Antioxidants and Other Phytochemicals: Current Scientific Perspective

Many "antioxidant" products are marketed with claims that, by blocking the action free radicals, they can help prevent heart disease, cancer, and various other conditions associated with aging.
Free radicals are atoms or groups of atoms that have at least one unpaired electron, which makes them highly reactive. Free radicals promote beneficial oxidation that produces energy and kills bacterial invaders. In excess, however, they produce harmful oxidation that can damage cell membranes and cell contents. It is known that people who eat adequate amounts of fruits and vegetables high in antioxidants have a lower incidence of cardiovascular disease, certain cancers, and cataracts. Fruits and vegetables are rich in antioxidants, but it is not known which dietary factors are responsible for the beneficial effects. Each plant contains hundreds of phytochemicals (plant chemicals) whose presence is dictated by hereditary factors. Only well-designed long-term research can determine whether any of these chemicals, taken in a pill, would be useful for preventing any disease. The most publicized phytochemicals with antioxidant properties have been vitamin C, vitamin E, and beta-carotene (which the body converts into vitamin A). Evidence exists that vitamin E can help prevent atherosclerosis by interfering with the oxidation of low-density lipoproteins (LDL), a factor associated with increased risk of heart disease. However, vitamin E also has an anticoagulant effect that can promote excessive bleeding. In 1993, The New England Journal of Medicine published two epidemiologic studies which found that people who took vitamin E supplements had fewer deaths from heart disease. These studies did not prove that taking vitamin E was useful because they did not rule out the effects of other lifestyle factors or consider death rates from other diseases. Moreover, other studies have had conflicting results. The only way to settle the question scientifically is to conduct long-term double-blind clinical studies comparing vitamin users to nonusers and checking death rates from all causes.

Clinical Trials Have Been Disappointing
So far, the results of clinical trials have been mostly negative. The first trial compared the effects of vitamin E (alpha-tocopherol) , beta-carotene, and a placebo among heavy smokers. The researchers found no benefit from vitamin E and 18% more lung cancer among those who received beta-carotene. In addition, the overall death rate of beta-carotene recipients was 8% higher, and those who took vitamin E had a higher frequency of hemorrhagic stroke. In 1997, the researchers reported on the effect of vitamin E or beta-carotene on the incidence of heart attacks or death among the subjects who had had a previous heart attack (myocardial infarction). The report covered 1,862 men aged 50 to 69 who were followed for a median of 5.3 years. The men had received dietary supplements of alpha-tocopherol (50 mg/day), beta-carotene (20 mg/day), both, or a placebo. There were significantly more deaths from coronary heart disease among those who took beta-carotene supplements, and a trend toward more deaths (but not enough to be statistically significant) in the vitamin E group.
The second study found no evidence that supplementing with vitamin C, vitamin E, or beta-carotene prevented colorectal cancer. The third study, which followed 22,000 physicians for 12 years, found no difference in cancer or cardiovascular disease rates between users and nonusers of beta-carotene. The fourth trial, which tested a combination of beta-carotene and vitamin A, was terminated after four years because it appeared that the supplement-takers who smoked had a 28% higher incidence of lung cancer and a 17% higher death rate.
More recently, a double-blind clinical trial found that taking high doses of vitamins C and E and beta-carotene did not reduce the odds of arteries reclogging after balloon coronary angioplasty. The patients took either probucol (a cholesterol- lowering drug), probucol plus the three antioxidants, the antixoidants alone, or a placebo. More than 200 patients completed the study without protocol violations. Patients in the antioxidant groups received 30,000 IU of beta-carotene, 500 mg of vitamin C, and 700 IU of vitamin E twice daily. All of the patients received aspirin, which is known to reduce the incidence of reclogging. After six months, the rates of repeated angioplasty were 11% in the probucol group, 16.2% in the combined treatment group, 24.4% in the multivitamin group, and 26.6% in the placebo group.
Another study involved 2,545 women and 6,996 men 55 years of age or older who were at high risk for cardiovascular events because they had cardiovascular disease or diabetes in addition to one other risk factor. These patients were randomly assigned to receive either 400 IU of natural vitamin E or a matching placebo for an average of 4.5 years. There were no significant differences in heart attacks, strokes, or death between the vitamin E and placebo groups. The researchers concluded that "In patients at high risk for cardiovascular events, treatment with vitamin E for a mean of 4.5 years has no apparent effect on cardiovascular outcomes." Yet another study tested aspirin, vitamin E, and beta-carotene in the prevention of cancer and cardiovascular disease among 39,876 women aged 45 years or older. Among those randomly assigned to receive 50 mg of beta-carotene or a placebo every other day, there were no statistically significant differences in incidence of cancer, cardiovascular disease, or overall death rate after a median of two years of treatment and two years of follow-up.
Charles Hennekens, M.D., a who participated in two of the above studies, has pointed out that even if antioxidants could provide the benefits suggested by epidemiologic studies, smoking cessation and other lifestyle factors would have a far greater effect on the rates of lung cancer and coronary heart disease. In 1998, The Medical Letter concluded:

• The benefits of taking high doses of vitamin E remain to be established.
• There is no convincing evidence that taking supplements of vitamin C prevents any disease.
• No one should take beta carotene supplements.
  

Shortly afterward, a study was published that may explain why very high doses of beta-carotene appeared to increase lung cancer rates among smokers. The study was conducted in ferrets, which metabolize beta-carotene much like humans. Researchers at the Jean Mayer USDA Human Nutrition Research Center at Tufts University reported that excess amounts stored in the lungs became oxidized into substances that decreased a tumor suppressor and increased a tumor promoter in the animals' lungs. The ferrets were divided into four groups. One received beta-carotene and was exposed to cigarette smoke equivalent to a human smoking 1.5 packs per day. Two other groups got either the supplement or smoke exposure, and a control group got neither. The first group had the strongest precancerous changes. Two studies have found that antioxidants may interfere with the protective action of drugs intended to improve cholesterol levels.

• A 1-year study of 153 patients found that supplements of vitamin C,vitamin E, beta-carotene and selenium may interfere with the ability of simvastatin (Zocor) and niacin to raise the HDL levels of patients with abnormally low HDL levels. The patients receiving antioxidants and drugs had an average HDL increase of 18%, whereas the patients who received drugs alone has a 25% increase. However, HDL2-C, an HDL component thought to account for much of HDL's cardioprotective benefit, rose by 42% with drugs alone but was unchanged in patients who also received antioxidants. Although the study was small, it casts further doubt on the value of antioxidant supplementation.
• A 3-year, double-blind, controlled study of 160 patients with significant coronary artery disease and low HDL levels found that those who received niacin and simvastatin had fewer heart attacks and a slight regression of coronary lesions, as measured by angiography. However, comparable patients who received just antioxidants (vitamins E and C, beta-carotene, and selenium) had no benefit, and patients who received the antioxidants in addition to niacin and simvastatin did worse than those who received niacin and simvastatin alone. The researchers believe that the negative effect resulted from blocking an increase in HDL2 that would have had a cardio protective effect. An accompanying editorial noted that "although the study completely refute claims that other combinations of antioxidant treatments are useful in distinct populations, the findings add to the growing body of evidence that certain supplemental antioxidant regimes have limited benefit in patients with cardiovascular disease."
  

The American Heart Association' s nutrition committee has issued a science advisory discussing relationships between antioxidants and heart disease.
The statement concludes:
Considerable evidence now suggests that oxidants are involved in the development and clinical expression of coronary heart disease and that antioxidants may contribute to disease resistance. Consistent with this view is epidemiological evidence indicating that greater antioxidant intake is associated with lower disease risk. Although this increased antioxidant intake generally has involved increased consumption of antioxidant- rich foods, some recent observational studies have suggested the importance of levels of vitamin E intake achievable only by supplementation. There is currently no such evidence from primary prevention trials, but results from secondary prevention trials have shown beneficial effects of vitamin E supplements on some disease end points. In contrast, trials directly addressing the effects of beta-carotene supplements have not shown beneficial effects, and some have suggested deleterious effects, particularly in high-risk population subgroups.
In view of these findings, the most prudent and scientifically supportable recommendation for the general population is to consume a balanced diet with emphasis on antioxidant- rich fruits and vegetables and whole grains. This advice, which is consistent with the current dietary guidelines of the American Heart Association, considers the role of the total diet in influencing disease risk. Although diet alone may not provide the levels of vitamin E intake that have been associated with the lowest risk in a few observational studies, the absence of efficacy and safety data from randomized trials precludes the establishment of population-wide recommendations regarding vitamin E supplementation. In the case of secondary prevention [protection of people known to have coronary artery disease], the results from clinical trials of vitamin E have been encouraging, and if further studies confirm these findings, consideration of the merits of vitamin E supplementation in individuals with cardiovascular disease would be warranted.
In 2003, researchers at the Cleveland Clinic concluded that long-term supplementation with vitamin E or beta-carotene has not been proven beneficial in preventing cardiovascular disease. To reach this conclusion, they analyzed seven randomized controlled trials of vitamin E treatment and eight of beta-carotene treatment, all of which included at least 1,000 patients. The dosage ranged from 50 to 800 IU for vitamin E and 15 to 50 mg of beta-carotene; and follow-up ranged from 1.4 to 12.0 years. The vitamin E trials involved a total of 81,788 patients, and the beta-carotene trials involved 138,113. Compared with control treatment, Vitamin E did not increase the overall death rate or significantly decrease the risk of cardiovascular death or stroke. Beta-carotene led to a small but significant increase in overall deaths and a slight increase in cardiovascular death. Thus, although epidemiologic evidence has suggested that these antioxidant supplements may be beneficial, clinical trials have found otherwise. In 2003, the U.S. Preventive Services Task Force (USPSTF) has concluded there is insufficient scientific evidence to recommend vitamin supplements as a way to prevent cancer or heart disease and recommended against the use of beta carotene supplements in smokers because of a possible increased risk of lung cancer and death. The Task Force, sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. A apokesperson commented:
Vitamin supplements may be necessary for individuals whose diets don't provide the recommended amounts of specific vitamins and especially important for pregnant and nursing women and people with specific illnesses. However, the benefits of vitamin supplements for the general population remain uncertain. . . . There are currently a number of important studies underway which might help answer this important question. In 2004, after reviewing their results, the American Heart Association Council on Nutrition, Physical Activity, and Metabolism concluded that antioxidants have little or no proven value for preventing or treating cardiovascular disease. The committee found:

