falling, or getting cut by damaged floors, walls, and items in the path of escape. Identifying potential "void areas" and planning on using them for earthquake protection is more difficult to teach, and hard to remember for people who are not educated in earthquake engineering principles.
The Red Cross is not saying that identifying potential voids is wrong or inappropriate.
What we are saying is that "Drop, Cover, and Hold On!" is NOT wrong -- in the United States. The American Red Cross, being a U.S.-based organization, does not extend its recommendations to apply in other countries.
What works here may not work elsewhere, so there is no dispute that the "void identification method" or the "Triangle of Life" may indeed be the best thing to teach in other countries where the risk of building collapse, even in moderate earthquakes, is great.

What to Do During an Earthquake

2011-03-14T18:43:00.000-07:00

from Federal Emergency Management Agency
U.S. Department of Homeland Security

Stay as safe as possible during an earthquake. Be aware that some earthquakes are actually foreshocks and a larger earthquake might occur. Minimize your movements to a few steps to a nearby safe place and if you are indoors, stay there until the shaking has stopped and you are sure exiting is safe.
If indoors

* DROP to the ground; take COVER by getting under a sturdy table or other piece of furniture; and HOLD ON until the shaking stops. If there isn’t a table or desk near you, cover your face and head with your arms and crouch in an inside corner of the building.
* Stay away from glass, windows, outside doors and walls, and anything that could fall, such as lighting fixtures or furniture.
* Stay in bed if you are there when the earthquake strikes. Hold on and protect your head with a pillow, unless you are under a heavy light fixture that could fall. In that case, move to the nearest safe place.
* Use a doorway for shelter only if it is in close proximity to you and if you know it is a strongly supported, loadbearing doorway.
* Stay inside until the shaking stops and it is safe to go outside. Research has shown that most injuries occur when people inside buildings attempt to move to a different location inside the building or try to leave.
* Be aware that the electricity may go out or the sprinkler systems or fire alarms may turn on.
* DO NOT use the elevators.

If outdoors

* Stay there.
* Move away from buildings, streetlights, and utility wires.
* Once in the open, stay there until the shaking stops. The greatest danger exists directly outside buildings, at exits and alongside exterior walls. Many of the 120 fatalities from the 1933 Long Beach earthquake occurred when people ran outside of buildings only to be killed by falling debris from collapsing walls. Ground movement during an earthquake is seldom the direct cause of death or injury. Most earthquake-related casualties result from collapsing walls, flying glass, and falling objects.

If in a moving vehicle

* Stop as quickly as safety permits and stay in the vehicle. Avoid stopping near or under buildings, trees, overpasses, and utility wires.
* Proceed cautiously once the earthquake has stopped. Avoid roads, bridges, or ramps that might have been damaged by the earthquake.

If trapped under debris

* Do not light a match.
* Do not move about or kick up dust.
* Cover your mouth with a handkerchief or clothing.
* Tap on a pipe or wall so rescuers can locate you. Use a whistle if one is available. Shout only as a last resort. Shouting can cause you to inhale dangerous amounts of dust.

Last Modified: Wednesday, 11-Aug-2010 14:41:22 EDT
http://www.fema.gov/hazard/earthquake/eq_during.shtm

Earthquake Triangle of Life

2011-03-14T18:39:00.000-07:00

http://en.wikipedia.org/wiki/Triangle_of_Life

The Triangle of Life is a controversial theory about how to survive a major earthquake, typically promoted via viral emails.

The theory advocated methods of protection very different from the mainstream advice of "drop, cover, and hold on" method widely supported by reputable agencies. In particular, the method's developer and key proponent, Doug Copp, recommends that at the onset of a major earthquake, building occupants should seek shelter near solid items that will provide a protective space, a void or space that could prevent injury or permit survival in the event of a major structural failure, a "pancake collapse", and specifiably advises against sheltering under tables.

Officials of many agencies have found themselves forced to respond to these viral emails spreading the "Triangle of Life" method.

Theory

According to Copp's theory, when buildings collapse, the weight of the ceilings falling upon the objects or furniture inside tends to crush them, but the height of the object that remains acts as a kind of roof beam over the space or void next to it, which will tend to end up with a sloping roof over it.
This space for survival Copp terms the triangle of life.
The larger and stronger the object, the less it will compact; the less it compacts, the larger the void next to it will be. Such triangles are the most common shape to be found in a collapsed building.

Criticisms of theory

According to United States Geological Survey, the Triangle of Life is a misguided idea about the best location a person should try to occupy during an earthquake. Critics have argued that it is actually very difficult to know where these triangles will be formed, as objects (including large, heavy objects) often move around during earthquakes. It is also argued that this movement means that lying beside heavy objects is very dangerous.
Statistical studies of earthquake deaths show most injuries/deaths occur due to falling objects, not structures.
Also, given that there are no warnings for earthquakes, you are more likely to be injured trying to move during an earthquake rather than immediately seeking a doorway, furniture, or near an interior wall. This strategy, combined with good engineering and educated search and rescue teams is the safest.
The Triangle of Life theory encourages individuals to put themselves at far higher risk by seeking safe zones which they are unlikely to reach.

Mahdavifar et al. (2010) analyzed and compared both methods in detail, considering their application, the extent of people who are under the coverage, simplicity in transferring concepts, and the probability of reducing casualties and damage in developing countries such as Iran.

Based on the results and observations, they concluded that duck and cover is still regarded as a better option for people during an earthquake.

Testing

In 1996, Copp claims to have made a film to prove this methodology and to have recreated a model school and home, filling them with 20 mannequins. However Marla Petal, a critic of Copp, has stated that this was a rescue exercise rather than an experiment as claimed by Copp, and because it did not simulate the lateral movement of earthquakes, the results are highly misleading.

The buildings were collapsed by earthmoving equipment that knocked the supporting pillars out. Half the mannequins were in 'duck and cover' positions and the others in what Copp calls the 'triangle of life' positions. When Copp and his crew re-entered the building after the blast, they calculated that there would have been no survivors amongst the mannequins in 'duck and cover' positions, as against 100% survival for those hiding in the triangles beside solid objects. Copp is categorical about the importance of this technique, saying "Everyone who simply ducks and covers when buildings collapse is crushed to death - every time without exception."
Petal disputes this on the exercise did not simulate the lateral motion of an earthquake, but instead they induced a pancake collapse which is rare in developed countries. However these collapses can occur in areas of extremely poor construction.

References

1. ^ "What to Do During an Earthquake", Federal Emergency Management Agency website
2. ^ "Drop, Cover, and Hold On!", Southern California Earthquake Center
3. ^ "DROP, COVER, AND HOLD ON! " Alaskan Red Cross
4. ^ "Drop, cover and hold still the best advice", New Zealand government website
5. ^ "DROP, COVER, AND HOLD ON! ", www.shropshire.gov.uk
6. ^ "protect yourself from falling debris by hiding under a strong table or structure", United Nations Educational, Scientific and Cultural Organization
7. ^ "Discredited earthquake safety advice circulated", Press Release: National Crisis Management Centre
8. ^ http://www.caymannetnews.com/article.php?news_id=19996 "'Safe practice' urged for earthquake preparedness"], Hazard Management Cayman Islands (HMCI) spokesperson
9. ^ "ODPEM dismisses quake tips from Doug Copp", JAMAICA'S Office of Disaster Preparedness and Emergency Management
10. ^ http://earthquake.usgs.gov/learn/faq/?categoryID=6&faqID=141 USGS - Common Myths about Earthquakes
11. ^ a b c d Douglas Copp - Worse than urban legend: dangerous advice! and now for some good advice for earthquake safety by Marla Petal, Ph.D. is Director of Bogaziçi University, Kandilli Observatory and Earthquake Research Institute's Disaster Preparedness Education Program.
12. ^ Mahdavifar, M., Izadkhah, Y.O., Heshmati, V. 2010. "Appropriate and Correct Reactions during Earthquakes: “Drop, Cover and Hold on” or “Triangle of Life”"; Journal of Seismology and Earthquake Engineering, Vol. 11, No. 1.
13. ^ Copp, Doug. "American Rescue Team Survival Magazine Article". The American Rescue Team International. http://www.amerrescue.org/arti_survivalarticle.htm. Retrieved 2010-03-13.

