Mark Reiter, MD, Emergency Medicine, Dec 14, 2009
Emergency Physician, Bethlehem, PA
Last week, The Cochrane Review, concluded that the existing literature (they looked at 5 higher quality studies out of 20 studies of antivirals for influenza) did not support the use of neuramidase inhibitors for healthy patients for treatment of influenza. They could not detect a statistically significant clinical impact, and did not an increase in side effects, particularly nausea. (www.medscape.com/viewarticle/713604) Many physicians had come to a similar conclusion, but Cochrane's findings certainly adds significant weight.
A few days ago, the World Health Organization endorsed The Cochrane Review's findings, and recommends that antivirals only be used in influenza at high risk for complications. (www.medscape.com/viewarticle/713775) The CDC has been offering similar advice for several months.
In the week ending October 31st, 587,960 prescriptions for antiviral flu medicines were filled in the U.S. (98% for Tamiflu), according to the LA Times.
Do we really think we are helping people? Are we hurting people? Are we trying to make satisfied patients what they think they want? Are we trying to avoid complaints or lawsuits? We need to do better....
Saturday, December 26, 2009
Wednesday, December 23, 2009
Ten Minor Steps To Develop Your Wellbeing
By: Jayden Shemayah
Countless of us make wellbeing-related resolutions, such as to lose weight, to stop smoking or sign up for the neighborhood fitness center. While it is common to set excessive goals, trainers say that making lesser goals might do more for our health.
"Lesser steps are reachable and are easier to squeeze into your daily routine," says James O. Hill, Ph.D., Director of the Center for Human Nutrition at the University of Colorado Health Sciences Center. "They are less overpowering than a big, rapid conversion."
Here are 10 Steps to try:
1. Stop gaining weight. Even if you acquire only a pound or two each year, the extra weight adds up rapidly.
2. Walk more. Use a pedometer to add up your daily steps; after that add 2,000 extra steps into your day, the equivalent of one additional mile. Keep adding steps, 1,000 to 2,000 each month or so, until you take 10,000 steps on most days.
3. Eat breakfast. Breakfast eaters tend to have healthier diets and weigh less too. For a filling and nutrition-packed breakfast, top Whole Grain Total® with fresh fruit slices and low-fat or fat-free milk.
4. Replace three grain servings each day to whole grain. If you're like the average American, you eat fewer than one whole grain serving daily.
5. Have a minimum of one healthy green salad per day. Eating a salad (with low-fat or fat-free dressing) is filling and may help you eat a smaller amount during the meal. It also counts toward your five daily cups of fruits and vegetables.
6. Eliminate Fat. Fat has a lot of calories, and calories are a significant factor in weight loss. Purchase lean meats, eat poultry skinless, switch over to lower-fat cheeses, invest in a nonstick pan with just a dab of oil or butter.
7. Consider calcium by eating' two or three daily servings of low-fat or fat-free milk or yogurt. Dairy calcium is healthy for bones and may well also help you drop weight.
8. Downsize. If the package is small, the serving size will be smaller as well.
9. Aim to drop just 5 to 10 percent of your present weight. The benefits to losing weight are great-lower blood pressure, blood sugar, cholesterol and triglycerides.
10. Keep track of your eating. Jot down everything you eat over the next couple of days and be on the lookout for problem spots. Often, just writing things down can help you consume a reduced amount.
For more information on how to lose fat, gain muscle, and to find out how to get abs check out this site - How To Get A Six Pack Fast
Smart Articles @ http://www.articlebrain.com
Countless of us make wellbeing-related resolutions, such as to lose weight, to stop smoking or sign up for the neighborhood fitness center. While it is common to set excessive goals, trainers say that making lesser goals might do more for our health.
"Lesser steps are reachable and are easier to squeeze into your daily routine," says James O. Hill, Ph.D., Director of the Center for Human Nutrition at the University of Colorado Health Sciences Center. "They are less overpowering than a big, rapid conversion."
Here are 10 Steps to try:
1. Stop gaining weight. Even if you acquire only a pound or two each year, the extra weight adds up rapidly.
2. Walk more. Use a pedometer to add up your daily steps; after that add 2,000 extra steps into your day, the equivalent of one additional mile. Keep adding steps, 1,000 to 2,000 each month or so, until you take 10,000 steps on most days.
3. Eat breakfast. Breakfast eaters tend to have healthier diets and weigh less too. For a filling and nutrition-packed breakfast, top Whole Grain Total® with fresh fruit slices and low-fat or fat-free milk.
4. Replace three grain servings each day to whole grain. If you're like the average American, you eat fewer than one whole grain serving daily.
5. Have a minimum of one healthy green salad per day. Eating a salad (with low-fat or fat-free dressing) is filling and may help you eat a smaller amount during the meal. It also counts toward your five daily cups of fruits and vegetables.
6. Eliminate Fat. Fat has a lot of calories, and calories are a significant factor in weight loss. Purchase lean meats, eat poultry skinless, switch over to lower-fat cheeses, invest in a nonstick pan with just a dab of oil or butter.
7. Consider calcium by eating' two or three daily servings of low-fat or fat-free milk or yogurt. Dairy calcium is healthy for bones and may well also help you drop weight.
8. Downsize. If the package is small, the serving size will be smaller as well.
9. Aim to drop just 5 to 10 percent of your present weight. The benefits to losing weight are great-lower blood pressure, blood sugar, cholesterol and triglycerides.