• Of nine studies on vitamin E and cardiovascular disease (CVD), five showedno effect on CVD events, three showed beneficial effects, and one showed a negative effect.
• Of four studies of beta-carotene, three showed no effects on CVD and one showed a negative effect.
• Of five studies of antioxidant "cocktails," two showed no effects and three showed negative effects.
• Two studies of vitamins E and C together showed beneficial effects.
  

Antioxidants for Macular Degeneration?
Research is also being done to determine whether taking supplements or eating foods rich in antioxidants can protect against age-related macular degeneration (AMD), a disease in which the central portion of the retina deteriorates so that only peripheral vision remains. A team of Australian researchers who followed 3,654 subjects age 49 or older found no statistically significant association between AMD and dietary intake of either carotene, zinc, or vitamins A or C, either from diet, supplements, or both. Other published studies have had conflicting results, with some finding correlations and others finding none.
The most elaborate study is the Age-Related Eye Disease Study (AREDS), an 11-center clinical trial cosponsored by the National Eye Institute and Bausch & Lomb. In 2001, the researchers reported on what had happened to about 3600 study participants aged 55 to 80 who had been followed for an average of 6.3 years. Patients received either high doses of antioxidants (vitamin C 500 mg, vitamin E 400 IU, beta-carotene 15 mg); 80 mg of zinc oxide; the antioxidants plus zinc; or a placebo. No benefit was found in patients with a relatively small probability of AMD progression. When these patients were excluded from the analysis, the estimated probability of developing advanced AMD was 28% with placebo, 23% with antioxidants alone, 22% with zinc alone, and 20% with both zinc and antioxidants. The authors concluded that patients at high risk for AMD progression "should consider taking a supplement of antioxidants plus zinc such as that used in this study."

Questionable Promotions
Despite the negative findings of most of the clinical trials, many manufacturers continue to market antioxidants as though they have been proven beneficial. Many also hype mixtures of beta-carotene and other carotenoids, which, they suggest, may provide the same benefits as fruits and vegetables.
Many types of pills described as "concentrates" of fruits and/or vegetables are being marketed. However, it is not possible to condense large amounts of produce into a pill without losing fiber, nutrients, and many other phytochemicals. Although some products contain significant amounts of nutrients, these nutrients are readily obtainable at lower cost from foods.
Since publication of the 2001 AREDS report, many dietary supplements have been marketed through the Internet to ""promote" and/or "preserve" healthy vision. The most widely promoted product is Bausch and Lomb's Ocuvite PreserVision, which contains the amounts of beta carotene, vitamin C, vitamin E, and zinc oxide, used in the study. However, The Medical Letter has cautioned that
(a) the magnitude of the reported effect was "modest";
(b) no data suggest any benefit for people who do not have AMD or who have only mild disease; and
(c) the increased death rate from lung cancer in smokers who took beta carotene in other studies is evidence enough that high doses of vitamins and minerals are not necessarily harmless."
In 2002, Pharmanex began promoting its BioPhotonic Scanner for measuring "the antioxidant level in the body" when a person's hand is placed in front of the device. The test is said to measure carotenoid level. Shortly after its availability was announced, I took the company's online "BioScan Quiz," which asked questions about my diet and supplement intake. I found that no matter what answers I gave, I was advised to get scanned and to start using one of the company's antioxidant products, which are quite expensive. As far as I know, however, neither the scan nor the products have been proven to lead to improved health outcomes. I believe that both the scan and the products are a waste of money.

The Bottom Line
There is widespread scientific agreement that eating adequate amounts of fruits and vegetables can help lower the incidence of cardiovascular disease and certain cancers. With respect to antioxidants and other phytochemicals, the key question is whether supplementation has been proven to do more good than harm. So far, the answer is no, which is why the FDA will not permit any of these substances to be labeled or marketed with claims that they can prevent disease.

Sex During Pregnancy

George Macones

If you're pregnant or even planning a pregnancy, you've probably found an abundance of information about sex before pregnancy (that is, having sex in order to conceive) and sex after childbirth (general consensus: expect a less active sex life when there's a newborn in the house).
But there's less talk about the topic of sex during pregnancy, perhaps because of our culture's tendency to dissociate expectant mothers from sexuality. Like many parents-to-be, you may have questions about the safety of sex and what's normal for most couples.
Well, what's normal tends to vary widely, but you can count on the fact that there will be changes in your sex life. Open communication will be the key to a satisfying and safe sexual relationship during pregnancy.

Is It Safe to Have Sex During Pregnancy?
If you're having a normal pregnancy, sex is considered safe during all stages of the pregnancy. So what's a "normal pregnancy"? It's one that's considered low-risk for complications such as miscarriage or pre-term labor. Talk to your doctor, nurse-midwife, or other pregnancy health care provider if you're uncertain about whether you fall into this category. (The next section of this article may help, too.)
Of course, just because sex is safe during pregnancy doesn't mean you'll necessarily want to have it! Many expectant mothers find that their desire for sex fluctuates during certain stages in the pregnancy. Also, many women find that sex becomes uncomfortable as their bodies get larger.
You and your partner need to keep the lines of communication open regarding your sexual relationship. Talk about other ways to satisfy your need for intimacy, such as kissing, caressing, and holding each other. You also may need to experiment with other positions for sex to find those that are the most comfortable.
Many women find that they lose their desire and motivation for sex late in the pregnancy - not only because of their size but also because they're preoccupied with the impending delivery and the excitement of becoming a new parent.

When It's Not Safe
There are two types of sexual behavior that aren't safe for any pregnant woman:

• If you engage in oral sex, your partner should not blow air into your vagina. Blowing air can cause an air embolism (a blockage of a blood vessel by an air bubble), which can be potentially fatal for mother and child.
• You should not have sex with a partner whose sexual history is unknown to you or who may have a sexually transmitted disease, such as herpes, genital warts, chlamydia, or HIV. If you become infected, the disease may be transmitted to your baby, with potentially dangerous consequences.
  

If your doctor, nurse-midwife, or other pregnancy health care provider anticipates or detects certain significant complications with your pregnancy, he or she is likely to advise against sexual intercourse. The most common risk factors include:

• a history or threat of miscarriage
• a history of pre-term labor (you've previously delivered a baby before 37 weeks) or signs indicating the risk of pre-term labor (such as premature uterine contractions)
• unexplained vaginal bleeding, discharge, or cramping
• leakage of amniotic fluid (the fluid that surrounds the baby)
• placenta previa, a condition in which the placenta (the blood-rich structure that nourishes the baby) is situated down so low that it covers the cervix (the opening of the uterus)
• incompetent cervix, a condition in which the cervix is weakened and dilates (opens) prematurely, raising the risk for miscarriage or premature delivery
• multiple fetuses (you're having twins, triplets, etc.)
  

Common Questions and Concerns
The following are some of the most frequently asked questions about sex during pregnancy.

Can sex harm my baby?
No, not directly. Your baby is fully protected by the amniotic sac (a thin-walled bag that holds the fetus and surrounding fluid) and the strong muscles of the uterus. There's also a thick mucus plug that seals the cervix and helps guard against infection. The penis does not come into contact with the fetus during sex.

Can intercourse or orgasm cause miscarriage or contractions?
In cases of normal, low-risk pregnancies, the answer is no. The contractions that you may feel during and just after orgasm are entirely different from the contractions associated with labor. However, you should check with your health care provider to make sure that your pregnancy falls into the low-risk category. Some doctors recommend that all women stop having sex during the final weeks of pregnancy, just as a safety precaution, because semen contains a chemical that may actually stimulate contractions. Check with your health care provider to see what he or she thinks is best.

Is it normal for my sex drive to increase or decrease during pregnancy?
Actually, both of these possibilities are normal (and so is everything in between). Many pregnant women find that symptoms such as fatigue, nausea, breast tenderness, and the increased need to urinate make sex too bothersome, especially during the first trimester. Generally, fatigue and nausea subside during the second trimester, and some women find that their desire for sex increases. Also, some women find that freedom from worries about contraception, combined with a renewed sense of closeness with their partner, makes sex more fulfilling. Desire generally subsides again during the third trimester as the uterus grows even larger and the reality of what's about to happen sets in.
Your partner's desire for sex is likely to increase or decrease as well. Some men feel even closer to their pregnant partner and enjoy the changes in their bodies. Others may experience decreased desire because of anxiety about the burdens of parenthood, or because of concerns about the health of both the mother and their unborn child.
Your partner may have trouble reconciling your identity as a sexual partner with your new (and increasingly visible) identity as an expectant mother. Again, remember that communication with your partner can be a great help in dealing with these issues.