Another Explosion at Stricken Japanese Nuclear Plant; Radiation Risk Is Low Zosia Chustecka

2011-03-14T18:30:00.000-07:00

From Medscape Medical News

March 14, 2011 — Another explosion has hit the Japanese nuclear plant damaged by last Friday's earthquake and resultant tsunami, raising new fears about potential meltdown and radiation exposure.

Japanese prime minister Naoto Kan described the situation at the nuclear plant as "alarming" and said the earthquake has thrown Japan into "the most severe crisis since World War II."

The earthquake and tsunami on March 11 have wrought terrible destruction across northeast Japan, with tens of thousands of people missing and presumed dead. One town alone has officially listed more than 9500 missing — more than half of the total population of Minamisanriku. Situated on the coast nearest the epicenter of the earthquake, it was flattened by the tsunami, and only a few concrete structures, including the hospital, now remain standing.

Amid the devastation, there is increasing concern over a potential nuclear disaster, following explosions at the Fukushima Daiichi nuclear plant, also situated on the coast.

Damage from the earthquake and tsunami, as well as from aftershocks, have resulted in failure of automatic cooling systems, leading to a build-up of heat and hydrogen, escape of radioactive steam, resulting in explosions.

According to the Tokyo Electric Power Company's (TEPCO) Web site, the Fukushima Daiichi plant has 6 functioning nuclear reactors. However, reactors 4, 5, and 6 were down because of regular inspections. The 3 reactors that were operating were all shut down after the earthquake, but soon afterward the Japanese government announced a nuclear emergency because of a reactor cooling system malfunction at reactor 1.

Even when reactors are shut down safely, they have to be cooled constantly to avoid a meltdown of the core. "Reactors are not like your car that you can turn off and walk away. They're going to continue generating a great amount of heat until the core is disassembled," explained Ron Chesser, PhD, director of the Center for Environmental Radiation Studies at Texas Tech University in Lubbock. "Without cooling water, then you stand a real chance of a meltdown of core that could result in a large release of radiation, potentially."

Despite efforts to cool the reactor, including pumping in seawater, there was an explosion at reactor 1 on Saturday afternoon, and another at reactor 3 today. TEPCO said that 4 people were injured in the first explosion, and 7 in the latest explosion.

In addition, reactor 2 is also has problems with its cooling system: water levels are falling, and sea water is being pumped in, said Japan's Chief Cabinet Secretary Yukio Edano. These were the same problems that preceded the explosions in the other 2 reactors.

The area around the nuclear plants has been evacuated — initially to a radius of 1.9 miles, affecting 3000 people, but after the first explosion that was increased to a radius of 12 miles, affecting 140,000 local residents.

The fear is that there will be a release of radiation if the problems at the nuclear plant cannot be contained.

The Japanese government was reported to be distributing potassium iodide tablets to prevent radiation sickness. This is a standard procedure in the event of a nuclear alarm. Ingestion of potassium iodide saturates the body with a stable form of iodine and protects the thyroid gland from taking up radioactive iodine, which may be released in a nuclear accident.

Understandably, this is a highly sensitive issue in the only country in the world to have suffered from widespread radiation sickness after the atomic bombs fell on Hiroshima and Nagasaki.

So far, however, there has been limited release of radiation. At a news conference on Sunday, Edano dismissed worries that the radiation posed a public-health threat, according to an article published today in the English-speaking version of The Japan Times.
Dr. Michael Corradini

An emergency status is triggered when the radiation released per hour amounts to more than one tenth of the natural background radiation, explained Michael Corrandini, PhD, chair of engineering physics at the University of Wisconsin in Madison. Some radiation released on Friday after the earthquake reached this level, but since then the radiation levels have been decreasing continually, and the measurements are now below this trigger level, he said.

The radioactivity would have been released in steam escaping from the plant as the reactor was being cooled, he explained. This is part of the safety procedure, he continued, to vent the steam coming off the reactor into the building that surrounds it.

"The impression I get from reading the news reports is that they had a stoppage that allowed the coolant to fall to a level inside the reactor core such that the metal cladding of the core, which is made of zirconium, started to chemically react with the steam, which produced hydrogen," he told Medscape Medical News. Following safety procedures, they would have then vented the steam into the containment building, and the released hydrogen would have normally been inert, but it appears to have built up and ignited and that exploded, blowing off the top of the building, he said.

Dr. Corrandini emphasized that only the outer building was in the explosion. The nuclear material is in the reactor core, which is surrounded by metal cladding, and this is housed in a steel reactor vessel within a larger steel containment. "It's the building outside this containment that we see in the explosion," he said. The Japanese Nuclear and Industrial Safety Agency has made a point of emphasizing that the containment vessel is still intact, he noted.

These hydrogen combustion explosions "are not a disaster," Dr. Corrandini commented; what's gone is the "industrial building that keeps out the weather."

"That's not the safety issue," he said. "The issue is, has this promoted any radiation release, and the answer to that, as far as I can tell, is no."

From the reports both inside Japan and from measurements taken by US ships in nearby waters, the radiation release so far has been comparable to that seen in the 1979 disaster at Three Mile Island (TMI) in Pennsylvania, Dr. Corrandini commented.

In that incident, which involved a partial meltdown, there was also a venting of gases, and there was release of small amounts of radioactivity and radioactive iodine, but there have been no documented health consequences — there were no early effects, no genetic damage, and no latent cancers recorded in the 32 years since then, he pointed out.

"For me to say it's the same here [regarding Japan] is inappropriate, as we are only 3 days into this calamity, but as far as I can see from what I have read, they have the situation under control, and I would predict that the radiological consequences would be similar to that seen after TMI," he said.

"That's a million times less than after Chernobyl," Dr. Corrandini added, referring to the 1986 disaster at Chernobyl in the former USSR, which resulted in widespread release of radioactivity and documented adverse health consequences for years afterward, including cancers.

A Chernobyl-like disaster is not possible in this case, he emphasized — this is a totally different type of reactor with a different design.

"Some news reports have been very misleading and causing inappropriate amounts of concern by suggesting that this may lead to another Chernobyl-like disaster," he said. "It's fair and rational to inform the general public that there has been radiation release, and to ask questions about the health consequences about that...but we should be fair and rational about this."

The medical aid group Doctors Without Borders (Médicins sans Fronti`res) said that they are "closely monitoring the situation around Fukushima nuclear power plants. If there is a serious nuclear incident, it is only the Japanese government that will be in a position to react."

"The longer-term impact of the tsunami and the resulting nuclear problem cannot really be understood at present. However, there are international teams of experts on the scene and so the world's expertise is being brought to bear on this serious issue," commented Kirby Kemper, PhD, professor of physics at Florida State University in Tallahassee.

"To me, it will be another 3 days before the reactors are fully under control, and then the assessment can begin," he told Medscape Medical News.

CBRNE - Nuclear and Radiologic Decontamination

2011-03-14T18:28:00.001-07:00

eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

Author: Scott D Weingart, MD, Assistant Clinical Professor and Director, Division of Emergency Department Critical Care, Department of Emergency Medicine, Mount Sinai School of Medicine
Coauthor(s): Ben R Maltz, MD, State Surgeon, Washington Army National Guard, Science Officer, 10th Civil Support Team (Weapons of Mass Destruction)

Updated: Mar 9, 2009

In light of the events of September 11, 2002, terrorist attack has moved to the forefront of emergency department (ED) and Emergency Medical Services (EMS) planning. The use of radiologic weaponry is one threat that must be considered. In addition to attack by terrorists, preparations must also be made for a nuclear power plant disaster or contamination by radiologic medical sources. In the event of radiologic contamination, rapid treatment can be lifesaving.

Properly completed, rapid decontamination can reduce morbidity and mortality, limit the spread of contamination, and keep the ED functioning for the treatment of other patients.

For related information, see CBRNE - Radiation Emergencies. For excellent patient education resources, visit eMedicine's Bioterrorism and Warfare Center. Also, see eMedicine's patient education article Chemical Warfare.