10. Keep track of your eating. Jot down everything you eat over the next couple of days and be on the lookout for problem spots. Often, just writing things down can help you consume a reduced amount.
For more information on how to lose fat, gain muscle, and to find out how to get abs check out this site - How To Get A Six Pack Fast
Smart Articles @ http://www.articlebrain.com
Friday, December 18, 2009
Thousands of New Cancers Predicted Due to Increased Use of CT
From Medscape Medical News
Roxanne Nelson
December 17, 2009 — Computed tomography (CT) scans are widely used and are an invaluable tool for medical imaging. However, the possible overuse of CT scans and the variability in radiation doses might subsequently lead to thousands of cases of cancer, according to findings from 2 new studies published in the December 14/28 issue of the Archives of Internal Medicine.
In the first study, researchers found that radiation doses from common CT procedures are higher and more variable than what is typically cited. For example, the authors note that the median effective dose of an abdomen and pelvis CT scan is often cited as 8 to 10 mSv, but they found that the median dose of this type of scan was actually 66% higher, and the median dose of a multiphase CT scan of the abdomen and pelvis was nearly 4 times higher.
The authors also found a considerable range in doses within and across the institutions included in their study, with a mean 13-fold variation between the highest and lowest dose for each CT type studied.
In the second study, researchers estimated future cancer risks from current CT scan use in the United States, and projected that 29,000 future cancers will be directly attributable to CT scans that were performed in 2007. It is expected that the majority of these projected cancers will be caused by scans of the abdomen and pelvis (n = 14,000), chest (n = 4100), and head (n = 4000), and by CT coronary angiography (n = 2700).
What is becoming clear . . . is that the large doses of radiation from such scans will translate, statistically, into additional cancers.
More than 19,500 CT scans are performed every day in the United States; these expose each patient to the equivalent of 30 to 442 chest radiographs per scan, notes Rita F. Redberg, MD, MSc, professor of medicine at the University of California, San Francisco School of Medicine and editor of the Archives of Internal Medicine, in an accompanying editorial.
However, there is a question of benefit — whether these scans will lead to "demonstrable benefits through improvements in longevity or quality of life are hotly debated," she writes. "What is becoming clear, however, is that the large doses of radiation from such scans will translate, statistically, into additional cancers."
"We need to do something now, not wait 10 or 20 years to see the effects. It's not like radiation exposure can be undone after we find out that it does cause cancer," Dr. Redberg told Medscape Oncology.
Roxanne Nelson
December 17, 2009 — Computed tomography (CT) scans are widely used and are an invaluable tool for medical imaging. However, the possible overuse of CT scans and the variability in radiation doses might subsequently lead to thousands of cases of cancer, according to findings from 2 new studies published in the December 14/28 issue of the Archives of Internal Medicine.
In the first study, researchers found that radiation doses from common CT procedures are higher and more variable than what is typically cited. For example, the authors note that the median effective dose of an abdomen and pelvis CT scan is often cited as 8 to 10 mSv, but they found that the median dose of this type of scan was actually 66% higher, and the median dose of a multiphase CT scan of the abdomen and pelvis was nearly 4 times higher.
The authors also found a considerable range in doses within and across the institutions included in their study, with a mean 13-fold variation between the highest and lowest dose for each CT type studied.
In the second study, researchers estimated future cancer risks from current CT scan use in the United States, and projected that 29,000 future cancers will be directly attributable to CT scans that were performed in 2007. It is expected that the majority of these projected cancers will be caused by scans of the abdomen and pelvis (n = 14,000), chest (n = 4100), and head (n = 4000), and by CT coronary angiography (n = 2700).
What is becoming clear . . . is that the large doses of radiation from such scans will translate, statistically, into additional cancers.
More than 19,500 CT scans are performed every day in the United States; these expose each patient to the equivalent of 30 to 442 chest radiographs per scan, notes Rita F. Redberg, MD, MSc, professor of medicine at the University of California, San Francisco School of Medicine and editor of the Archives of Internal Medicine, in an accompanying editorial.
However, there is a question of benefit — whether these scans will lead to "demonstrable benefits through improvements in longevity or quality of life are hotly debated," she writes. "What is becoming clear, however, is that the large doses of radiation from such scans will translate, statistically, into additional cancers."
"We need to do something now, not wait 10 or 20 years to see the effects. It's not like radiation exposure can be undone after we find out that it does cause cancer," Dr. Redberg told Medscape Oncology.
Tuesday, December 1, 2009
Brain Care 101
Jan 11, 2008
It is Not Only Cars That Deserve Good Maintenance:
By: Alvaro Fernandez
Last week, the US Car Care Council released a list of tips on how to take care of your car and “save big money at the pump in 2008.”
You may not have paid much attention to this announcement. Yes, it’s important to save gas these days; but, it’s not big news that good maintenance habits will improve the performance of a car, and extend its life.
If we can all agree on the importance of maintaining our cars that get us around town, what about maintaining our brains sitting behind the wheel?
A spate of recent news coverage on brain fitness and “brain training” has missed an important constituency: younger people. Recent advancements in brain science have as tremendous implications for teenagers and adults of all ages as they do for seniors.