When to Call Your Doctor
Call your health care provider if you're unsure whether sex is safe for you. Also, call if you notice any unusual symptoms after intercourse, such as pain, bleeding, or discharge, or if you experience contractions that seem to continue after sex.
Remember, "normal" is a relative term when it comes to sex during pregnancy. You and your partner need to discuss what feels right for both of you.
(AAFP)

Taking Care of Burns

What causes burns?
You can get burned by heat and fire, radiation, sunlight, electricity or chemicals. There are 3 degrees of burns:

• First-degree burns are red and painful. They swell a little. They turn white when you press on the skin. The skin over the burn may peel off after 1 or 2 days.
• Thicker burns, called second-degree burns, have blisters and are painful. The skin is very red or splotchy, and it may swell a lot.
• Third-degree burns cause damage to all layers of the skin. The burned skin looks white or charred. These burns may cause little or no pain because the nerves in the skin are damaged.
  

How long does it take for burns to heal?
* First-degree burns usually heal in 3 to 6 days.
* Second-degree burns usually heal in 2 to 3 weeks.
* Third-degree burns usually take a very long time to heal.

How are burns treated?
The treatment depends on what kind of burn you have. If a first- or second-degree burn covers an area larger than 2 to 3 inches in diameter, or is on your face, hands, feet or genitals, you should see a doctor right away. Third-degree burns require emergency medical attention.
Do not put butter, oil, ice or ice water on burns. This can cause more damage to the skin.

First-degree burn
Soak the burn in cool water. Then treat it with a skin care product like aloe vera cream or an antibiotic ointment. To protect the burned area, you can put a dry gauze bandage over the burn. Take an over-the-counter pain reliever, such as paracetamol/ acetaminophen, ibuprofen or naproxen, to help with the pain.

Second-degree burn
Soak the burn in cool water for 15 minutes. If the burned area is small, put cool, clean, wet cloths on the burn for a few minutes every day. Then put on an antibiotic cream, or other creams or ointments prescribed by your doctor. Cover the burn with a dry nonstick dressing held in place with gauze or tape. Check with your doctor's office to make sure you are up-to-date on tetanus shots. Change the dressing every day. First, wash your hands with soap and water. Then gently wash the burn and put antibiotic ointment on it. If the burn area is small, a dressing may not be needed during the day. Check the burn every day for signs of infection, such as increased pain, redness, swelling or pus. If you see any of these signs, see your doctor right away. To prevent infection, avoid breaking any blisters that form. Burned skin itches as it heals. Keep your fingernails cut short and don't scratch the burned skin. The burned area will be sensitive to sunlight for up to one year.

Third-degree burn
For third-degree burns, go to the hospital right away. Don't take off any clothing that is stuck to the burn. Don't soak the burn in water or apply any ointment. You can cover the burn with a sterile bandage or clean cloth until you receive medical assistance.

What do I need to know about electrical and chemical burns?
A person with an electrical burn (for example, from a power line) should go to the hospital right away. Electrical burns often cause serious injury inside the body. This injury may not show on the skin. A chemical burn should be washed with large amounts of water. Take off any clothing that has the chemical on it. Don't put anything on the burned area. This might start a chemical reaction that could make the burn worse. If you don't know what to do, call your local poison control center, or see your doctor right away.
(AAFP)

(Almost) Everybody Does It

A new study finds that the vast majority of doctors have some kind of financial relationship with the pharmaceutical industry.

Who's getting what? And what impact does it have on patient care?
Who hasn't been to a doctor's office and seen drug logos decorating pens, clocks, sticky notes? As one health-industry expert puts it, "It's the medical equivalent of NASCAR advertising. " Almost every doctor in the country has some type of relationship with pharmaceutical manufacturers, whose clear goal is to influence physicians to prescribe the company's newest, most expensive drugs. The companies offer physicians everything from scratch pads to trips worth thousands of dollars to attend medical conferences. But which doctors receive the biggest perks? A new study appearing this week in the New England Journal of Medicine reveals that it varies with the type of practice, the medical specialty, the patient mix and the doctor's professional activities. The study-the first of its kind-was led by Eric Campbell and David Blumenthal, both at the Institute for Health Policy at Massachusetts General Hospital. Anne Underwood spoke with Campbell.
Excerpts:

Underwood: How did you conduct the study?
Campbell: It's based on a survey of 1,662 practicing physicians in late 2003 and 2004. We focused on six specialties- family practice, internal medicine, pediatrics, cardiology, general surgery and anesthesiology. We also looked at whether these doctors worked in hospitals, universities, HMOs, group practice or solo or two-person practice. And we looked at gender.

Were you surprised at the findings?
I was surprised at the sheer percentage of physicians who have financial relationships with the drug industry. Ninety-four percent of all physicians have these relationships. Most commonly, it's things like receiving free samples of drugs or receiving food and beverages which may be consumed by their staffs. But a third of physicians are reimbursed for costs associated with professional meetings or CME [continuing medical education]. About a quarter are paid to serve on advisory boards, work as consultants or enroll patients in clinical trials. Those are the big-ticket items, versus getting free Chinese food for your staff on Wednesdays.

In recent years, the American Medical Association, the American College of Physicians, and the Pharmaceutical Research and Manufacturers of America (PhRMA) have all been promoting voluntary codes of conduct that set limits on these relationships. What effect have these had?
The most egregious examples have been reined in. PhRMA recommends that gifts not exceed $100 in value and be limited to items that are for the patient's benefit. There's really no benefit to the patient if the doctor receives free tickets to a Giants game, so you don't find much of that any more. Only 7 percent of doctors reported this type of payment. On the other hand, the drug companies now meet with physicians more frequently. In 2000, it was 4.4 meetings a month on average. Now family practitioners report an average of 16 meetings per month, followed by internists at 10 per month and cardiologists at 9 a month. All specialties except anesthesiology seem to be meeting more frequently with industry. What we don't know is how long these meetings last.
What fascinates me about this study is that I had assumed there were equal-opportunity handouts for all doctors. But you say that pharmaceutical manufacturers are actually fairly selective in who gets the best treatment. Drug samples and gifts of free food are widely given. But other types of relationships- serving as consultants, on boards, receiving speakers' fees-are concentrated among "thought leaders" in a specialty. Those are the doctors who develop guidelines for clinical practice, who publish the leading papers in big medical journals, who run large residency programs in major health centers. They have the potential to influence the prescribing practices of other physicians. The industry appears to form tighter relationships with these doctors.

And who is least likely to have these tight relationships?
Women physicians are significantly less likely to receive payments than their male counterparts. Also physicians with a high percent of patients who are uninsured or covered by Medicaid. There are a number of potential explanations, but our study did not address those.

In the second case, at least, it's pretty clear-those are not patients going out and buying a lot of expensive drugs. But you also say that doctors in group practices and private practices are more likely than doctors in hospitals to have these relationships.

Why is that?
Compared with those in hospitals, clinics and HMOs, physicians in solo, two-person and group practices were six times as likely to receive samples, three times as likely to receive gifts and nearly four times as likely to receive payments for professional services. We can only speculate why. It may reflect the fact that physicians in group practices have more freedom in their prescribing choices than physicians in hospitals, clinics and HMOs, whose formularies [lists of approved drugs] limit their ability to choose what drugs they prescribe. Hospitals and clinics may also be more likely to have policies limiting physician-industry relationships. Larger institutions are also more likely to provide medical information through educational programs, which may make physicians less dependent on industry. But more research is needed. And certain specialties are more likely to receive payments, especially cardiologists. Cardiologists were more than twice as likely as family practitioners to receive payments for professional services, such as serving on boards or as consultants. The prescribing patterns of cardiologists are thought to influence the prescribing patterns of non-specialists. Also, their patients take drugs for years, as opposed to a child who may take an antibiotic for a week. True. We didn't look at other specialties whose patients may also take drugs for a very long time, such as psychiatrists or endocrinologists [for diabetes].

What's the impact on patient care?
That's what we don't know, because there's no national data linking these relationships to patient outcomes. We know these relationships benefit companies, because they're selling drugs. They wouldn't do it if it didn't work. We know it benefits doctors because they get meals and CME. We don't know to what extent if benefits patients. If you look at the cost of all these things-billions of dollars per year-there's no doubt that it increases the prices people are paying for drugs. That price is not just reflected in what you shell out at the pharmacy, because you may only have a copay. It also drives up prices for Medicare and Medicaid, which we all pay for
through our taxes. And what if you're taking a medicine that's not covered by your insurance?
Does this lead to a situation where people are taking inappropriate drugs?
In some cases, older, tried-and-true drugs are actually better than the newer, fancier drugs that are still under patent protection. I'm not a physician. I can't speak to that. But even small gifts create a quid pro quo. The question becomes, is a gift really just a gift? If a man gives a woman a diamond ring, there's an expectation of a certain behavior there.

So expectations still exist, despite curtailing the most egregious forms of payment?
If a company hosts a continuing-medical- education seminar at a beautiful resort in Florida, and I get to go down there for a few days, listen to the leading people in the field and maybe whack a white ball around on the golf course, does that create the opportunity to influence my behavior? Or if a doctor receives $5,000-$10,000 for serving on a speakers' board, does that influence him? Some might say that's not much money, but it would pay for a normal vacation for a family of four.