Recognition of Contamination

The first step of recognizing contamination is to understand the difference between exposure to and contamination by radiologic agents.
Exposure is defined by an individual's proximity to material emitting ionizing radiation.
Actually touching, inhaling, or swallowing that material is contamination.1

A useful analogy is to imagine a person sitting around a campfire. By merely sitting next to the fire, the individual is exposed to the heat. If the person sits close enough to the fire, he or she might even get burned; however, as soon as the person is removed from the proximity of the fire, he or she would certainly not burn anyone else. If the person falls into the fire, in addition to being burned, he or she becomes covered in ash. This is external contamination. If other people touch the individual who fell into the fire, they would get ash on their hands, spreading the contamination. In the course of falling into the fire, if the individual swallowed, inhaled, or absorbed any of the ashes through cut skin, he or she would be internally contaminated as well.
Personal Protective Equipment

For an isolated radiologic incident, level D personal protective equipment (PPE) is all that is required. Level D PPE consists of surgical gown, mask, and latex gloves (universal precautions). If airborne contamination is a possibility, the use of a fitted air-purifying respirator (N95 or 100 filter mask) increases protection. Eye protection should also be worn to prevent ocular contamination from any splashing during the decontamination procedure. If any possibility of mixed exposure exists, higher levels of PPE may be required as dictated by the chemical or biological agents involved (see CBRNE - Personal Protective Equipment). Local and state laws, facility protocols, and Occupational Safety and Health Administration (OSHA) regulations must be followed.2,3

Shielding devices that are normally used for radiology studies are not recommended for radiologic decontamination. These devices, such as lead aprons, were designed to block low-energy radionuclides and are not effective shields for the high-energy emissions present in most decontamination situations. In addition, their bulk hinders the decontamination process and therefore leads to an increased exposure time.

Shielding capacity is limited in the hospital environment. However, other factors may potentially limit exposure to those providing patient decontamination. These factors are time, distance, and quantity.
The longer the time spent in the contaminated environment, the greater the dose of radiation to the worker; therefore, a rotating team approach is advised. Doubling the distance from the radioactive source decreases the dose by a factor of 4. Likewise, limiting the quantity of radioactive items in the decontamination area is advisable.

External Decontamination

The process of external decontamination can be divided into 2 stages: gross decontamination and secondary decontamination.

Gross decontamination

Gross decontamination is usually performed before the patient reaches a hospital environment. It consists of removal of all the patient's clothing and, if possible, brief irrigation of the patient's entire body with water. Clothing should be removed with a careful "roll-down" method to prevent inhalation of airborne particulates. If the patient is contaminated solely by a radiologic source, water is sufficient for the washing. If a possibility of mixed contamination exists, the protocols for biologic and/or chemical decontamination should be used because these regimens are more extensive than those used for radiologic decontamination. Since most radiologic contamination is located on the head and hands, the patient should be in the "head-back" position during initial showering to prevent run-off into the eyes, nose, or mouth. Early handwashing is also important.

Gross decontamination removes more than 95% of external contamination and renders the patient safe for access by care providers.1 If gross decontamination has not occurred in the field, it must be performed by ED personnel in a designated decontamination site. In most centers, the decontamination site is outside and immediately adjacent to the ED. The small amount of radioactivity present in the irrigation runoff produces minimal risk to the communal water supply or groundwater; therefore, patient decontamination should not be delayed by attempts to contain run-off. However, facility protocols and local, state, and federal laws should always be followed. After gross decontamination, the patient should be wrapped in a sheet for transport into the ED.

If the patient requiring decontamination becomes medically unstable at any point during the process, provision of medical care should take precedence over decontamination. The risk to care providers when treating a patient with radiologic contamination is virtually nil. If available, a radiation survey meter can be used to identify the extremely rare case of a patient who is emitting an amount of radiation sufficient to cause concern.

In the event of a mass casualty incident, gross decontamination is all that is immediately necessary. Patients should disrobe, with assistance if necessary. If able to ambulate, patients can briefly shower in a decontamination area. Likewise, the decontamination team needs only water to briefly wash patients who are unable to shower themselves. At this point, patients are sufficiently decontaminated and can receive treatment of any medical problems. Secondary decontamination of these patients can be postponed until more resources are available.

Secondary decontamination

Secondary decontamination is a stepwise methodical cleansing of any remaining radioactive areas of the patient. It should be performed under the guidance of the hospital's Radiation Safety Officer (RSO) or another member of the team trained in the use of radiation detection devices (RDD), such as a radiac instrument.

An area in the ED should be set aside for the decontamination procedure. Because this area may be out of service for a significant period, a location should be chosen that would not interrupt the normal workings of the department. A path to the decontamination room should be made with paper floor coverings and clear barriers to prevent the spread of contamination. In addition, these barriers prevent the entrance of extraneous personnel and visitors.

A decontamination team customarily consists of the RSO and two assistants, one of whom may be a clinician. However, in a mass-casualty setting, clinicians will likely not be available to perform decontamination. All members of the team should change out of their normal clothing into attire that can be bagged after the procedure. Shoe coverings, surgical masks, and eye protection should also be worn. Each member should be issued a dosimeter, which is a device that passively measures exposure to radioisotopes.

The general procedure for secondary decontamination involves using an RDD to perform a head-to-toe survey of all areas of the patient's body. Further irrigation is required for any areas with readings above the threshold, which is determined by the RSO on the basis of the RDD calibration. All secretions and runoff should be collected for sampling and dose estimation. After irrigation, the areas are surveyed again. This process is continued until acceptable levels are reached. Acceptable levels may be slightly above baseline and should be determined by the RSO and treating physicians.

Certain areas of the body require special procedures, as follows:2

* Mouth: Remove and bag any dentures, loose dental work, or foreign bodies. Take swab samples from the oral cavity. Preferable sites for swabs are under the tongue and between gums and teeth. The patient or physician should gently brush the teeth, gums, and tongue, being careful to avoid irritating the gums and causing bleeding. The mouth should then be copiously rinsed, taking care to avoid swallowing the rinse water. Resample with the RDD as above.
* Nose: Obtain nasal swabs. The patient should then gently blow his or her nose. Irrigate the nares while the patient leans forward, taking care to prevent the irrigating solution from being swallowed or aspirated.
* Eyes: If no contraindications exist, anesthetize the eyes with a topical agent. Sample the conjunctiva with moistened swabs, and copiously irrigate with saline. This can be facilitated with commercial eye irrigation devices, or a nasal canula attached to an intravenous (IV) bag can be used as an improvised eye irrigation system. If irrigating manually, irrigate medial to lateral with the patient's head turned to the side to minimize contamination of the lacrimal duct.
* Ears: Take samples from the external canals with moistened swabs. Examine the tympanic membranes for perforation, especially after blast incidents. If no perforation is found, copiously irrigate the canals with saline warmed to body temperature.
* Open wounds: Obtain wound swabs. If any particulate matter or foreign bodies are present, they should be removed and saved. Copiously irrigate the area and resurvey as in intact skin. Cover the wound with waterproof dressing to avoid recontamination from the run-off from irrigating other areas.

Internal Decontamination

Internal decontamination can be achieved by a number of methods, including the blockade of enteral absorption, blockade of end-organ uptake, dilution, and chelation. Speed is of the essence because some isotopes can be incorporated by end organs within an hour of exposure and are very difficult to remove. Therefore, EDs that are expected to care for these individuals must have the resources for internal decontamination available.

Blockade of enteral absorption

Gastric lavage and emetic agents: Although these strategies may decrease absorption of radioisotopes if initiated early after gastric contamination, they also create the risk of aspiration of radioisotopes, leading to respiratory contamination. No studies using gastric lavage or emetic agents for radiologic decontamination have been performed. However, a comparison can possibly be made with toxicologic exposures in which there are few recommended uses for these procedures. The authors currently do not recommend the routine use of gastric lavage or emetic agents.