In a recent conversation with neuroscientist Yaakov Stern of Columbia University, he related how surprised he was when, years ago, a reporter from Seventeen magazine requested an interview. The reporter told Dr. Stern that he wanted to write an article to motivate kids to stay in school and not to drop out, in order to start building their Cognitive Reserve early and age more gracefully.
What is the Cognitive Reserve?
Emerging research since the 90s from the past decade shows that individuals who lead mentally stimulating lives, through their education, their jobs, and also their hobbies, build a “Cognitive Reserve” in their brains. Only a few weeks ago another study reinforced the value of intellectualy demanding jobs.
Stimulating the brain can literally generate new neurons and strengthen their connections which results in better brain performance and in having a lower risk of developing Alzheimer’s symptoms. Studies suggest that people who exercise their mental muscles throughout their lives have a 35-40% less risk of manifesting Alzheimer’s.
As astounding as these insights may be, most Americans still devote more time to changing the oil, taking a car to a mechanic, or washing it, than thinking about how to maintain, if not improve, their brain performance.
Further, better brain scanning techniques like fMRI (glossary) are allowing scientists to investigate healthy live brains for the first time in history. Two of the most important findings from this research are that our brains are plastic (meaning they not only create new neurons but also can change their structure) throughout a lifetime and that frontal lobes are the most plastic area. Frontal lobes, the part of our brains right behind the forehead, controls “executive functions” — which determine our ability to pay attention, plan for the future and direct behavior toward achieving goals. They are critical for adapting to new situations. We exercise them best by learning and mastering new skills.
This part of the brain is delicate: our frontal lobes wait until our mid to late 20s to fully mature. They are also the first part of our brain to start to decline, usually by middle age.
In my view, not enough young and middle-aged people are benefiting from this emerging research, since it has been perceived as something “for seniors.” Granted, there are still many unknowns in the world of brain fitness and cognitive training, we need more research, better assessments and tools. But, this does not mean we cannot start caring for our brains today.
Recent studies have shown a tremendous variability in how well people age and how, to a large extent, our actions influence our rate of brain improvement and/or decline. The earlier we begin the better. And it is never too late.
What can we do to maintain our brain, especially the frontal lobes? Focus on four pillars of brain health: physical exercise, a balanced diet, stress management, and brain exercise.
Stress management is important since stress has been shown to actually kill neurons and reduce the rate of creation of new ones.
Brain exercises range from low-tech (i.e. meditation, mastering new complex skills, lifelong learning and engagement) to high-tech (i.e. using the growing number of brain fitness software programs).
I know, this is starting to sound like those lists we all know are good for us but we actually don’t do. Let me make it easier by proposing a new New Year Resolution for 2008: every time you wash your car or have it washed in 2008, ask yourself, “What have I done lately to maintain my brain?”
It is Not Only Cars That Deserve Good Maintenance:
By: Alvaro Fernandez
Last week, the US Car Care Council released a list of tips on how to take care of your car and “save big money at the pump in 2008.”
You may not have paid much attention to this announcement. Yes, it’s important to save gas these days; but, it’s not big news that good maintenance habits will improve the performance of a car, and extend its life.
If we can all agree on the importance of maintaining our cars that get us around town, what about maintaining our brains sitting behind the wheel?
A spate of recent news coverage on brain fitness and “brain training” has missed an important constituency: younger people. Recent advancements in brain science have as tremendous implications for teenagers and adults of all ages as they do for seniors.
In a recent conversation with neuroscientist Yaakov Stern of Columbia University, he related how surprised he was when, years ago, a reporter from Seventeen magazine requested an interview. The reporter told Dr. Stern that he wanted to write an article to motivate kids to stay in school and not to drop out, in order to start building their Cognitive Reserve early and age more gracefully.
What is the Cognitive Reserve?
Emerging research since the 90s from the past decade shows that individuals who lead mentally stimulating lives, through their education, their jobs, and also their hobbies, build a “Cognitive Reserve” in their brains. Only a few weeks ago another study reinforced the value of intellectualy demanding jobs.
Stimulating the brain can literally generate new neurons and strengthen their connections which results in better brain performance and in having a lower risk of developing Alzheimer’s symptoms. Studies suggest that people who exercise their mental muscles throughout their lives have a 35-40% less risk of manifesting Alzheimer’s.
As astounding as these insights may be, most Americans still devote more time to changing the oil, taking a car to a mechanic, or washing it, than thinking about how to maintain, if not improve, their brain performance.
Further, better brain scanning techniques like fMRI (glossary) are allowing scientists to investigate healthy live brains for the first time in history. Two of the most important findings from this research are that our brains are plastic (meaning they not only create new neurons but also can change their structure) throughout a lifetime and that frontal lobes are the most plastic area. Frontal lobes, the part of our brains right behind the forehead, controls “executive functions” — which determine our ability to pay attention, plan for the future and direct behavior toward achieving goals. They are critical for adapting to new situations. We exercise them best by learning and mastering new skills.
This part of the brain is delicate: our frontal lobes wait until our mid to late 20s to fully mature. They are also the first part of our brain to start to decline, usually by middle age.
In my view, not enough young and middle-aged people are benefiting from this emerging research, since it has been perceived as something “for seniors.” Granted, there are still many unknowns in the world of brain fitness and cognitive training, we need more research, better assessments and tools. But, this does not mean we cannot start caring for our brains today.
Recent studies have shown a tremendous variability in how well people age and how, to a large extent, our actions influence our rate of brain improvement and/or decline. The earlier we begin the better. And it is never too late.