So what differentiates this from old-fashioned payola?
It's not fair to compare it to payola. If you took the world's expert in schizophrenia and paid him for consulting with a drug company in order to help make better drugs, that's a good thing. It should happen. You want companies to have access to doctors' expertise. But you also have to say, what are the risks? To what extent are companies altering physician decisions in ways that are not consistent with evidence-based medicine? We don't know.

Should we be concerned?
It's clearly something the physician community is thinking about. They realize it's an area that requires attention. But I've also heard doctors say that they work hard, they studied a long time to acquire this expertise, and if someone wants to send them to a conference in Cancun along with their wives, then they deserve it. They claim it doesn't bias them in prescribing.
There's a new article in the online journal PLoS Medicine looking at the ways drug companies influence doctors and showing that doctors are not trained to recognize this subtle manipulation. This is not an issue that is going to disappear off the radar screen. The fact is, scrutiny will likely become more aggressive rather than less.
(Newsweek)

All About Allergies

B.P. Homeier

Dust, cats, peanuts, cockroaches. An odd grouping, but one with a common thread: allergies - a major cause of illness. Up to 50 million people, including millions of children, have some type of allergy. In fact, allergies account for the loss of an estimated 2 million school days per year.

What Are Allergies?
An allergy is an overreaction of the immune system to a substance that's harmless to most people. But in someone with an allergy, the body's immune system treats the substance (called an allergen) as an invader and reacts inappropriately, resulting in symptoms that can be anywhere from annoying to possibly harmful to the person.
In an attempt to protect the body, the immune system of the allergic person produces antibodies called immunoglobulin E (IgE). Those antibodies then cause mast cells (which are allergy cells in the body) to release chemicals, including histamine, into the bloodstream to defend against the allergen "invader."
It's the release of these chemicals that causes allergic reactions, affecting a person's eyes, nose, throat, lungs, skin, or gastrointestinal tract as the body attempts to rid itself of the invading allergen. Future exposure to that same allergen (things like nuts or pollen that you can be
allergic to) will trigger this allergic response again. This means every time that person eats that particular food or is exposed to that particular allergen, he or she will have an allergic reaction.

Who Gets Allergies?
The tendency to develop allergies is often hereditary, which means it can be passed down through your genes. However, just because you, your partner, or one of your children might have allergies doesn't mean that all of your children will definitely get them, too. And a person usually doesn't inherit a particular allergy, just the likelihood of having allergies. But a few children have allergies even if no family member is allergic. And if a child is allergic to one substance, it's likely that he or she will be allergic to others as well.

What Are the Most Common Airborne Allergens?
Some of the most common things people are allergic to are airborne (carried through the air):
Dust mites are one of the most common causes of allergies. These microscopic insects live all around us and feed on the millions of dead skin cells that fall off our bodies every day. Dust mites are the main allergic component of house dust, which is made up of many particles and can contain things such as fabric fibers and bacteria, as well as microscopic animal allergens.
Present year-round, dust mites live in bedding, upholstery, and carpets. Pollen is another major cause of allergies (most people know pollen allergy as hay fever or rose fever). Trees, weeds, and grasses release these tiny particles into the air to fertilize other plants. Pollen allergies are
seasonal, and the type of pollen a child is allergic to determines when he or she will have symptoms. For example, tree pollination begins in February and March, grass from May through June, and ragweed from August through October; so people with these allergies are likely to experience increased symptoms during those times. Pollen counts measure how much pollen is in the air and can help people with allergies determine how bad their symptoms might be on any given day. Pollen counts are usually higher in the morning and on warm, dry, breezy days, whereas they're lowest when it's chilly and wet. Although they're not exact, the local weather report's pollen count can be helpful when planning outside activities.
Molds, another common allergen, are fungi that thrive both indoors and out in warm, moist environments. Outdoors, molds may be found in poor drainage areas, such as in piles of rotting leaves or compost piles. Indoors, molds thrive in dark, poorly ventilated places such as bathrooms and damp basements with water leaks or floods. A musty odor suggests mold growth. Although molds tend to be seasonal, many can grow year-round, especially
those indoors. Pet allergens from warm-blooded animals can cause problems for kids and parents alike. When the animal - often a household pet - licks itself, the saliva gets on its fur or feathers. As the saliva dries, protein particles become airborne and work their way into fabrics in the home. Cats are the worst offenders because the protein from their saliva is extremely tiny and they tend to lick themselves more than other animals as part of grooming. Cockroaches are also a major household allergen, especially in inner cities. Exposure to cockroach-infested buildings may be a major cause of the high rates of asthma in inner-city children.

What Are the Most Common Food Allergens?
The American Academy of Allergy, Asthma, and Immunology estimates that up to 2 million, or 8%, of children are affected by food allergies, and that eight foods account for most of those food allergy reactions in kids: eggs, fish, milk, peanuts, shellfish, soy, tree nuts, and wheat.
Cow's milk (or cow's milk protein): Between 1% and 7.5% of infants are allergic to the proteins found in cow's milk and cow's milk-based formulas. About 80% of formulas on the market are cow's milk-based. Cow's milk protein allergy (also called formula protein allergy) means that the infant (or child or adult) has an abnormal immune system reaction to proteins found in the cow's milk used to make standard baby formulas. Eggs: One of the most common food allergies in infants and young children, egg allergy can pose many challenges for parents. Because eggs are used in many of the foods kids eat - and in many cases they're "hidden" ingredients - an egg allergy is hard to diagnose. An egg allergy usually begins when children are very young, but most outgrow the allergy by age 5.
Most kids with an egg allergy are allergic to the proteins in egg whites, but some can't tolerate proteins in the yolk. Fish and shellfish: The proteins in fish can cause a number of different types of allergic reactions, including a gastrointestinal reaction that leads to diarrhea and vomiting. Children can also have skin reactions to fish causing itching and dryness. Fish allergy is also one of the more common adult food allergies and one that children don't always grow out of.
Peanuts and tree nuts: Peanuts are one of the most severe food allergens, often causing life-threatening reactions. About 1.5 million people are allergic to peanuts (which are not a true nut, but a legume - in the same family as peas and lentils). Half of those allergic to peanuts are also allergic to tree nuts, such as almonds, walnuts, pecans, cashews, and often sunflower and sesame seeds.
Soy: Like peanuts, soybeans are legumes. Soy allergy is more prevalent among babies than older children; about 30% to 40% of infants who are allergic to cow's milk are also allergic to the protein in soy formulas. Wheat: Wheat proteins are found in many of the foods we eat - some are more obvious than others. As with any allergy, an allergy to wheat can happen in different ways and to different degrees. Although wheat allergy is often confused with celiac disease, there is a difference. Celiac disease is caused by a permanent sensitivity to gluten, which is found in wheat, oat, rye, and barley. It typically develops between 6 months and 2 years of age and the sensitivity causes damage to the small intestine.

What Are Some Other Common Allergens?
Insect Stings: For most children, being stung by an insect means swelling, redness, and itching at the site of the bite, in addition to a few tears. But for children with insect venom allergy, an insect bite can cause more severe symptoms. Although some doctors and parents have believed that most children eventually outgrow insect venom allergy, a recent study found that insect venom allergies often persist into adulthood.
Medicines: Antibiotics - medications used to treat infections - are the most common types of medicines that cause allergic reactions. Many other medicines, including over-the-counter medications, can also cause allergic reactions.
Chemicals: Some cosmetics or laundry detergents can cause people to break out in an itchy rash. Usually, this is because the person has a reaction to the chemicals in these products. Dyes, household cleaners, and pesticides used on lawns or plants can also cause allergic reactions in some people. Some children also have what are called cross-reactions. For example, kids who are allergic to birch pollen might have reactions when they eat an apple because that apple is made up of a protein similar to one in the pollen. Another example is that children who are allergic to latex (as in gloves or certain types of hospital equipment) are more likely to be allergic to kiwifruit or bananas.

What Are the Signs and Symptoms of Allergies?
The type and severity of allergy symptoms vary from allergy to allergy and child to child. Symptoms can range from minor or major seasonal annoyances (for example, from pollen or certain molds) to year-round problems (from allergens like dust mites or food).
Because different allergens are more prevalent in different parts of the country and the world, allergy symptoms can also vary, depending on where you live. For example, peanut allergy is unknown in Scandinavia, where they don't eat peanuts, but is common, where peanuts are not only a popular food, but are also found in many of the things we eat.

Airborne Allergy Symptoms
Airborne allergens can cause something known allergic rhinitis, which occurs in about 15% to 20% of Americans. It typically develops by 10 years of age and reaches its peak in the early 20s, with symptoms often disappearing between the ages of 40 and 60. Symptoms can include:
* sneezing
* itchy nose and/or throat
* nasal congestion
* coughing
These symptoms are often accompanied by itchy, watery, and/or red eyes, which is called allergic conjunctivitis. (When dark circles are present around the eyes, it's called allergic "shiners"). Those who react to airborne allergens usually have allergic rhinitis and/or allergic conjunctivitis. If a person has these symptoms, as well as wheezing and shortness of breath, the allergy may have progressed to become asthma.