Enteral binding methods: Some enteral binding methods have been shown to effectively bind specific agents of contamination.4,2

* Barium sulfate: This drug, which is commonly used for radiographic contrast studies, forms irreversible bonds with strontium and radium, which are used in older military, industrial, and medical equipment. Once bound, these agents pass through the gastrointestinal tract unabsorbed. A 1-time dose of 200 mL of 100% barium sulfate should be administered for internal decontamination.
* Aluminum and magnesium salts: Commercially available in agents such as Maalox and Mylanta, these salts bind to and reduce the absorption of strontium, radium, and phosphorus in a manner similar to barium sulfate. A dose of 100 mL of either of these agents should be given by mouth or nasogastric tube as soon as possible after exposure.
* Prussian blue: This agent binds to and increases the elimination of cesium and thallium. Cesium is found in medical radiotherapy devices and was used by terrorists in Russia during an attempted attack; thallium is used in medical imaging. Prussian blue also blocks the absorption of rubidium. If internal contamination with one of these agents is present, administer 1 g by mouth tid for 3 weeks. This medication has recently received FDA approval under the name Radiogardase.
* Activated charcoal: In patients without a decreased level of consciousness, the administration of one dose of activated charcoal may bind to and speed the elimination of some radioisotopes. Because the adverse effects of this medication are rare, activated charcoal is recommended if administered shortly after exposure. A dose of 50-100 g should be given by mouth or gastric tube; if the patient is at risk for aspiration, this medication should be avoided.

Blockade of end-organ uptake

Potassium iodide (KI): This medication has recently received much attention by the press. It is viewed by the public as a universal blocking agent for all the effects of a radiologic or nuclear attack. Radioactive iodine (RAI) is present in nuclear reactor fuel rods; therefore, in the event of any reactor accident, terrorist attack, or use of fuel rods for terrorist explosive devices (radiation dispersal devices, ie, dirty bombs), RAI can be released. The primary toxicity of RAI is to the thyroid gland. Competitive blockade of RAI and technetium uptake can be achieved with large doses of KI. Effectiveness is directly proportional to the speed of administration, which is preferably within 6 hours of exposure. Toxicity of RAI is highest in the pediatric population, but this medication should be administered to any patient who has been contaminated. The dose is 300 mg/d by mouth for 1-2 weeks.

Calcium: Calcium gluconate or calcium chloride can be administered to limit the incorporation of strontium or radioactive calcium into bone. Patients can receive 1 g of calcium chloride or 3 g of calcium gluconate administered intravenously.

Dilution

Oral fluids: Tritium is present in nuclear weapons and is used by the military for luminescent gun sights. If internal contamination with tritium is suspected, administer copious oral or intravenous fluids to cause dilution and increase renal excretion of tritiated water. Oral fluid in the amount of 5-10 L/d should be administered for 1 week. Sodium monitoring is necessary if hypotonic fluids are used.

Phosphorus: Similar to dilution of tritium, oral loading with phosphorus salts (Neutra-Phos) can enhance the elimination of radioactive phosphorus. One packet of Neutra Phos or 2 tablets of K Phos should be administered qid by mouth for 3 days.

Chelation

Diethylenetriamine pentaacetic acid (DTPA): Americium (a daughter product of plutonium), uranium, plutonium, and other heavy metals (present in nuclear reactors and weapons) are poorly excreted by the kidneys. Pentetate calcium trisodium (CaDTPA) and pentetate zinc trisodium (ZnDTPA) form compounds with specific radioisotopes (ie, americium, curium, plutonium), rendering them more easily excreted by the kidneys and enhancing elimination. These drugs were recently FDA approved. The Oak Ridge Institute of Science and Education has given DTPA IND status. Immediately contact REAC/TS in the event of a contamination (see Obtaining Expert Advice).

If within the first 24 hours of exposure, use Ca-DTPA. For subsequent doses, or if first treating after 24 hours of exposure, use Zn-DTPA. The dose for either agent is 1 g dissolved in 250 mL of saline or D5W given over 1 hour qd. If the exposure is solely respiratory, 1 g of either agent can be mixed 1:1 with normal saline and nebulized.

Penicillamine: Radioactive cobalt is used for medical radiotherapy and food irradiation. In the case of internal contamination caused by radioactive cobalt, similar clinical effects to DTPA administration can be achieved with the use of penicillamine. The dose is 250-500 mg by mouth 4 times per day.

Decrease organ damage

Sodium bicarbonate: Depleted uranium is found in reactor fuel rods and nuclear weapons. It can cause acute tubular necrosis (ATN) and renal failure in cases of internal contamination. The alkalinization provided by sodium bicarbonate makes the uranium less nephrotoxic. Administer an initial bolus of 2 mEq/kg intravenously. Then add 4 ampules to 1 L of D5W and titrated to a urinary pH of 6.5-7.5. (Urinary acidification has been proposed to enhance the elimination of strontium.)

Wound excision

Wound excision may be considered when the wound is contaminated with an isotope that has a very long half-life, such as plutonium.
Obtaining Expert Advice

The treatment of patients with internal contamination involves complicated diagnostic and therapeutic regimens. In addition to the local poison center (nationwide number, 1-800-222-1222), one of the following agencies should be contacted for guidance as soon as possible.

* Armed Forces Radiobiology Research Institute (AFRRI) Web site; telephone, (301) 295-0530
* Radiation Emergency Assistance Center/Training Site (REAC/TS) Web site; telephone, (865) 576-1005 (ask for REAC/TS)

Obesity and Women's Health: An Evidence-based Review

2011-03-09T20:58:00.000-08:00

From Journal of the American Board of Family Medicine

Teresa Kulie, MD; Andrew Slattengren, DO; Jackie Redmer, MD, MPH; Helen Counts, MD; Anne Eglash, MD; Sarina Schrager, MD, MS

Posted: 02/27/2011; J Am Board Fam Med. 2011;24(1):75-85. © 2011 American Board of Family Medicine

Abstract

Obesity negatively impacts the health of women in many ways.
Being overweight or obese increases the relative risk of diabetes and coronary artery disease in women.
Women who are obese have a higher risk of low back pain and knee osteoarthritis. Obesity negatively affects both contraception and fertility as well.
Maternal obesity is linked with higher rates of cesarean section as well as higher rates of high-risk obstetrical conditions such as diabetes and hypertension. Pregnancy outcomes are negatively affected by maternal obesity (increased risk of neonatal mortality and malformations).
Maternal obesity is associated with a decreased intention to breastfeed, decreased initiation of breastfeeding, and decreased duration of breastfeeding.
There seems to be an association between obesity and depression in women, though cultural factors may influence this association.
Obese women are at higher risk for multiple cancers, including endometrial cancer, cervical cancer, breast cancer, and perhaps ovarian cancer.

Introduction

The prevalence of obesity is rising.
The World Health Organization estimates that more than 1 billion people are overweight, with 300 million meeting the criteria for obesity.
Twenty-six percent of nonpregnant women ages 20 to 39 are overweight and 29% are obese.
This article will review the wide-ranging effects that obesity has on both reproductive health and chronic medical conditions in women.

A PubMed search was performed using the key words "obesity," "overweight," "body mass index" (BMI), "gender," "women's health," and the condition reviewed.
The most recent evidence-based articles were included in the review.
The evidence level of each article was determined by the authors based on the type of study, randomization, the number of participants, and loss to follow-up.

Table 1 provides a classification for overweight and obesity based on BMI.
Waist circumference can also be used to classify overweight and obesity.
In women, a waist circumference of >35 inches (88 cm) is high risk, whereas in men the level is >40 inches (102 cm).
Research varies in the measurements of obesity used to classify participants in each study.

Obesity and Type 2 Diabetes Mellitus

The risk of diabetes mellitus (DM) increases with the degree and duration of being overweight or obese and with a more central or visceral distribution of body fat. Increased visceral fat enhances the degree of insulin resistance associated with obesity.
In turn, insulin resistance and increased visceral fat are the hallmarks of metabolic syndrome, an assembly of risk factors for developing diabetes and cardiovascular disease.