What can we do to maintain our brain, especially the frontal lobes? Focus on four pillars of brain health: physical exercise, a balanced diet, stress management, and brain exercise.
Stress management is important since stress has been shown to actually kill neurons and reduce the rate of creation of new ones.
Brain exercises range from low-tech (i.e. meditation, mastering new complex skills, lifelong learning and engagement) to high-tech (i.e. using the growing number of brain fitness software programs).
I know, this is starting to sound like those lists we all know are good for us but we actually don’t do. Let me make it easier by proposing a new New Year Resolution for 2008: every time you wash your car or have it washed in 2008, ask yourself, “What have I done lately to maintain my brain?”
Why Smart Brains Make Stupid Decisions
Jun 20, 2008
By: Alvaro Fernandez
It happens. Often.
Why?
We just secured an interview with Ori Brafman, co-author of Sway: The Irresistible Pull of Irrational Behavior (Doubleday Business, 2008), to discuss our Dark Side (well, he calls it “different hidden forces” and “psychological undercurrents”).
While reading some reviews about his book, I particularly enjoyed finding, after the usual impressive long collection of endorsements, this “disclaimer”:
*DISCLAIMER: If you decide to buy this book because of these endorsements, you just got swayed. One of the psychological forces you’ll read about in Sway is our tendency to place a higher value on opinions from people in positions of prominence, power, or authority. (But you should still buy the book.)
Alvaro Fernandez (AF): Ori, what is SWAY? can you give us a couple quick examples?
Ori Brafman (OB): Sway is about why perfectly rational people make irrational choices. We interviewed business executives, airline pilots, doctors, and even a Supreme Court Justice to uncover the psychological forces that affect our decision-making. What was especially interesting was to find out that we all get swayed, and that these psychological forces are much more ubiquitous than we thought.
Take, for instance, the story of Jacob Van Zanten who was the head of safety for KLM. One foggy afternoon, Van Zanten took off without getting tower clearance, causing the biggest airline accident in history. Why would this man, who’s the head of safety make such an irrational choice?
Or look at the story of Harvard Business School students who paid $204 for a twenty-dollar bill.
Â
AF: Happy to have attended Stanford… Now, how did that happen?
OB: The professor set up an auction for a $20 bill. But there was a twist. The winner would get the $20 bill. But the second place bidder, would still have to honor his bid, but would get nothing. At first there are lots of bidders, but then as the bidding approaches $20 people start pulling out. Inevitably, though two people stay in. As the bidding continued to rise, the second-place person became determined to not be the sucker who pays good money for nothing in return. The amazing thing is that time after time the auction continues well past the $20 point. People are just so determined not to lose, that they keep on bidding up.
AF: Why do people get Swayed?
OB: Without realizing it, we get swept up by a host of different hidden forces. I think of it like being in a boat in the middle of the ocean. It may look like we’re standing still, but underneath the surface, undercurrents move us without us realizing it. The same thing happens with psychological undercurrents. In Sway, we look at some of the major undercurrents and explore how they intersect triggering so many different irrational behaviors. The thing is that we’re prone to psychological sways all of the time–whether we’re conducting a job interview, going out on a first date, or deciding whether to sell a stock.
AF: Let’s be practical for a minute… what can people do to Sway other people?
OB: We’re constantly engaged in a hidden dance of sorts where we sway people around us and are swayed by others. One of the most unusual studies we encountered has to do with what we call the chameleon effect. In the study, a group of men and women–who had never met each other–were told to have a short phone conversation. Now, before the conversation, each man was shown a picture of the woman he’d be talking to. Unbeknownst to the men, the pictures were fake. And half the men were shown a picture of a beautiful woman, while the other half were shown a picture of a less attractive woman. The pictures had nothing to do with how the real women looked like, and the real women had no idea that there were any pictures shown. The kicker is that the women who the men thought were pretty ended up sounding beautiful on the phone. And the women who the men thought were less attractive ended up sounding less beautiful. We take on the roles others ascribe to us. Think about that with employees or even with your kids. If we think someone is smart, there’s a good chance they’ll live up to that role.
AF: And what can people do to prevent being Swayed?
OB: The biggest step is to recognize how often we get swayed. We have a tendency to think that our decisions are rational, when in fact, different sways may have informed the decision. Once we realize that we’re prone to get swayed, the second step is figuring out specific strategies to counter the sway.
It ranges from taking a long-term perspective to using empirical models for job interviews.
AF: For example?
OB: We have a propensity to “diagnose” a job candidate from the first moment we meet him or her. We assign a diagnosis, and are unable to see things in a different light despite objective evidence to the contrary. It’s for this reason that job interviews are terrible predictors of actual performance. A much more effective approach is to conduct very structured interviews that don’t allow managers to get swayed. In these interviews, the questions are pre-scripted and focus on experience and ability rather than vague things like “what’s your biggest strength?” We call these the Joe Friday interview (just the facts…) These interviews may seem less personal, but they’re actually much more effective for actually selecting a good candidate.
AF: Ori, thank you very much for your time.
OB: My pleasure!
http://www.sharpbrains.com/blog/2008/06/20/why-smart-brains-make-stupid-decisions/
By: Alvaro Fernandez
It happens. Often.
Why?