Food Allergy Symptoms

The severity of food allergy symptoms and when they develop depends on:

• how much of the food is eaten
• the amount of exposure the child has had to the food
• the child's sensitivity to the food
  

Symptoms of food allergies can include:

• itchy mouth and throat when food is swallowed (some children have only this symptom - called "oral allergy syndrome")
• hives (raised, red, itchy bumps)
• rash
• runny, itchy nose
• abdominal cramps accompanied by nausea and vomiting or diarrhea (as the body attempts to flush out the food allergen)
  

Insect Venom Allergy Symptoms
Being stung by an insect that a child is allergic to may cause some of the following symptoms:

• throat swelling
• hives over the entire body difficulty breathing nausea
• diarrhea
  

What's Anaphylaxis?
In rare instances, if the sensitivity to an allergen is extreme, a child may experience anaphylaxis (or anaphylactic shock) - a sudden, severe allergic reaction involving various systems in the body (such as the skin, respiratory tract, gastrointestinal tract, and cardiovascular system).
Severe symptoms or reactions to any allergen, from certain foods to insect bites, require immediate medical attention and can include:

• difficulty breathing
• swelling (particularly of the face, throat, lips, and tongue in cases of food allergies)
• rapid drop in blood pressure
• dizziness
• unconsciousness
• hives
• tightness of the throat
• hoarse voice
• nausea
• vomiting
• abdominal pain diarrhea
• lightheadedness
  

Anaphylaxis can happen just seconds after being exposed to a triggering substance or can be delayed for up to 2 hours if the reaction is from a food. It can involve various areas of the body.
Fortunately, though, severe or life-threatening allergies occur in only a small group of children. In fact, the annual incidence of anaphylactic reactions is small - about 30 per 100,000 people - although those with asthma, eczema, or hay fever are at greater risk of experiencing them.
Most - up to 80% - of the anaphylactic reactions are caused by peanuts or tree nuts.

How Are Allergies Diagnosed?
Some allergies are fairly easy to identify because the pattern of symptoms following exposure to certain allergens can be hard to miss. But other allergies are less obvious because they can masquerade as other conditions.
If your child has cold-like symptoms lasting longer than a week or 2 or develops a "cold" at the same time every year, consult your child's doctor, who will likely ask questions about your child's symptoms and when they appear. Based on the answers to these questions and a physical exam, your child's doctor may be able to make a diagnosis and prescribe medications or may refer you to an allergist for allergy skin tests and more extensive therapy.
To determine the cause of an allergy, an allergist will likely perform skin tests for the most common environmental and food allergens. Skin tests can be done in young infants, but they're more reliable in children over the age of 2 years.

A skin test can work in one of two ways:

• A drop of a purified liquid form of the allergen is dropped onto the skin and the area is pinched with a small pricking device.
• A small amount of allergen is injected just under the skin.

This test stings a little but isn't extremely painful. After about 15 minutes, if a lump surrounded by a reddish area appears (like a mosquito bite) at the injection site, the test is positive.
If reactions to a food or other allergen are severe, a blood test may be used to diagnose the allergy so as to avoid exposure to the offending allergen. Skin tests are less expensive and more sensitive than blood tests for allergies. But blood tests may be required in children with skin conditions or those who are extremely sensitive to a particular allergen.
Blood tests are also helpful in deciding whether a child has outgrown a food allergy, because the skin tests tend to remain positive even after the food allergy has disappeared.
Even if a skin test and/or a blood test shows an allergy, a child must also have symptoms to be definitively diagnosed with an allergy. For example, a toddler who has a positive test for dust mites and sneezes frequently while playing on the floor would be considered allergic to dust mites.

How Are Allergies Treated?
There is no real cure for allergies, but it is possible to relieve a child's symptoms. The only real way to cope with them on a daily basis is to reduce or eliminate exposure to allergens. That means that parents must educate their children early and often, not only about the allergy itself but also about what reaction they will have if they consume or come into contact with the offending allergen.
Informing any and all caregivers (from child-care personnel to teachers, from extended family members to parents of your child's friends) about your child's allergy is equally important to help keep your child's allergy symptoms to a minimum.
If reducing exposure isn't possible or is ineffective, medications may be prescribed including antihistamines (which you can also buy over the counter) and inhaled or nasal spray steroids. In some cases, an allergist may recommend immunotherapy (allergy shots) to help desensitize your child.

And here are some things that can help your child avoid airborne allergens:

• Keep family pets out of certain rooms, like your child's bedroom, and bathe them if necessary.
• Remove carpets or rugs from your child's room (hard floor surfaces don't collect dust as much as carpets do).
• Don't hang heavy drapes and get rid of other items that allow dust to accumulate.
• Clean frequently.
• Use special covers to seal pillows and mattresses if your child is allergic to dust mites.
• If your child is allergic to pollen, keep your windows closed when the pollen season's at its peak, change your child's clothing after being outdoors, and don't let your child mow the lawn.
• Have your child avoid damp areas, such as basements, if he or she is allergic to mold, and keep bathrooms and other mold-prone areas clean and dry.
  

What Does Injectable Epinephrine Do?
Food allergies usually aren't lifelong (although those to peanut, tree nut, and seafood can be). Avoiding the food is the only way to avoid symptoms while the sensitivity persists. If your child is extremely sensitive to a particular food, or if he or she has asthma in addition to the food allergy, your child's doctor will probably recommend that you carry injectable epinephrine (adrenaline) to counteract any allergic reactions. He or she may also recommend carrying injectable epinephrine if your child is allergic to insect venom.
Available in an easy-to-carry container that looks like a pen, injectable epinephrine is carried by millions of parents across the country everywhere they go. With one injection into the thigh, the device administers epinephrine to ease the allergic reaction.
An injectable epinephrine prescription usually includes two auto-injections and a "trainer" that contains no needle or epinephrine, but allows you and your child (if he or she is old enough) to practice using the device. It's essential that you familiarize yourself with the procedure by practicing with the trainer. Your child's doctor can also give you instructions on how to use and store injectable epinephrine.
If your child is 12 years or older, make sure he or she keeps injectable epinephrine readily available at all times. If your child is younger than 12, talk to the school nurse, your child's teacher, and your child-care provider about keeping injectable epinephrine on hand in case of an
emergency.
It's also important to make sure that injectable epinephrine devices are available at your home, as well as at the homes of friends and family members if your child spends time there. Your child's doctor may also encourage your child to wear a medical alert bracelet. It's also a good idea to carry an over-the-counter antihistamine, which can help alleviate allergy symptoms in some people. But antihistamines should not be used as a replacement for the epinephrine pen.
Kids who have had to take injectable epinephrine should go immediately to a medical facility or hospital emergency department, where additional treatment can be given if needed. Up to one third of anaphylactic reactions can have a second wave of symptoms several hours following the initial attack, so these kids might need to be observed in a clinic or hospital for 4 to 8 hours following the reaction even though they seem well.
The good news is that only a very small group of kids will experience severe or life-threatening allergies. With proper diagnosis, preventive measures, and treatment, most children will be able to keep their allergies in check and live, happy, healthy lives.
(AAFP)

10 Things That Might Surprise You About Being Pregnant

B.P. Homeier

Pregnancy is a subject that generates a lot of paper. Bookstores and libraries devote not just shelves but entire aisles to it. At your first prenatal visit, your doctor will likely load you down with armfuls of pamphlets that cover every test and trimester. But despite all this information, pregnancy can take any soon-to-be parent by surprise.

What the Doctor May Leave Out
If your doctor hasn't mentioned the following topics during your visits, he or she isn't purposefully omitting the information. More likely, your doctor hasn't brought them up because pregnancy affects women in different ways. For example, some pregnant women experience morning sickness in the morning, some feel it all day, and some never have it. Or your doctor might not mention something because it doesn't have a medical focus - a doctor may not have any more insight into your increasing shoe size than your neighbor does! Also, some women may think questions about breast size or hemorrhoids are too personal or embarrassing to ask their doctors.
Any concerns you have about your or your baby's emotional or physical health, regardless of how unrelated or trivial they may seem, should be discussed with your doctor. He or she has seen many expectant parents, some less worried and some more worried than you, and can reassure you when there is no problem or give you more information when there is one. And if your doctor doesn't take the time to listen to your concerns or doesn't seem to take them seriously, you should feel free to get a second opinion.

Altered States
Pregnancy doesn't just change your body - it affects the rest of you, too.

1. The Nesting Instinct
Many pregnant women experience the nesting instinct, a powerful urge to prepare their home for the baby by cleaning and decorating. Or perhaps you'll want to tackle projects you haven't had time to do, like organizing your garage or closets.
As your due date draws closer, you may find yourself cleaning cupboards or washing walls - things you never would have imagined doing in your ninth month of pregnancy! This desire to prepare your home can be useful because it will give you more time to recover and nurture your baby after the birth. But be careful not to overdo it.

2. Inability to Concentrate
In the first trimester, fatigue and morning sickness can make many women feel worn out and mentally fuzzy. But even well-rested pregnant women may experience an inability to concentrate and periods of forgetfulness. A preoccupation with the baby is partially the cause, as are hormonal changes. Everything - including work, bills, and doctor appointments - may seem less important than the baby and the impending birth. You can combat this forgetfulness by making lists to help you remember dates and appointments.