The Nurses' Health Study followed 84,000 female nurses for 16 years and found that being overweight or obese was the single most important predictor of DM.
An increased risk of DM was seen in women with BMI values >24 and a waist-to-hip ratio >0.76.
After adjusting for age, family history of diabetes, smoking, exercise, and several dietary factors, the relative risk (RR) of DM for the 90th percentile (BMI = 29.9) versus the 10th percentile (BMI = 20.1) was 11.2 (95% CI, 7.9–15.9). A recent meta-analysis similarly found a pooled RR for developing DM of 12.41 (95% CI, 9.03–17.06) among obese women.

In morbidly obese patients (BMI >40 or >35 with major comorbidities), weight loss surgery can be considered if conservative measures fail.
In one Swedish study, 68% of obese patients with DM who underwent gastric bypass surgery and subsequently lost weight went into remission.A systematic review that included more than 135,000 patients (80% women) found that bariatric surgery resulted in complete resolution of diabetes in 78% of patients and improvement in diabetic control in more than 86% of patients. These patients had improvements in insulin levels, fasting glucose levels, and glycosylated hemoglobin levels.

Obesity and Coronary Artery Disease

Obesity is an independent risk factor for the development of coronary artery disease (CAD) in women and is an important modifiable risk factor for prevention of CAD. The mechanism of action is likely the relationship between obesity and insulin resistance. In a large cohort study of 37,000 women in Washington state, women with a BMI ≥35 had an odds ratio (OR) of 2.7 for CAD and an OR of 5.4 for hypertension.

Abdominal obesity may be more harmful in women than BMI or weight alone.
Waist circumference is an independent risk factor for developing CAD in both normal-weight women and overweight women.The Interheart global case-control study of 6787 women from 52 countries found that abdominal obesity was more predictive of myocardial infarction than was BMI alone.
A prospective cohort study of more than 44,000 women in the Nurses Health Study found an association between having a waist circumference of >88 cm and the risk of cardiovascular mortality. Women with a waist circumference of >88 cm had a RR of death from cardiovascular disease of 3.02 (95% CI, 1.31–6.99).
Waist-to-hip ratio is another significant predictor of death from cardiovascular disease, with a RR of 3.45 (95% CI, 2.02 to 6.92) in women with a ratio of >0.88.

A meta-analysis that included data on more than 22,000 patients (72% women) looking at the relationship between bariatric surgery and cardiovascular risk factors found that hyperlipidemia improved in 70% of patients after surgery and hypertension was resolved in 62% and improved in 78%.

Obesity and Musculoskeletal Pain

In the United States, the Center for Disease Control and Prevention statistics show that more than 31% of obese adults reported a doctor diagnosis of arthritis compared with only 16% of nonobese adults.Obesity has been implicated in the development or progression of low back pain and knee osteoarthritis (OA) in women.

The mechanism by which obesity causes lumbar back pain is poorly understood, but the contribution of both mechanical and system factors is likely. Direct mechanical stress on the intervertebral discs and the indirect effects of atherosclerosis on blood flow to the lumbar spine are suspected to be mechanisms through which obesity affects the discs, leading to subsequent low back pain. Further research to elucidate the exact mechanism is needed.

Obesity at age 23 increases the risk of low back pain onset for women within 10 years[19] (Table 2). The increased burden of obesity is more obvious as women age, with significantly more obese women over the age of 40 reporting low back pain and lumbosacral radicular symptoms.[23] These symptoms increase further in obese women over the age of 54.[24] This data supports the theory that obesity over time contributes to low back pain and that weight loss may help prevent the onset of low back pain in obese women. There is no evidence to support the recommendation of weight loss to treat low back pain once the pain is present.

The data supporting the link between obesity and knee OA in women is even more staggering. The factors underlying the association of obesity with knee OA have not been entirely elucidated. Obesity leads to an excess load on the joint, increased cartilage turnover, increased collagen type 2 degradation products, and increased risk of degenerative meniscal lesions. Although all of these have been theorized to lead to knee OA no causal relationships have been demonstrated to date.[25,26]

Studies have shown that women with a diagnosis of knee OA have an average BMI that is 24% higher than women without OA.For every 2 units of BMI gain, the risk of knee OA increases by 36%,and 1 category shift downward in BMI from obese to overweight may avoid 19% of new cases of severe knee pain (Table 3). The importance of prevention of knee OA is highlighted by the subsequent burden of surgery. An estimated 69% of knee replacements in middle-aged women in the United Kingdom have been attributable to obesity. Dietary weight loss in combination with exercise effectively led to significant improvements in pain and physical function in women with knee OA over 18 months in the Arthritis, Diet, and Activity Promotion Trial.A separate, randomized clinical trial evaluating rapid weight loss found that a 10% weight reduction improved function by 28%, with a number needed to treat of <4 patients (95% CI, 2–9 patients) to achieve a 50% improvement in the WOMAC score, which is a measure of joint pain, stiffness, and function.[35]Obesity and Infertility (Including Polycystic Ovary Syndrome)Obesity affects fertility throughout a woman's life. The impact of obesity and Polycystic Ovary Syndrome (PCOS) on reproductive function can be attributed to multiple endocrine mechanisms. Abdominal obesity is associated with an increase in circulating insulin levels. This results in increased functional androgen levels (caused by suppression of sex hormone–binding globulin synthesis and increased ovarian androgen production). Chronic elevation of circulating estrogen is caused by aromatization in peripheral adipose tissue. The resulting hyperandrogenism and menstrual cycle abnormalities are clinically manifested in part by anovulatory cycles and subfertility. Additionally, leptin inhibits ovarian follicular development and steroidogenesis and thus may contribute to reproduction difficulties in obese women.The impact of obesity on reproduction starts at a young age. Obese girls frequently experience the onset of puberty at a younger age than their normal-weight peers. Between the late 1960s and 1990, during a time of increasing prevalence of childhood obesity, the median age of menarche decreased by approximately 3 months in white girls and 5.5 months in black girls in the United States.Obesity negatively affects contraception. Older studies have shown that hormonal contraception methods are less effective in obese women.For example, a retrospective cohort analysis of 2822 person-years of oral contraceptive use suggested that women in the highest quartile of body weight (≥70.5 kg) had a 60% higher risk of failure than women of lower weight. This study also found that the increased risk of failure associated with weight was higher for women using very low-dose or low-dose oral contraceptives. However, a recent large cohort study in Europe did not show a difference in contraceptive efficacy of oral contraceptive pills based on BMI.[39]A multicenter study of 1672 healthy, ovulating, sexually active women randomized to receive the transdermal patch Ortho-Evra (Ortho-McNeil-Janssen Pharmaceuticals, Inc., Raritan, NJ) for 6 or 13 cycles found a higher rate of failure (pregnancy) in women weighing >90 kg (RR 58; 95% CI, 10.8–310. Additionally, a study of 1005 women using the levonorgestrol vaginal ring demonstrated higher rates of pregnancy at 1 year for heavier patients (1.7% for a 40-kg woman; 9.8% for an 80-kg woman).[37] Obesity is a risk factor for technical failure of tubal ligation surgery (OR, 1.7; 95% CI, 1.2–2.6).[40] The intrauterine device may be one of the few reliable contraception options whose efficacy does not seem to be affected by BMI.[37] Product inserts rarely comment on weight-specific guidelines (Table 4).