We just secured an interview with Ori Brafman, co-author of Sway: The Irresistible Pull of Irrational Behavior (Doubleday Business, 2008), to discuss our Dark Side (well, he calls it “different hidden forces” and “psychological undercurrents”).
While reading some reviews about his book, I particularly enjoyed finding, after the usual impressive long collection of endorsements, this “disclaimer”:
*DISCLAIMER: If you decide to buy this book because of these endorsements, you just got swayed. One of the psychological forces you’ll read about in Sway is our tendency to place a higher value on opinions from people in positions of prominence, power, or authority. (But you should still buy the book.)
Alvaro Fernandez (AF): Ori, what is SWAY? can you give us a couple quick examples?
Ori Brafman (OB): Sway is about why perfectly rational people make irrational choices. We interviewed business executives, airline pilots, doctors, and even a Supreme Court Justice to uncover the psychological forces that affect our decision-making. What was especially interesting was to find out that we all get swayed, and that these psychological forces are much more ubiquitous than we thought.
Take, for instance, the story of Jacob Van Zanten who was the head of safety for KLM. One foggy afternoon, Van Zanten took off without getting tower clearance, causing the biggest airline accident in history. Why would this man, who’s the head of safety make such an irrational choice?
Or look at the story of Harvard Business School students who paid $204 for a twenty-dollar bill.
Â
AF: Happy to have attended Stanford… Now, how did that happen?
OB: The professor set up an auction for a $20 bill. But there was a twist. The winner would get the $20 bill. But the second place bidder, would still have to honor his bid, but would get nothing. At first there are lots of bidders, but then as the bidding approaches $20 people start pulling out. Inevitably, though two people stay in. As the bidding continued to rise, the second-place person became determined to not be the sucker who pays good money for nothing in return. The amazing thing is that time after time the auction continues well past the $20 point. People are just so determined not to lose, that they keep on bidding up.
AF: Why do people get Swayed?
OB: Without realizing it, we get swept up by a host of different hidden forces. I think of it like being in a boat in the middle of the ocean. It may look like we’re standing still, but underneath the surface, undercurrents move us without us realizing it. The same thing happens with psychological undercurrents. In Sway, we look at some of the major undercurrents and explore how they intersect triggering so many different irrational behaviors. The thing is that we’re prone to psychological sways all of the time–whether we’re conducting a job interview, going out on a first date, or deciding whether to sell a stock.
AF: Let’s be practical for a minute… what can people do to Sway other people?
OB: We’re constantly engaged in a hidden dance of sorts where we sway people around us and are swayed by others. One of the most unusual studies we encountered has to do with what we call the chameleon effect. In the study, a group of men and women–who had never met each other–were told to have a short phone conversation. Now, before the conversation, each man was shown a picture of the woman he’d be talking to. Unbeknownst to the men, the pictures were fake. And half the men were shown a picture of a beautiful woman, while the other half were shown a picture of a less attractive woman. The pictures had nothing to do with how the real women looked like, and the real women had no idea that there were any pictures shown. The kicker is that the women who the men thought were pretty ended up sounding beautiful on the phone. And the women who the men thought were less attractive ended up sounding less beautiful. We take on the roles others ascribe to us. Think about that with employees or even with your kids. If we think someone is smart, there’s a good chance they’ll live up to that role.
AF: And what can people do to prevent being Swayed?
OB: The biggest step is to recognize how often we get swayed. We have a tendency to think that our decisions are rational, when in fact, different sways may have informed the decision. Once we realize that we’re prone to get swayed, the second step is figuring out specific strategies to counter the sway.
It ranges from taking a long-term perspective to using empirical models for job interviews.
AF: For example?
OB: We have a propensity to “diagnose” a job candidate from the first moment we meet him or her. We assign a diagnosis, and are unable to see things in a different light despite objective evidence to the contrary. It’s for this reason that job interviews are terrible predictors of actual performance. A much more effective approach is to conduct very structured interviews that don’t allow managers to get swayed. In these interviews, the questions are pre-scripted and focus on experience and ability rather than vague things like “what’s your biggest strength?” We call these the Joe Friday interview (just the facts…) These interviews may seem less personal, but they’re actually much more effective for actually selecting a good candidate.
AF: Ori, thank you very much for your time.
OB: My pleasure!
http://www.sharpbrains.com/blog/2008/06/20/why-smart-brains-make-stupid-decisions/
Sunday, November 22, 2009
Management of Vitamin D Deficiency Reviewed
Am Fam Physician. 2009;80:841-846. Abstract
Clinical Context
Skeletal development, bone health, and neuromuscular function all require vitamin D. There are 2 forms of vitamin D: vitamin D2 (ergocalciferol), produced by irradiating ergosterol found in yeast and plants; and vitamin D3 (cholecalciferol), found in oily fish and synthesized in the skin in response to sunlight.
Because few foods contain vitamin D2, it is difficult to maintain adequate levels of vitamin D from dietary sources alone, and humans typically obtain 90% of vitamin D from sunlight. Because milk and other foods have been fortified with vitamin D, the rickets epidemic has subsided, but vitamin D deficiency and insufficiency are still linked to other pathologic conditions affecting persons of all ages.
Study Highlights
Signs and symptoms of vitamin D deficiency develop slowly or are nonspecific.
These may include symmetric low back pain in women, proximal muscle weakness, muscle aches, and throbbing bone pain.
Vitamin D deficiency is defined as a 25-hydroxyvitamin D level of less than 20 ng/mL (50 nmol/L).