3. Mood Swings
Premenstrual syndrome and pregnancy are alike in many ways. Your breasts swell and become tender, your hormones fluctuate, and you may feel moody. If you suffer from premenstrual syndrome, you're likely to have more severe mood swings during pregnancy. They can make you go from feeling happy one minute to feeling like crying the next. You may be irrationally angry with your partner one day, then a coworker may inexplicably irritate you the next.
Mood swings are incredibly common during pregnancy, although they tend to occur more frequently in the first trimester and toward the end of the third trimester.
About 10% of pregnant women experience depression during pregnancy. If you have symptoms such as sleep disturbances, changes in eating habits (a complete lack of appetite or an inability to stop eating), and exaggerated mood swings for longer than 2 weeks, you should talk to your doctor.

Unexpected Effects of Pregnancy

4. Bra Size
An increase in breast size is one of the first signs of pregnancy. Breasts usually become swollen and enlarged in the first trimester because of increased levels of the hormones estrogen and progesterone. That growth in the first trimester isn't necessarily the end, either - your breasts can continue to grow throughout your pregnancy!
In addition to the size of your breasts, your bra size may be affected by your rib cage. When you're pregnant, your lung capacity increases so you can take in extra oxygen for yourself and the baby, which may result in a bigger chest size. You may need to replace your bras several times over the course of your pregnancy.

5. Skin
Are your friends saying you have that pregnancy glow? It's only one of many skin changes you may experience during pregnancy due to hormonal changes and the stretching of your skin to accommodate a larger body. Pregnant women experience an increase in blood volume to provide extra blood flow to the uterus and to meet the metabolic needs of the fetus. They also have increased blood flow to their other organs, especially the kidneys. The greater volume brings more blood to the vessels and increases oil gland secretion.
Some women develop brownish or yellowish patches called chloasma, or the "mask of pregnancy," on their faces. And some will notice a dark line on the midline of the lower abdomen, known as the linea nigra (or linea negra), as well as hyperpigmentation (darkening of the skin) of the nipples, external genitalia, and anal region. These are the result of pregnancy hormones, which cause the body to produce more pigment. The body may not produce this increased pigment evenly, however, so the darkened skin may appear as splotches of color. Unfortunately, chloasma can't be prevented, but wearing sunscreen and avoiding UV light can minimize its effects.
Acne is common during pregnancy because the skin's sebaceous glands increase their oil production. And newly formed pimples might not be the only evolving spots on your face or body - moles or freckles that you had prior to pregnancy may become bigger and darker. Even the areola, the area around the nipples, becomes darker. Except for the darkening of the areola, which is usually permanent, these skin changes will likely disappear after you give birth. Many women also experience heat rash, caused by dampness and perspiration, during pregnancy.
In general, pregnancy can be an itchy time for a woman. Skin stretching over the abdomen may cause itchiness and flaking. Your doctor can recommend creams to soothe dry or itchy skin.

6. Hair and Nails
Many women experience changes in hair texture and growth during pregnancy. The hormones secreted by your body will cause your hair to grow faster and fall out less. But these hair changes usually aren't permanent; most women lose a significant amount of hair in the postpartum period or after they stop breastfeeding.
Some women find that they grow hair in unwanted places, such as on the face or belly or around the nipples. Others experience changes in hair texture that make hair drier or oilier. Some women even find their hair changing color.
Nails, like hair, can change noticeably during pregnancy. Extra hormones can make them grow faster and become stronger. Some women, however, find that their nails tend to split and break more easily during pregnancy. Like the changes in hair, nail changes aren't permanent. If your nails split and tear more easily when you're pregnant, keep them trimmed and avoid the chemicals in nail polish and nail polish remover.

7. Shoe Size
Even though you can't fit into any of your prepregnancy clothes, you still have your shoes, right? Maybe - but maybe not. Because of the extra fluid in their pregnant bodies, many women experience swelling in their feet and may even have to start wearing a larger shoe size. Wearing slip-on shoes in a larger size will be more comfortable for many pregnant women, especially in the summer months.

8. Joint Mobility
During pregnancy, your body produces a hormone known as relaxin, which is believed to help prepare the pubic area and the cervix for the birth. The relaxin loosens the ligaments in your body, making you less stable and more prone to injury. It's easy to overstretch or strain yourself, especially the joints in your pelvis, lower back, and knees. When exercising or lifting objects, go slowly and avoid sudden, jerky movements.

9. Varicose Veins, Hemorrhoids, and Constipation
Varicose veins, which are usually found in the legs and genital area, occur when blood pools in veins enlarged by the hormones of pregnancy. Varicose veins often disappear after pregnancy, but you can lessen them by:

• avoiding standing or sitting for long periods of time
• wearing loose-fitting clothing
• wearing support hose
• elevating your feet when you sit
  

Hemorrhoids - varicose veins in the rectum - frequently occur during pregnancy as well. Because your blood volume has increased and your uterus puts pressure on your pelvis, the veins in your rectum may enlarge into grape-like clusters. Hemorrhoids can be extremely painful, and they may bleed, itch, or sting, especially during or after a bowel movement. Coupled
with constipation, another common pregnancy woe, hemorrhoids can make going to the bathroom downright unpleasant
Constipation is common throughout pregnancy because pregnancy hormones slow the rate of food passing through the gastrointestinal tract. During the later stages of pregnancy, your uterus may push against your large intestine, making it difficult for waste to be eliminated. Constipation can contribute to hemorrhoids because straining may enlarge the veins of the rectum.
The best way to combat constipation and hemorrhoids is to prevent them. Eating a fiber-rich diet, drinking plenty of fluids daily, and exercising regularly can help keep bowel movements regular. Stool softeners (not laxatives) may also help. If you do have hemorrhoids, see your doctor for a cream or ointment that can shrink them.

Birth Day Surprises

10. Things That Will Come Out of Your Body
So you've survived the mood swings and the hemorrhoids, and you think your surprises are over. Guess again - the day you give birth will probably hold the biggest surprises of all.
Only 1 in 10 mothers' water breaks before labor contractions begin. Some women never experience it - a doctor may need to rupture the amniotic sac (if the cervix is already dilated) when they arrive at the hospital. How much water can you expect? For a full-term baby, there are normally about 2.1 to 5.9 cups (500 to 1400 milliliters) of amniotic fluid. Some women may feel an intense urge to urinate that leads to a gush of fluid when their waters break. Others may have only a trickling sensation down their leg because the baby's head acts like a stopper to prevent most of the fluid from leaking out. In any case, amniotic fluid is generally sweet-smelling and pale or colorless and is replaced by your body every three hours, so don't be surprised if you continue to leak fluid, about a cup an hour, until delivery.
Other unexpected things may come out of your body during labor in addition to your baby, blood, and amniotic fluid. Some women experience nausea and vomiting. Others have diarrhea before or during labor, and flatulence (passing gas) is also common. During the pushing phase of labor, you may lose control of your bladder or bowels. A birth plan can be especially helpful in communicating your wishes to your health care providers about how to handle these and other discomforts of labor and delivery.
There are lots of surprises in store for you once you become pregnant - but none sweeter than the way you'll feel once your newborn is in your arms!
(AAFP)

Allergic Conjunctivitis

Alergi pada Mata

What is allergic conjunctivitis and what causes it?
A clear, thin membrane called the conjunctiva covers your eyeball and the inside of your eyelids. If something irritates this covering, your eyes may become red and swollen. Your eyes also may itch, hurt or water. This is called conjunctivitis. It is also known as "pink eye."
When an allergen causes the irritation, the condition is called allergic conjunctivitis. This type of conjunctivitis is not contagious. Some common allergens include: pollen from trees, grass and ragweed; animal skin and secretions such as saliva; perfumes and cosmetics; skin medicines; air pollution; and smoke. Viral and bacterial infections can also cause conjunctivitis.

Will allergic conjunctivitis damage my eyesight?
No. Allergic conjunctivitis is irritating and uncomfortable, but it will not hurt your eyesight.

What can I do to avoid getting conjunctivitis?
Try to identify and avoid the allergens that cause your symptoms. For example, if you are allergic to pollen or mold, stay indoors when pollen and mold levels are high. You can usually find out when allergen levels are high from the weather report. Keep your doors and windows closed, and use an air conditioner during the summer months.

How is allergic conjunctivitis treated?
Several types of eye drops are available to treat allergic conjunctivitis. They can help relieve itchy, watery eyes and may keep symptoms from returning. Eye drops may contain an antihistamine, a decongestant, a nonsteroidal anti-inflammatory drug (NSAID), or a mast-cell stabilizer. Some drops contain a combination of these. Some eye drops require a prescription. Antihistamine pills (which many people take for their allergies) may also help. Your doctor will talk with you about which treatment is right for you.

Do these treatments have side effects?
Many eye drops can cause burning and stinging when you first put them in, but this usually goes away in a few minutes. It is important to remember that all medicines may potentially cause side effects, so talk with your doctor before using any medicine, including eye drops.

What else can I do to feel better?
It may help to put a cold washcloth over your eyes for relief. Lubricating eye drops (sometimes called artificial tears) may also make your eyes feel better. You can buy these drops without a prescription.