Although most attention has focused on the impact of obesity on ovulation, other studies suggest a multifactorial impact. A recent national survey in France found that obese women were less likely to access contraceptive health care services and had more unplanned pregnancies.[42] The US National Longitudinal Survey of Youth prospectively examined the association between body weight in young adulthood and achieved fertility in later life.[43] Obese young women and men were less likely to have their first child by the age of 47 than were their normal-weight counterparts (for women: RR, 0.69; 95% CI, 0.61–0.78; for men: RR, 0.75; 95% CI, 0.66–0.84). This association was partly explained by a lower probability of marriage among obese patients, suggesting both a social and biologic effect on reproductive behavior.[43]

A retrospective cohort study of 22,840 women demonstrated that obesity was associated with reduced fecundity for all weight-adjusted groups of women and persisted for women with regular cycles.[44] In addition, obesity may alter the quality of oocytes and embryos.[45] Some studies demonstrate increased female sexual dysfunction in obese patients, whether caused by the physical or psychological impacts of obesity on female sexuality.[36]

Obesity is frequently associated with disturbances in the menstrual cycle. Cross-sectional studies indicate that 30% to 47% of overweight and obese women have irregular menses.[46] PCOS frequently causes menstrual irregularity and is very common among obese women, though the actual prevalence is unclear. Although obesity may amplify the effects of PCOS, it is not a diagnostic criteria for PCOS. Approximately 20% of women with PCOS are not obese.[47]

Weight loss can improve the fertility of obese women by the return of spontaneous ovulation, thus leading to the recommendation of implementing weight-loss interventions (diet, exercise, medication treatment) as initial management of infertile overweight and obese women.[48]

A systematic review[49] assessing pregnancy and fertility after bariatric surgery reported that although the available data are not optimal, surgery may have a beneficial influence on fertility. This is supported by the normalization of hormones in PCOS and the correction of abnormal menstrual cycles after surgery.
Obesity and Pregnancy

An Australian study of more than 14,000 pregnant women found that 34% were overweight, obese, or morbidly obese.[50] In a US study of 9 states that included more than 66,000 women, there was a 22% rate of obesity among pregnant women in 2002 to 2003, which was up 69% since 1993.[51] The subgroups of women with the highest increases in obesity rates were women aged 20 to 29 years, were African American, who had ≥3 children, and who were enrolled in the US Department of Agriculture's Women, Infants, and Children program.[51] Obesity causes pregnancy complications because of elevated risks of antepartum complications and mechanical difficulties with delivery.

Obesity during pregnancy is related to higher overall health care expenditures, measured by length of stay after delivery and use of other services. The majority of this difference is caused by higher cesarean section rates and higher rates of high-risk obstetric conditions such as diabetes and hypertension. The mean length of stay after delivery was directly correlated to BMI[52] (3.6-day stay for women with a normal BMI vs 4.4-day stay for women with a BMI >40.0).

Prepregnancy obesity contributes to the development of many pregnancy complications including pregnancy-induced hypertension, preeclampsia, gestational diabetes, c-section, and neonatal death (Table 5). Compounding this finding is the fact that performing a cesarean section is more difficult in obese women.

Rates of fetal anomalies are increased in obese mothers as well, including neural tube defects (OR, 1.87; 95% CI, 1.62–2.15), spina bifida (OR, 2.24; 95% CI, 1.86–2.69), cardiovascular anomalies (OR, 1.30; 95% CI, 1.12–1.51), and cleft lip and palate (OR, 1.20; 95% CI, 1.03–1.40).[61] However, maternal obesity was protective for gastroschesis (OR, 0.17; 95% CI, 0.10–0.30).[61]

Weight loss via bariatric surgery s to decrease many pregnancy complications. A retrospective cohort study that included 585 women who had undergone bariatric surgery found that women who had delivered children after surgery (as compared with women who delivered before surgery) had decreased rates of hypertension during pregnancy (OR, 0.39; 95% CI, 0.20–0.74) and preeclampsia (OR, 0.20; 95% CI, 0.09–0.44). Another study compared women who delivered before surgery to women who delivered after surgery and found decreased rates of diabetes (17.3% vs 11%; P = .009), hypertensive disorders (23.6% vs 11.2%; P < .001), and fetal macrosomia (7.6% vs 3.2%; P = .004).[63]Obesity and BreastfeedingMaternal obesity is associated with a decreased intention to breastfeed, decreased initiation of breastfeeding, and decreased duration of breastfeeding. Some of these effects may be cultural, having to do with one's body image, or physiologic caused by metabolic and hormonal effects of adipose tissue (ie, decreased milk supply). However, obesity may also be related to some confounders such as more pregnancy complications, which also have negative effects on breastfeeding rates.A large study in the United Kingdom asked approximately 11,000 women at 32 weeks' gestation about their level of concern regarding their shape and weight. After adjusting for multiple variables, those with "marked concern" for both were significantly less likely to intend to breastfeed.[65] Another smaller study done in the United States among 114 women found that obese women intended to breastfeed for a significantly shorter period of time than other women.[66]Several studies have demonstrated decreased breastfeeding initiation rates among obese women compared with normal-weight women.64,[67–70] One chart review of 1109 white mother-baby dyads found that the overweight and obese mothers were more likely to quit breastfeeding at the time of discharge from the hospital compared with mothers who were normal weight (12.2% vs 4.3%).[67]Obese women are at greater risk of a delay in milk production, which may be related to decreased rates of breastfeeding initiation. One study found that obese women had lower prolactin responses to suckling in the first week compared with normal-weight women.[71] There is also evidence that excess body fat may impair mammary gland development before conception and during pregnancy by hormonal and metabolic effects.[72]Maternal obesity is also associated with a shortened duration of breastfeeding.[64,69,70,73,74] A Danish study of nearly 38,000 women observed that the greater the prepregnant BMI, the earlier the termination of breastfeeding.[73] There is no data looking at future breastfeeding rates with subsequent pregnancies after weight loss.Obesity and DepressionPopulation-based studies looking at the association between obesity and depression have yielded inconsistent results, with only some finding an association.[75–78] The difference between sexes is similarly inconsistent. Some studies found an association between obesity and higher rates of depression in women but not in men;[79,81] others reported inverse associations between obesity and depression in both women and men.[81]Most recently, data from the third National Health and Nutrition Examination Survey (1988–1994) showed that obesity was associated with past-month depression in women (OR, 1.82; 95% CI, 1.01–3.3) but not in men (OR, 1.73; 95% CI, 0.56–5.37).[82] This relationship was stronger when obesity was stratified by severity. One 5-year prospective study following a cohort of 2298 persons from Alameda County, CA, showed that the obese were at increased risk of depression (prevalence: OR, 2.16; 95% CI, 1.47–3.19; incidence: OR, 2.11; 95% CI, 1.29–3.47) but there was no effect of sex on this association.[77]Although many social, psychological, and cultural factors likely contribute to the development of depression in obese women, one explanation argues that the stigma toward obese individuals in American society leads to low self-esteem and ultimately depression. Thus, in communities where a higher weight is acceptable, less psychological impact is observed. Another theory argues that obesity is not stressful per se, but the pressure to fit a norm and continued dieting leads to depression.[83]Obesity and Cancer in WomenGeneral There is mounting evidence that obesity is a risk factor for developing gynecologic and breast cancers and that a higher BMI may also adversely impact survival. Obese women with cancer may have decreased survival because of later screening, comorbid illnesses, or poorer response to treatment. Obese women have increased surgical and possibly radiation complications. In addition, there is no current consensus regarding appropriate chemotherapy dosing for the obese patient.[84] The increased levels of endogenous estrogen contribute to higher risk of several types of cancer.[85,86]Endometrial Cancer Endometrial carcinoma is strongly related to obesity. In premenopausal women, anovulation or oligoovulation that is associated with PCOS results in an endometrium that is chronically exposed to unopposed estradiol. This causes proliferation and the potential for neoplastic changes. Additionally, in premenopausal and postmenopausal obese women, increased insulin and androgens decrease the production of sex hormone–binding globulin. This leads to more and unregulated bioavailable estrogens in postmenopausal women.In 2001 the International Agency for Research on Cancer found that there was convincing evidence based on large cohort and case-control studies that obesity is associated with a 2- to 3-fold risk in endometrial cancer.[84,87] Epidemiologic data has found a 2- to 5-fold increased risk of developing endometrial carcinoma in premenopausal and postmenopausal women, and obesity has been associated with at least 40% of the incidence of endometrial cancer.[86,88,89] Mortality from uterine cancer also seems to increase with BMI. A prospective study through the American Cancer Society following 495,477 women found that those with a BMI >40 had an endometrial cancer mortality increased RR of 6.25 (95% CI, 3.75–10.42.).[85,90]