Vitamin D insufficiency is defined as a serum 25-hydroxyvitamin D level of 20 to 30 ng/mL (50 - 75 nmol/L).
To prevent vitamin D deficiency, infants and children should have vitamin D intake of at least 400 IU/day from diet and supplements.
Unless infants are ingesting at least 1 L/day (33.8 fl oz) of vitamin D-fortified formula or milk, they should receive supplementation of 400 IU/day.
Vitamin D supplementation, 400 IU/day, is recommended for all children and adolescents who do not get regular sunlight exposure, who do not consume 1 L/day or more of vitamin D-fortified formula or milk, or who do not take a daily multivitamin supplement containing at least 400 IU of vitamin D.
In adults, vitamin D supplementation of 700 to 800 IU or more per day may reduce rates of falls and fractures.
Contraindications to vitamin D supplementation include tuberculosis or other granulomatous diseases, metastatic bone disease, sarcoidosis, or Williams syndrome.
Patients with vitamin D deficiency should receive oral ergocalciferol (vitamin D2), 50,000 IU per week for 8 weeks.
Serum 25-hydroxyvitamin D levels should be checked when this 8-week course is completed, and if these levels are not at least 30 ng/mL, the most likely cause is nonadherence to therapy or malabsorption.
A second 8-week course of ergocalciferol should be given if the level is not at least 30 ng/mL. Patients with suspected malabsorption may need gastroenterologic consultation.
Once vitamin D levels normalize in patients who were deficient, patients should receive maintenance dosages of cholecalciferol (vitamin D3), 800 to 1000 IU per day from dietary sources and/or supplements.
Because vitamin D is fat soluble, toxicity may result from excessive supplementation.
Signs and symptoms of vitamin D toxicity may include headache, metallic taste, nephrocalcinosis or vascular calcinosis, pancreatitis, nausea, and/or vomiting.
Clinical Implications
The diagnosis of vitamin D deficiency is often missed because the signs and symptoms develop slowly or are nonspecific, such as symmetric low back pain, proximal muscle weakness, muscle aches, and throbbing bone pain. Diagnosis of suspected vitamin D deficiency or insufficiency is confirmed with measurement of 25-hydroxyvitamin D levels.
In older adults, vitamin D supplementation of 700 to 800 IU per day is associated with a lower risk for falls and fractures. Suggested treatment in patients with vitamin D deficiency is oral ergocalciferol, 50,000 IU per week for 8 weeks. Adults with vitamin D deficiency, except for those with malabsorption syndromes, should receive maintenance dosages of 800 to 1000 IU of vitamin D per day.
Clinical Context
Skeletal development, bone health, and neuromuscular function all require vitamin D. There are 2 forms of vitamin D: vitamin D2 (ergocalciferol), produced by irradiating ergosterol found in yeast and plants; and vitamin D3 (cholecalciferol), found in oily fish and synthesized in the skin in response to sunlight.
Because few foods contain vitamin D2, it is difficult to maintain adequate levels of vitamin D from dietary sources alone, and humans typically obtain 90% of vitamin D from sunlight. Because milk and other foods have been fortified with vitamin D, the rickets epidemic has subsided, but vitamin D deficiency and insufficiency are still linked to other pathologic conditions affecting persons of all ages.
Study Highlights
Signs and symptoms of vitamin D deficiency develop slowly or are nonspecific.
These may include symmetric low back pain in women, proximal muscle weakness, muscle aches, and throbbing bone pain.
Vitamin D deficiency is defined as a 25-hydroxyvitamin D level of less than 20 ng/mL (50 nmol/L).
Vitamin D insufficiency is defined as a serum 25-hydroxyvitamin D level of 20 to 30 ng/mL (50 - 75 nmol/L).
To prevent vitamin D deficiency, infants and children should have vitamin D intake of at least 400 IU/day from diet and supplements.
Unless infants are ingesting at least 1 L/day (33.8 fl oz) of vitamin D-fortified formula or milk, they should receive supplementation of 400 IU/day.
Vitamin D supplementation, 400 IU/day, is recommended for all children and adolescents who do not get regular sunlight exposure, who do not consume 1 L/day or more of vitamin D-fortified formula or milk, or who do not take a daily multivitamin supplement containing at least 400 IU of vitamin D.
In adults, vitamin D supplementation of 700 to 800 IU or more per day may reduce rates of falls and fractures.
Contraindications to vitamin D supplementation include tuberculosis or other granulomatous diseases, metastatic bone disease, sarcoidosis, or Williams syndrome.
Patients with vitamin D deficiency should receive oral ergocalciferol (vitamin D2), 50,000 IU per week for 8 weeks.
Serum 25-hydroxyvitamin D levels should be checked when this 8-week course is completed, and if these levels are not at least 30 ng/mL, the most likely cause is nonadherence to therapy or malabsorption.
A second 8-week course of ergocalciferol should be given if the level is not at least 30 ng/mL. Patients with suspected malabsorption may need gastroenterologic consultation.
Once vitamin D levels normalize in patients who were deficient, patients should receive maintenance dosages of cholecalciferol (vitamin D3), 800 to 1000 IU per day from dietary sources and/or supplements.
Because vitamin D is fat soluble, toxicity may result from excessive supplementation.
Signs and symptoms of vitamin D toxicity may include headache, metallic taste, nephrocalcinosis or vascular calcinosis, pancreatitis, nausea, and/or vomiting.