Can I wear my contact lenses?
It's not a good idea to wear contacts while you have allergic conjunctivitis because you might get an eye infection. Instead, wear your glasses until your eyes feel better.
(AAFP)

Eardrum Perforation

Gendang Telinga Robek/Berlubang

A perforation is a hole in the eardrum.
A middle ear infection (otitis media) is the most common cause of eardrum perforation. The eardrum can also be perforated by a sudden change in pressure-either an increase, such as that caused by an explosion, a slap, or diving underwater; or a decrease, such as occurs while flying in an airplane. Another cause is burns from heat or chemicals. The eardrum may also be perforated (punctured) by objects placed in the ear, such as a cotton-tipped swab, or by objects entering the ear accidentally, such as a low-hanging twig or a thrown pencil. An object that penetrates the eardrum can dislocate or fracture the chain of small bones (ossicles) that connect the eardrum to the inner ear. Pieces of the broken ossicles or the object itself may even penetrate the inner ear. A blocked eustachian tube may lead to the perforation because of severe imbalance of pressure (barotrauma) .

Symptoms and Diagnosis
Perforation of the eardrum causes sudden severe pain, sometimes followed by bleeding from the ear, hearing loss, and noise in the ear (tinnitus). The hearing loss is more severe if the chain of ossicles has been disrupted or the inner ear has been injured. Injury to the inner ear may also cause vertigo (a whirling sensation). Pus may begin to drain from the ear in 24 to 48 hours, particularly if water or other foreign material enters the middle ear. A doctor diagnoses eardrum perforation by looking in the ear with a special instrument called an otoscope.

Treatment
The ear is kept dry. Ear drops containing an antibiotic may be used if the ear becomes infected. Usually, the eardrum heals without further treatment, but if it does not heal within 2 months, surgery to repair the eardrum (tympanoplasty) may be needed. If a perforation is not repaired, the person may develop a smoldering infection-chronic otitis media-in the middle ear. A persistent conductive hearing loss following perforation of the eardrum suggests a disruption or fixation of the ossicles, which may be repaired surgically. A sensorineural hearing loss or vertigo that persists for more than a few hours after the injury suggests that something has injured or
penetrated the inner ear.
(Merck)

Using Vitamin & Mineral Supplements Wisely

To use dietary supplements wisely, assess your needs, evaluate the merits of taking supplements, and understand how to choose and use them.
Can you skip your daily servings of fruits and vegetables and take a vitamin and mineral supplement instead? Unfortunately, no. Dietary supplements aren't meant to be food substitutes, as they can't replicate all of the nutrients and benefits of whole foods, such as fruits and vegetables. But dietary supplements can still play a role in your health by complementing your regular diet if you have trouble getting enough nutrients.

Vitamin and mineral ABCs
Vitamins and minerals are substances your body needs in small but steady amounts for normal growth, function and health. Together, vitamins and minerals are called micronutrients. Your body can't make most micronutrients, so you must get them from the foods you eat or, in some
cases, from dietary supplements.

• Vitamins. These nutrients are needed for a variety of biological processes, among them growth, digestion and nerve function. Vitamins are involved in many processes that enable your body to use carbohydrates, fats and proteins for energy and repair. Though vitamins are involved in converting food into energy, they supply no calories.
• Minerals. These nutrients are the main components in your teeth and bones, and they serve as building blocks for other cells and enzymes. Minerals also help regulate the balance of fluids in your body and control the movement of nerve impulses. Some minerals also help deliver oxygen to cells and help carry away carbon dioxide.
  

Whole foods: Your best source of micronutrients Whole foods are your best sources of vitamins and minerals. They offer three main benefits over dietary supplements:

• Greater nutrition. Whole foods are complex, containing a variety of the micronutrients your body needs - not just one. An orange, for example, provides vitamin C but also some beta carotene, calcium and other nutrients. A vitamin C supplement lacks these other micronutrients.
• Essential fiber. Whole foods provide dietary fiber. Fiber can help prevent certain diseases, such as diabetes and heart disease, and it can also help manage constipation.
• Protective substances. Whole foods contain other substances recognized as important for good health. Fruits and vegetables, for example, contain naturally occurring food substances called phytochemicals, which may help protect you against cancer, heart disease, diabetes and high blood pressure.
  

Many are also good sources of antioxidants - substances that slow down oxidation, a natural process that leads to cell and tissue damage. If you depend on dietary supplements rather than eating a variety of whole foods, you miss the benefits of these substances.

Who needs dietary supplements?
Many people don't receive all of the nutrients they need from their diet because they either can't or don't eat enough, or they can't or don't eat a variety of healthy foods. For some people, including those on restrictive diets, dietary supplements can provide vitamins and minerals that their diets often don't. Pregnant women and older adults have altered nutrient needs and may also benefit from a dietary supplement.

Dietary supplements: Do you need them?
Choosing and using supplements
If you decide to take a vitamin or mineral supplement, consider these factors:

• Check the supplement label. Read labels carefully. Product labels can tell you what the active ingredient or ingredients are, which nutrients are included, the serving size - for example, capsule, packet or teaspoonful - and the amount of nutrients in each serving.
• Avoid supplements that provide 'megadoses.' In general, choose a multivitamin- mineral supplement that provides about 100 percent of the Daily Value (DV) of all the vitamins and minerals, rather than one which has, for example, 500 percent of the DV for one vitamin and only 20 percent of the DV for another. The exception to this is calcium. You may notice that calcium-containing supplements don't provide 100 percent of the DV. If they did, the tablets would be too large to swallow.
• Look for 'USP' on the label. This ensures that the supplement meets the standards for strength, purity, disintegration and dissolution established by the testing organization U.S. Pharmacopeia (USP).
• Beware of gimmicks. Synthetic vitamins are usually the same as so-called "natural" vitamins, but "natural" vitamins usually cost more. And don't give in to the temptation of added herbs, enzymes or amino acids - they add mostly cost. Note that some herbs can interact negatively with certain medications.
• Look for expiration dates. Dietary supplements can lose potency over time, especially in hot and humid climates. If a supplement doesn't have an expiration date, don't buy it. If your supplements have expired, discard them.
• Store all vitamin and mineral supplements safely. Store dietary supplements in a dry, cool place. Avoid hot, humid storage locations, such as the bathroom. Also, store supplements out of sight and away from children. Put supplements in a locked cabinet or other secure location. Don't leave them on the counter or rely on child-resistant packaging.

(Mayo)

Drug Resistance for Gonorrhea Treatment

Drug Resistance: major antibiotics used to the treat gonorrhea are no longer effective, now there's only one therapy left

For sexually active people, gonorrhea has always cast a frightening shadow-almost 340,000 cases are reported each year, and at least that many may go unreported or undiagnosed. According to the CDC, the situation just got even scarier. The agency announced Thursday that it will no longer recommend a major class of antibiotics used to cure gonorrhea, a group of drugs called fluoroquinolones, also known as quinolones, because strains of the bacteria have become resistant to them and are circulating throughout the nation. Since doctors started treating gonorrhea in the 1940s, the disease has developed resistance against almost every antibiotic used, including penicillin and tetracycline; it is now unresponsive to all previously recommended drugs except one last group called cephalosporins.
Someday, it may evolve resistance to those, too. Mary Carmichael spoke with Dr. John Douglas, director of the CDC's Division of Sexually Transmitted Diseases Prevention.
Excerpts:
Mary: A primary treatment for gonorrhea no longer works in more than 13 percent of cases surveyed by the CDC. What about the other 87 percent? Should those patients keep taking quinolones, or do the CDC's new recommendations apply to them as well?
John Douglas: For all practical purposes, the new recommendation affects everybody. The reason is that most of the time patients don't know what strain they have. The old clinical tests for gonorrhea, where you grow bacteria in a culture and see what it takes to kill it, could tell you whether a strain was resistant or not. But most clinics have replaced those tests with more convenient methods that don't have the capacity to test for antibiotic susceptibility. So people don't usually know if they're in the 13 percent or the 87 percent.

You've traced the quinolone-resistant strains to western Asia, so you know where they started circulating. Why did they develop resistance in the first place?
We haven't yet fully worked that out. People often use quinolones to treat other diseases like urinary-tract infections. Some of those people might also have had gonorrhea and not realized it, and they wouldn't have necessarily taken enough to kill the gonorrhea, leading to survival of resistant strains.

What, exactly, was it that changed and made the bacteria resistant?
The most important change was in an enzyme called DNA gyrase that helps the bacteria replicate their DNA. Quinolones work by inhibiting that enzyme. But there were several other mutations that occurred as well. Of all the bacterial STDs, gonorrhea is the most genetically versatile and complicated. It's got the biggest genome, and the bigger the genome, the more places there are for mutations to happen. It's also particularly susceptible to taking on new plasmids, or independent pieces of DNA that float around and get incorporated into the genome. When gonorrhea first became resistant to penicillin in the '80s, it was because it had picked up a new plasmid.

You started seeing quinolone-resistant strains in the United States as early as 2000. Why didn't you change the treatment recommendations then?
We saw them first in Hawaii, and in 2000 we stopped recommending quinolones to treat cases acquired there. We did the same thing for California in 2002. And in 2004 we stopped recommending quinolones for cases nationwide among men who have sex with men. But the thing is, with the nonresistant strains, the quinolones are really effective. They're also very cost-effective and easy to take. So when the resistant strains first got to Hawaii, the idea was that the rest of the U.S. was just fine. We were concerned the resistance would spread, but we didn't think continuing to use the quinolones would hasten that. But we also knew we should be ready to pull the plug when we needed to. And now we do.

After you changed the recommendations in Hawaii and California, did you see a drop in gonorrhea transmission there?
We did not. We would have expected to see that if we had been grossly mistreating a lot of infections. The good news is, it looks like our surveillance system picked up the drug-resistant strains early enough that we were able to maintain effective treatment for people who did get gonorrhea.