Ovarian Cancer The data linking ovarian cancer and obesity has been mixed.[91–93] The rationale for an increased risk of ovarian cancer in obese women focuses on the hormonal impact of obesity. In 2001, the International Agency for Research on Cancer group found that the "evidence from the relatively few studies on body weight and ovarian cancer has been inconsistent and does not allow any conclusion to be drawn on a possible association."[87] If some subtypes of ovarian cancer are hormonally responsive, it seems logical to assume that unopposed estrogen could increase the risk of these cancers in obese women.[84]

Cervical Cancer Several studies have shown both increased incidence and mortality from cervical cancer among obese women. This relationship may be because of decreased screening compliance among obese women.[84] Obesity likely plays a more prominent role in the development of cervical adenocarcinoma than squamous cell carcinoma secondary to the role of additional estrogenic hormones.[94] Disparities in cervical cancer screening by body weight persist for women who are severely obese. Obese white women may put off cervical cancer screening because of embarrassment or discomfort. Physicians recommend Papanicolaou smears for obese women at the same rate as for normal weight women.[95,96]

Breast Cancer There is a well-established link between obesity and postmenopausal breast cancer.[97] It is hypothesized that this is because of an increase in the serum concentration of bioavailable estradiol.[98] In 1997, a meta-analysis analyzed 51 studies, including 52,705 women with breast cancer and 108,411 women without breast cancer, and found that the strength of the estrogenic risk attenuated by obesity is stronger than with hormone replacement therapy. In fact, hormone replacement therapy does not increase the risk of breast cancer in obese, postmenopausal women (RR, 1.02 for BMI >25 kg/m2), though it is a significant risk for breast cancer in normal-weight women (RR, 1.73).[99,100]

Several meta-analyses, systematic reviews, and large cohort studies have shown obesity worsens breast cancer mortality. Obese women also have greater disease morbidity, including a higher recurrence rate, increased contralateral breast cancer, wound complications after breast surgery, and lymphedema.[101] Poorer outcomes associated with breast cancer may be related to more aggressive disease at diagnosis, a higher likelihood of treatment failure, and a higher likelihood of delayed detection. Morbidly obese women are significantly less likely to report recent mammography. This is particularly true for white women.[102,103] Obesity may also promote more rapid growth of metastatic disease because of impaired cellular immunity. In addition, the hyperinsulinemia found in some obese women may promote mammary carcinogenesis by increasing the levels of insulin-like growth factor and leptin, which have a synergistic effect with estrogen on mammary epithelial cells by promoting angiogenesis.[101]

Weight Loss and Cancer Studies evaluating the long-term impact of weight loss on cancer risk among women have shown mixed results. In one large US study, cancer incidence and mortality data were compared between 6596 patients who had gastric bypass (between 1984 and 2002) and 9442 morbidly obese persons who had not had surgery. This study showed decreased overall cancer rates in women (P < .0004), with the strongest impact on endometrial cancer (P < .0001) and with less significant impacts on premenopausal and postmenopausal breast cancer (P < .54), cervical cancer (P < .78), and ovarian cancer (P < .19).104 A large Swedish study followed 13,123 obesity surgery patients and found no overall decrease in obesity-related cancers compared with the baseline incidence among obese individuals. No statistically significant trends were found for breast cancer (P < .60) or endometrial cancer (P < .83) over time. Therefore, efforts directed toward prevention of obesity might be more helpful than weight reduction in attempts to reduce the incidence of obesity-related cancer.

Conclusion

Obesity is becoming more prevalent and has wide-ranging effects on a variety of women's health issues. Clinicians should counsel all women about the broad negative effects of obesity and the importance of controlling weight to prevent negative outcomes

Breast Implants, Safety and Efficacy of Silicone

2011-03-09T20:15:00.000-08:00

eMedicine Specialties > Plastic Surgery > Breast

Author: Garry S Brody, MD, MSc, FACS, Professor Emeritus, Department of Surgery, Division of Plastic Surgery, Keck School of Medicine, University of Southern California
Updated: May 1, 2009

Background

The number of women in the United States who have breast implants is unknown, but current estimates derived from national surveys range up to more than 6 million. This represents more than 5% of the adult female population. The American Society of Plastic Surgeons (ASPS) collects information annually on plastic surgery procedures performed by its members. In 2008, approximately 307,000 women received breast implants for cosmetic breast augmentation and 111,000 for reconstruction of congenital or postmastectomy deformities.1 These data do not include those procedures (mostly cosmetic) performed by non plastic surgeons such as otolaryngologists, general surgeons, gynecologists, and others.

Following adverse publicity in the early 1990s, interest in the procedure fell significantly, especially for gel-filled devices, but it seems to have recovered incrementally. According to the ASPS, in 2008, 53% of total breast implants were filled with saline; 47% were filled with silicone.1

Prior to 1963, various plastic foam materials were used; for breast augmentation, however, it became apparent that the air cells would collapse and, combined with tissue ingrowth, shrink and harden the device. These materials were wrapped in plastic film to minimize this effect to no avail. Amazingly, some of these implants were so well tolerated that they have stayed in place to this day.

The modern silicone breast implant has been available since 1963 and has gone through an evolution of change and improvement. Several types of devices, with many variations, shapes and styles within each class, are now available or under testing for US Food and Drug Administration (FDA) approval. Basic to all implants is a silicone rubber (elastomer) shell, which can be single or double, smooth or textured, barrier-coated, or covered with polyurethane foam. The foam-covered devices have not been available in the United States since 1990 but are still marketed in Europe.

The contents are either factory-filled with silicone gel of various consistencies or inflated at surgery with normal saline. One brand that was manufactured overseas was prefilled with saline at the factory. It was briefly marketed in the United States but was later withdrawn when the FDA denied approval.

The double-lumen devices consist of concentric balloons that contain silicone in one chamber and saline in the other. The only one still in use is the Becker, which has an outer layer of gel and an inner balloon that is valved to permit postoperative gradual inflation with saline. This is termed a "permanent tissue expander," since it permits gradual and temporary overinflation to create the pocket and then can be left in as a permanent implant after the size is adjusted appropriately. At this writing, the Becker devices are not generally available in the United States until current FDA mandated studies are evaluated.2 For more information on expandable implants, see eMedicine article Uses of the Postoperatively Adjustable Implant in Aesthetic Breast Surgery.

In 1990, the FDA placed a moratorium on gel-filled implant use for cosmetic augmentation. They remained available for reconstruction and replacement, but mandated extensive record keeping, follow-up, and IRB approval were required for use. In 2006, after extensive study and analysis, the FDA deemed the device safe for all augmentation and reconstructive purposes, but they continue to require tracking of patients.

Saline Implants
Saline filled implants are available as empty silicone balloonlike devices to be filled with normal saline at the time of surgery. This permits subtle size adjustments to compensate for asymmetry between the breasts. They are less popular than silicone implants, as they often may have a less natural feel. If the patient has very little breast tissue or only a skin covering after mastectomy, unsightly wrinkles and folds of the device may be visible on the breast. This is more common when the surface is textured.

Silicone Gel Implants

Three generations of basic design of this device have been created, with many variations within each type.

First generation

The first models to be marketed had envelopes of thick, smooth-walled silicone elastomer made in 2 sections, filled with a viscous silicone gel material (dimethylsiloxane) and glued together. They were available in only three sizes: small, medium, and large. In the first few years, surgeons believed that the device required attachment to the tissues to prevent migration. Scar ingrowth for fixation was accomplished by patches of material (eg, Dacron mesh or perforated silicone) attached to the back of the device or by an outer covering of polyurethane foam. The Dacron and silicone patches were subsequently found to be unnecessary; they actually detracted from the quality of the result. Some patches or tabs created a stress point that led to tears of the envelope. Fixation patches were eliminated in the early 1970s.

Second generation

Manufacturers varied the gel consistency and shell thickness in an attempt to improve performance. Beginning in the mid-1970s, the shells were made thinner and the gel less viscous (ie, more "responsive"), primarily in an ill-conceived attempt to control hardening from scar shrinkage (capsular contracture.) This trend reversed in the early 1980s when it was recognized as not effective in reducing contracture and as resulting in a more fragile device. Most were broken 10 years later.