Clinical Implications
The diagnosis of vitamin D deficiency is often missed because the signs and symptoms develop slowly or are nonspecific, such as symmetric low back pain, proximal muscle weakness, muscle aches, and throbbing bone pain. Diagnosis of suspected vitamin D deficiency or insufficiency is confirmed with measurement of 25-hydroxyvitamin D levels.
In older adults, vitamin D supplementation of 700 to 800 IU per day is associated with a lower risk for falls and fractures. Suggested treatment in patients with vitamin D deficiency is oral ergocalciferol, 50,000 IU per week for 8 weeks. Adults with vitamin D deficiency, except for those with malabsorption syndromes, should receive maintenance dosages of 800 to 1000 IU of vitamin D per day.
Thursday, November 19, 2009
Folate Supplementation Linked to Increased Cancer Incidence and Mortality
From Medscape Medical News
Zosia Chustecka
November 18, 2009 — Folic acid and vitamin B supplementation was associated with an increase in cancer incidence, cancer mortality, and all-cause mortality in a new analysis with long-term follow-up of data from 2 trials conducted in Norway, where there is no folic acid fortification of foods.
The results are reported in the November 18 issue of the Journal of the American Medical Association.
The authors, led by Marta Ebbing, MD, from Haukeland University Hospital in Bergen, Norway, say that these results, although in need of confirmation, suggest that there is a need for "safety monitoring" because there is now widespread folic acid fortification of foods and increasing use of folic acid in dietary supplements.
However, the authors of an accompanying editorial points out that data from the United States, where there has been mandatory folic acid fortification of flour and other foods since 1998, have been showing a significant decrease in cancer incidence. "These national incidence rates do not support a substantial population-wide adverse effect of the magnitude suggested in the study," write the editorialists, Bettina F. Drake, PhD, MPH, and Graham Colditz, MD, DrPH, both from the Washington University School of Medicine in St Louis, Missouri.
"The population data from the United States do not suggest that there is a problem," Dr. Drake said in an interview with Medscape Oncology. She pointed out that folate supplementation used in the study resulted in much higher blood levels than would be seen after eating foods fortified with folic acid. In addition, the study was conducted in individuals with heart disease and was of limited duration.
The findings from this study "do not nullify the potential long-term benefits that folic acid fortification may have on population health," Dr. Drake explained. The measure was introduced to reduce neural tube defects in newborns (which arise from folate deficiency during pregnancy). A reduction was seen within a "few years," the editorialists note.
Concerns about a link between cancer and folic acid supplementation have been raised previously, most recently with regard to colorectal cancer, as reported by Medscape Oncology. At that time, leading expert on nutrition and cancer Walter Willet MD, DrPH, from the Harvard School of Public Health in Boston, Massachusetts, said: "I am certain that we are not causing an epidemic of colorectal cancer with folic acid fortification of flour." He added that there was a small increase in the incidence of this cancer soon after fortification was introduced, but this coincided with an increase in colonoscopy, and he pointed out that mortality rates from this cancer have been declining steadily.
Latest Results from Norway
The latest results come from 2 trials conducted in 6837 patients with ischemic heart disease, in which half the participants took supplements of vitamin B (including folic acid) to lower homocysteine levels to see if this would reduce cardiovascular outcomes. It did not, and these results are in line with other large trials.
At the same time, both trials showed — independently — an increase in cancer in the supplementation group, compared with the placebo group, but this was not statistically significant.
In these 2 trials, participants took supplements containing folic acid (0.8 mg/d), vitamin B12 (0.4 mg/d), and B6 (40 mg/d), or various combinations of these. This dose of folic acid is 4 to 6 times higher than the average dose delivered by the mandatory fortification in the United States, and is twice the recommended daily allowance, the authors note, although they add that it is below the tolerable upper intake level of 1 mg/d set by the US Institute of Medicine.
The current analysis pooled results from the 2 trials, which had a median participation of 39 months, and added data from an observational posttrial follow-up of 38 months, giving a total duration of around 5.5 years. The authors note that pooling the data from the 2 trials is "justified" because they were nearly identical.
This pooled analysis found a statistically significant increase in cancer incidence, cancer mortality, and all-cause mortality.
These results for cancer outcomes are not supported by other studies of homocysteine-lowering vitamin B trials, the authors note.
Cancer Decreasing Significantly
In their editorial, Drs. Drake and Colditz write that these results indicate an excess of approximately 3.5 new cases of cancer per 1000 people per year, and 1 excess case of lung cancer per 1000 people per year. The excess deaths correspond to 1.7 cancer deaths per 1000 people per year.
"These numbers, if generalizable to the United States, would be substantial at the overall levels of total cancer incidence and mortality," they write. In addition, an increase in lung cancer incidence would be expected.
"However, the rates of total cancer incidence decreased significantly from 2001 to 2005, and the lung cancer incidence has also declined significantly," they point out.
Although the study suggests there is an association between folic acid supplementation and an increase in cancer, the US population data suggest that there isn't a problem with folic acid fortification of foods and cancer, Dr. Drake told Medscape Oncology. Folic acid fortification has been mandatory in the United States for more than 10 years and, given the results of this study, we would have expected a significant increase in the incidence of cancer by now, she suggested.