Gonorrhea is the second most common STD you track, but numbers are actually down overall, aren't they?
We reached historic heights in the '60s and '70s. And then starting in the early '80s, the numbers began to go way down. Since 1997 they've been relatively flat-although we did have a report last month that showed an almost 50 percent rise in reported cases in eight Western states. At least part of that increase seems to be because more people are getting tested. But not all of it. Some part of it can't be explained by increased testing, which has got us somewhat nervous. So far it doesn't look like this rise can be blamed on antibiotic resistance. There's been some concern that it's linked to the increased use of methamphetamines, which is in turn linked to risky sexual behavior. But that's very much a theory at this point.

So now gonorrhea is resistant to every recommended drug we have except the cephalosporins. Could it develop resistance to those drugs, too?
Absolutely. But we don't have any indication that that's happened with the cephalosporins yet. There have been suspicious reports from other countries of cephalosporin- resistant strains, but when those cultures have been sent to other labs, they haven't actually turned out to be resistant.

How long might it be before a true cephalosporin- resistant strain pops up?
There's no way to estimate it, and we don't truly know that it will happen at all. Cephalosporins have been used to treat gonorrhea for 25 years, and in that time, in terms of susceptibility, the disease hasn't budged. That's pretty good news. But it's not good enough news to allow us to say the cephalosporins will work forever.

How many types of effective cephalosporins are there?
There's a shot called Ceftriaxone, and then there's an oral drug called Cefixime that's only available in limited formulations. It used to be manufactured as a pill and a liquid, but the company that manufactured the pill, stopped making it, likely because it was not in their economic interest to continue making it. [The patent expired in 2002.] There's an Indian company called Lupin that's working now to bring the pill form back.

Are there new drugs in the pipeline that might help?
One of the reasons we're so concerned is the antibiotic pipeline is pretty skimpy. There are new varieties of cephalosporin antibiotics that might help, although they are pretty similar to existing drugs. But there's very little else in the pipeline that looks like it could be effective. We might end up trying some older drugs developed for other diseases. One is an alternative for people who are allergic to cephalosporins is called Spectinomycin, which is an injection. Unfortunately, it's currently not manufactured in the United States, so we are considering evaluating other drugs in this class that are still available. There's also a drug that's being used widely for chlamydia called Azithromycin. But the bottom line is, compared to the situation 20 years ago when we had to stop using penicillin for gonorrhea, we have a much less optimistic outlook.
(Newsweek)

Abstinence

Larissa Hirsch

What Is It?
Abstinence is not having sex. A person who decides to practice abstinence has decided not to have sex.

How Does It Work?
If two people don't have sex, then sperm can't fertilize an egg and there's no possibility of a pregnancy. Some forms of birth control depend on barriers that prevent the sperm from reaching the egg (such as condoms or diaphragms). Others interfere with the menstrual cycle (as birth control pills do). With abstinence, no barriers or pills are necessary because the person is not having sex. You don't have to be a virgin to practice abstinence. Sometimes people who have been having sex decide not to continue having sex. Even if a person has been having sex, he or she can still choose abstinence to prevent pregnancy and sexually transmitted diseases (STDs).

How Well Does It Work?
Abstinence is 100% effective in preventing pregnancy. Although many birth control methods can have high rates of success if used properly, they can fail occasionally. Practicing abstinence ensures that a girl will not become pregnant because there is no opportunity for sperm to fertilize an egg.

Protection Against STDs
Abstinence protects people against STDs. Some STDs spread through oral-genital sex, anal sex, or even intimate skin-to-skin contact without actual penetration (genital warts and herpes can be spread this way). So only avoiding all types of intimate genital contact can prevent STDs. Avoiding all types of intimate genital contact - including anal and oral sex - is complete abstinence.
Only complete and consistent abstinence can totally prevent pregnancy and protect against STDs. Because a person does not have any type of intimate sexual contact when he or she practices complete abstinence, there is no risk of passing on a sexually transmitted infection. Consistent abstinence means that someone practices abstinence all the time. Having sex even once means that the person risks getting an infection. Abstinence does not prevent AIDS and hepatitis B infections that come from nonsexual activities like using contaminated needles for doing drugs, tattooing, or taking steroids.

How Do You Do It?
Not having sex may seem easy because it's not doing anything. But peer pressure and things you see on TV and in the movies can make the decision to practice abstinence more difficult.
If it seems like everybody else is having sex, some people ay feel they have to do it, too, just to be accepted. Don't let kidding or pressure from friends, a girlfriend, a boyfriend, or even the media push you into something that's not right for you. The truth is that most teens are not having sex. A couple can still have a relationship without having sex. If you've made a decision not to have sex, it's an important personal choice and the people who care about you should respect that. You may have questions about making this choice or about other methods of birth control. Your family doctor, nurse or counselor can help provide some answers.
(AAFP)

What You Can Do to Keep Your Health

Does what I do really affect my health?
Very much so. All of the major causes of death--cancer, heart disease, stroke, lung disease and injury--can be prevented by things you do.

Don't smoke or use tobacco.
Using tobacco is one of the most dangerous things you can do. One out of every 6 deaths in the United States can be blamed on smoking. More preventable illnesses are caused by tobacco than by anything else.

Limit how much alcohol you drink.
This means no more than 2 drinks a day for men, and 1 drink a day for women. One drink is a can of beer (12 ounces), a 4-ounce glass of wine or a jigger (1 ounce) of liquor. Too much alcohol can damage the liver and contribute to some cancers, such as throat and liver cancer. Alcohol also contributes to deaths from car wrecks, murders and suicides.

Eat right.
See below for tips on eating healthy. Heart disease, some cancers, stroke, diabetes and damage to your arteries can be linked to what you eat. Fiber, fruits and vegetables can help reduce your risk of some cancers. Calcium helps build strong bones.

What to eat

• 2 to 4 servings of fruits and 3 to 5 servings of vegetables a day
• 6 to 11 servings of bread, cereal, rice and pasta a day
• 2 to 3 servings of low-fat or fat-free milk, yogurt and cheese a day
• 2 to 3 servings of meat, poultry, fish, dry beans, egg whites or nuts a day
• Lots of fiber (found in whole-grain breads and cereals, fruits and vegetables)
  

What not to eat

• Saturated fat. Saturated fats include animal fats, hydrogenated vegetable fats and tropical fats (coconut and palm oil). A high-fat diet increases your risk of heart disease, breast and colon cancer, and gallbladder disease.
• Sodium. Sodium, found in table salt and some foods, increases blood pressure in some people. Don't cook with salt, avoid prepared foods that are high in sodium and add salt sparingly, if at all, when you're eating.
  

Lose weight if you're overweight.
Many people are overweight. Carrying too much weight increases your risk for high blood pressure, high cholesterol, diabetes, heart disease, stroke, some cancers, gallbladder disease and arthritis in the weight-bearing joints (like the spine, hips or knees). A high-fiber, low-fat diet and regular exercise can help you lose weight gradually and help you keep it off.

Exercise.
Exercise can help prevent heart disease, high blood pressure, diabetes, osteoporosis, depression and, possibly, colon cancer, stroke and back injury. You'll also feel better and keep your weight under control if you exercise regularly. Try to exercise for 30 to 60 minutes, 4 to 6 times a week, but any amount is better than none.

Don't sunbathe or use tanning booths.
Sun exposure is linked to skin cancer, which is the most common type of cancer. So it's best to stay out of the sun altogether or to wear protective clothing and hats. Sunscreen may help protect your skin somewhat if you can't avoid being exposed to the sun's harmful rays.

Practice safer sex if you're having sex.
The safest sex is between 2 people who are only having sex with each other and who don't have a sexually transmitted disease (STD) or share needles to inject drugs. If you're at all uncertain about your partner, use latex condoms and a spermicide (sperm-killer) . If you're concerned you may be at risk of having an STD, see your doctor about being tested.

Control your cholesterol level.
If your cholesterol level is high, keep your level down by eating right, such as by reducing how much fat you eat, and by exercising.

Control high blood pressure.
High blood pressure increases your risk for heart disease, stroke and kidney disease. To control it, lose weight, exercise, eat less sodium, drink less alcohol, don't smoke and take medicine if your doctor prescribes it.

Keep your shots up to date.
Adults need a tetanus-diphtheria booster every 10 years. People 50 or older and others at risk should get a flu shot. Ask your doctor if you need other shots.

Check your breasts.
Breast cancer is the second most common cause of death for women. Examine your breasts every month beginning about age 20. Talk to your doctor about how to check your breasts. Have your doctor check your breasts every 1 to 2 years beginning when you're 40. After age 50, you should have a mammogram every 1 to 2 years.

Get regular Pap smears.
Cancer of the cervix in women can be detected by regular Pap smears. Start having them when you begin having sex or by age 18. You'll need them once a year at first, until you've had at least 3 normal Pap tests. After this, you should have them at least every 3 years.

Ask your doctor about other cancer screenings.
Adults over age 50 should ask their doctor about being checked for colorectal cancer. Men over age 50 should discuss with their doctor the risks and benefits of being screened for prostate cancer.

Should I have a yearly physical?
Health screenings are replacing the yearly physical. Instead of every person getting the same exams and tests, only the appropriate ones are given. Talk to your family doctor about your risk factors and what tests and exams are right for you.
(AAFP)