Third generation

New formulations of the shell and gel contents became available that were stronger and had a second barrier coat of diphenyl silicone. This coating almost totally eliminated so-called "gel bleed" or diffusion of small amounts of the silicone oil through the implant shell. The gel content also was made more viscous and cohesive.

In 1989, textured-surface shells that many surgeons hoped would minimize the incidence of unwanted firmness from capsular contracture became available. Recent studies are somewhat confusing regarding whether this was effective. The textured implants had the disadvantage of a higher rupture rate than the more traditional smooth shells and often produced visible wrinkles in the breast in women with very little overlying tissue to mask the ripples. Because of these shortcomings and lack of solid evidence that these devices were softer, they have become much less popular in recent years.

Polyurethane-covered implants

In the late 1960s, a variation of the device was developed containing a polyurethane sponge coating over an otherwise standard gel-filled implant. Although the coating originally was planned as a fixation layer, many surgeons came to believe that the foam cover resulted in a decreased incidence (or at least a delayed onset) of capsular contracture. These implants also evolved in shape and design, culminating in the early 1980s with the Meme and Optimam styles. In April 1991, the manufacturer voluntarily withdrew the foam-covered implants from the market.3

One style, the MemeME, had a unique construction. It had no true shell, but a skin of sorts was formed in situ by spraying the surface with silicone containing extra catalyst prior to curing. This increased the crosslinking of the surface to create a shell-like membrane. The polyurethane foam was then shaped and sealed over the surface. Implants of this particular type were known to occasionally extrude some of their gel contents through the foam when squeezed. This is a possible explanation for reports of blood being found within the substance of the gel in apparently intact implants. The MemeME model was marketed from 1983-1988.
Other filler materials

While silicone remains the only available shell material, new filler substances were in use in Europe and South America and, at one time, were under development or in experimental trial in the United States. Various hydrogels and a pure form of triglycerides were the 2 main formulations. The major advantage of the triglyceride formulation (Trilucent) was that it had a Z number (measure of radiolucency) similar to that of fat, thus resulting in little or no compromise of mammography. Another fill substance, polyvinyl pyrrolidone in saline, was briefly available, under the trade name Misty Gold. None of these products is currently available in the United States. At this time, only silicone gel or saline-filled models are available for use in the United States.

Recent developments

In late 2006, a new formulation of silicone gel filler called MemoryGel (Mentor Corp, Santa Barbara, Calif) gained FDA approval.4 This gel implant is thicker and more cohesive so as to minimize gel spread in the case of rupture and to resist scar shrinkage that would deform its contour. When cut, the gel retains its shape and doesn’t run. This device has a doughy feel to it.

Currently available devices in the United States are saline- or silicone-filled implants with either textured or smooth surfaces. They come in round or tear drop shapes with a choice of 3 different projections. Only 2 companies, Mentor Corporation and Allergen (a successor to McGhan and Inamed), have FDA approval to market these devices in the United States.

The implants produced currently are much improved devices compared to earlier units. The shell is still made of an outer layer of a mix of dimethyl siloxane and amorphous silica with an inner barrier coat of diphenyl siloxane to minimize silicone gel bleed. The shells, on testing for breakage, exceed the American Society for Testing and Materials (ASTM) requirements by more than 300%. The gel is more cohesive, varying from a standard 60% crosslinking to 80% for the more cohesive type nicknamed "gummy bear" (because of is consistency similar to the candy).

As evidenced by sales figures prior to the moratorium, and now following their release for cosmetic purposes, approximately 80-85% of surgeons and patients prefer the quality of results obtained by gel implants, making them the implants of choice. In 1997, sales figures for Europe, where usage was unrestricted, show a distribution of 70% for gel, 15% for saline, and 15% for alternate fills such as triglycerides (then still available) and hydrogels for cosmetic use.

Safety
Silicone is probably the most studied implantable material available today. After over 35 well-conducted studies from many countries, it seems certain that this material does not cause disease.
The results of more than 7 long-term follow-up studies show that women with implants have a reduced incidence of breast cancer than is otherwise expected in the general population.
No hard evidence reveals that a broken implant is harmful.
Almost all of the problems that can occur with breast implants, such as infection, hardening, extrusion, and malposition are related to the surgical procedure or the patient's own biology, not the device.

Summary

A great deal of recent safety research combined with more than 40 years of clinical experience has proven the value and relative safety of breast implants. Aside from the unique adverse effect of capsular contracture, the complication rate of this surgery approaches that of any clean elective procedure.
To date, no convincing evidence exists of any systemic disorder that can be attributed to silicone. As these are manmade devices, they have a failure rate and, in some patients, can require a significant amount of surgical maintenance. As with all natural body parts, these artificial substitutes may be subject to injury or disease and, when viewed from that perspective, have favorable risk-benefit characteristics

New Obesity Index Proposed, But Further Work Needed

2011-03-04T17:25:00.000-08:00

From Heartwire

Lisa Nainggolan

March 3, 2011 (Los Angeles, California) — US researchers have developed a new index of adiposity that they say is a more accurate measure of body fat than the traditionally used body-mass index (BMI); the latter is calculated by dividing weight by height [1].

Using measurements of hip circumference and height, the new body adiposity index (BAI) can be used to reflect percentage of body fat for adult men and women of differing ethnicities, without numerical correction or assessment of weight, say Dr Richard N Bergman (University of Southern California, Los Angeles) and colleagues in their paper published online March 3, 2011 in Obesity.

It remains to be seen if the BAI is a more useful predictor of health outcome than other indexes of body adiposity, including the BMI.

However, they note that further work will be needed to extend and confirm their findings--tested in Mexican Americans and African Americans--to whites and other ethnic groups and to assess the role of the new index in children. And "it remains to be seen if the BAI is a more useful predictor of health outcome, in both males and females, than other indexes of body adiposity, including the BMI itself."

Height and Hip Size Most Strongly Relate to Percentage Adiposity

"We were interested in determining whether we could find an index of body adiposity that at least in some ways may be better than the BMI, which has been around since the 1840s" and is not a very accurate measure of adiposity in individual patients, Bergman explained to heartwire .
BMI is particularly inaccurate in people with elevated lean body mass, such as athletes, and in children, and it cannot be generalized among different ethnic groups, he and his colleagues note.

Bergman et al are not the first to propose an alternative to BMI. Waist circumference is widely thought to be a better indicator of cardiovascular risk than BMI, although some studies have shown them to be equally predictive.
Other examples include the waist-to-hip ratio (WHR) and the waist-to-hip-to-height index, which have both been forwarded as potentially better measures of obesity than BMI. But critics have said that it is difficult and time-consuming to get very accurate measurements of waist and hip circumference and height and that BMI has remained popular because it is simple and fast.

We looked at which variables most strongly related to percent adiposity, and they were height and hip size.

In their study, Bergman and colleagues used a large database, BetaGene, which consisted of relatives of Mexican Americans with gestational diabetes, to determine whether there might be a better index. They chose the Mexican American population because of its prevalence in Los Angeles, observing, "Most of the world population is nonwhite."

"We looked at which variables most strongly related to percent adiposity, and they were height and hip size. Because these variables were uncorrelated, we proposed a new index, the BAI, based upon these measures alone," Bergman explains.

BAI Will Be Easy to Calculate

"We showed that the BAI, calculated as (hip circumference/height1.5)–18, was a good predictor of percent fat and worked for men and women," he continues. The BAI also yielded the percentage of fat itself, rather than just a correlate (or index) of it, which is what the BMI does, he notes. The BAI was validated against the "gold standard" of dual-energy X-ray absorption (DEXA).

"It will be very easy for a physician or a nurse practitioner to work out this index for individual patients, using a calculator, a computer program, or an iPhone app," Bergman says.

The researchers then went on to corroborate their findings in another population, the Triglyceride and Cardiovascular Risk in African Americans (TARA) study, and found that the behavior of the BAI was quite similar between the blacks in that population and the Hispanics in BetaGene.

"Thus, we believe that we have presented evidence of accuracy at least in two ethnic populations, and further work on the generalizability of BAI to other groups is under way," they state. It will also be important to see whether the index can reliably forecast percentage of adiposity in children and predict risk of cardiovascular disease, they note.