One of the issues with clinical trials is that observations are reported with a short time frame after the implementation of an intervention, the editorialists note. This can often lead to "looking for effects that fit the time frame," they add. "By analogy, when keys are missing it is common to look for them under the lamppost where the light is, rather than in the murky location where the keys were more likely to have been dropped."
One of the coauthors on the paper, Klaus Meyer, PhD, is employed at the laboratory of Bevital AS. The other authors and both editorialists have disclosed no relevant financial relationships.
JAMA. 2009;302:2119-2126, 2152-2153.
Zosia Chustecka
November 18, 2009 — Folic acid and vitamin B supplementation was associated with an increase in cancer incidence, cancer mortality, and all-cause mortality in a new analysis with long-term follow-up of data from 2 trials conducted in Norway, where there is no folic acid fortification of foods.
The results are reported in the November 18 issue of the Journal of the American Medical Association.
The authors, led by Marta Ebbing, MD, from Haukeland University Hospital in Bergen, Norway, say that these results, although in need of confirmation, suggest that there is a need for "safety monitoring" because there is now widespread folic acid fortification of foods and increasing use of folic acid in dietary supplements.
However, the authors of an accompanying editorial points out that data from the United States, where there has been mandatory folic acid fortification of flour and other foods since 1998, have been showing a significant decrease in cancer incidence. "These national incidence rates do not support a substantial population-wide adverse effect of the magnitude suggested in the study," write the editorialists, Bettina F. Drake, PhD, MPH, and Graham Colditz, MD, DrPH, both from the Washington University School of Medicine in St Louis, Missouri.
"The population data from the United States do not suggest that there is a problem," Dr. Drake said in an interview with Medscape Oncology. She pointed out that folate supplementation used in the study resulted in much higher blood levels than would be seen after eating foods fortified with folic acid. In addition, the study was conducted in individuals with heart disease and was of limited duration.
The findings from this study "do not nullify the potential long-term benefits that folic acid fortification may have on population health," Dr. Drake explained. The measure was introduced to reduce neural tube defects in newborns (which arise from folate deficiency during pregnancy). A reduction was seen within a "few years," the editorialists note.
Concerns about a link between cancer and folic acid supplementation have been raised previously, most recently with regard to colorectal cancer, as reported by Medscape Oncology. At that time, leading expert on nutrition and cancer Walter Willet MD, DrPH, from the Harvard School of Public Health in Boston, Massachusetts, said: "I am certain that we are not causing an epidemic of colorectal cancer with folic acid fortification of flour." He added that there was a small increase in the incidence of this cancer soon after fortification was introduced, but this coincided with an increase in colonoscopy, and he pointed out that mortality rates from this cancer have been declining steadily.
Latest Results from Norway
The latest results come from 2 trials conducted in 6837 patients with ischemic heart disease, in which half the participants took supplements of vitamin B (including folic acid) to lower homocysteine levels to see if this would reduce cardiovascular outcomes. It did not, and these results are in line with other large trials.
At the same time, both trials showed — independently — an increase in cancer in the supplementation group, compared with the placebo group, but this was not statistically significant.
In these 2 trials, participants took supplements containing folic acid (0.8 mg/d), vitamin B12 (0.4 mg/d), and B6 (40 mg/d), or various combinations of these. This dose of folic acid is 4 to 6 times higher than the average dose delivered by the mandatory fortification in the United States, and is twice the recommended daily allowance, the authors note, although they add that it is below the tolerable upper intake level of 1 mg/d set by the US Institute of Medicine.
The current analysis pooled results from the 2 trials, which had a median participation of 39 months, and added data from an observational posttrial follow-up of 38 months, giving a total duration of around 5.5 years. The authors note that pooling the data from the 2 trials is "justified" because they were nearly identical.
This pooled analysis found a statistically significant increase in cancer incidence, cancer mortality, and all-cause mortality.
These results for cancer outcomes are not supported by other studies of homocysteine-lowering vitamin B trials, the authors note.
Cancer Decreasing Significantly
In their editorial, Drs. Drake and Colditz write that these results indicate an excess of approximately 3.5 new cases of cancer per 1000 people per year, and 1 excess case of lung cancer per 1000 people per year. The excess deaths correspond to 1.7 cancer deaths per 1000 people per year.
"These numbers, if generalizable to the United States, would be substantial at the overall levels of total cancer incidence and mortality," they write. In addition, an increase in lung cancer incidence would be expected.
"However, the rates of total cancer incidence decreased significantly from 2001 to 2005, and the lung cancer incidence has also declined significantly," they point out.
Although the study suggests there is an association between folic acid supplementation and an increase in cancer, the US population data suggest that there isn't a problem with folic acid fortification of foods and cancer, Dr. Drake told Medscape Oncology. Folic acid fortification has been mandatory in the United States for more than 10 years and, given the results of this study, we would have expected a significant increase in the incidence of cancer by now, she suggested.
One of the issues with clinical trials is that observations are reported with a short time frame after the implementation of an intervention, the editorialists note. This can often lead to "looking for effects that fit the time frame," they add. "By analogy, when keys are missing it is common to look for them under the lamppost where the light is, rather than in the murky location where the keys were more likely to have been dropped."
One of the coauthors on the paper, Klaus Meyer, PhD, is employed at the laboratory of Bevital AS. The other authors and both editorialists have disclosed no relevant financial relationships.
JAMA. 2009;302:2119-2126, 2152-2153.
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