Destinys future is bright thanks to the liver transplant that saved her life.

Destiny wants to be a doctor when she grows up. The active 6-year-old loves to climb, dance and play. As an infant, she was given only six months to live. Thanks to the generous gift of an organ donor, Destiny is now the picture of health.

You have the power to Donate Life. Be an organ, eye and tissue donor.
To find out how, go today to www.donatelife.net or call 1-800-355-7427 .

On Call with Dr. Porter

June 10-16 is Mens Health Week. I think its interesting that we have set up a special week to call attention to Mens health. In my opinion, Mens health should be a focus 52 weeks of the year as it should be for everyones health. Setting aside a special week is well meaning, but we have to remember prevention and early detection is key and men dont like to go to the doctor ever. Even if it is Mens Health Week. Being healthy and living longer is a 365-day process that includes eating right, exercising and staying on top of our health. Of course, doing all this isnt easy but we found some help. On the cover this month we are featuring Cleveland Clinic. This is a medical entity that has created an international name for itself, because of the great strides to offer the best possible patient care. When you read the story, you will notice how Cleveland Clinic gets a pat on the back for being innovative, but the kudos are well deserved. Health care is a continually evolving process and Cleveland Clinic prides itself on being part of the evolution. Among the many things Cleveland Clinic works on is patient information. I encourage you to visit the Cleveland Clinic website for the Cleveland Clinic Health Hub. Here you will find information and tips on virtually every type of health issue in friendly, consumer language. We have been so impressed with the health hub that we have posted a few of the examples on our magazine website and will frequently run Health Hub pieces in our magazine. So remember, while Mens Health Week is this month, dont forget that Mens Health as well as every member of the family health is a full time endeavor.

Steve Porter, MD Publisher and Chairman

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WHAT DOCTORS KNOW

And you should, too!

Taking Control
14 Platelet-rich Plasma May
Benefit Early Knee OA

21 When to See a Physician 22 Your Microbes and You 24 High Blood Pressure, Afib
and Your Risk of Stroke

26 Get the Facts about Cystic Fibrosis

P21

P38

Health Hints
31 Itchy, Runny Nose 32 Taking Charge in 10 34 Online: Are My Medicines Safe? 37 High-Tech Dieting

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Vol. 2 Issue 6

Contents

Inquiring Minds
40 What is Testicular Cancer? 46 Re-Examining Chemotherapy Drugs 48 Can Men Get Breast Cancer? 50 A Link Between Atherosclerosis
and Macular Degeneration?

54 Zit Face?

P48

In Every Issue
01 02 04 17
On Call With Dr. Porter Table of Contents Medicine in the News CDC Vital Signs: Prescription Painkiller Overdoses Looking for Youth Urologist

On The Cover
12 Cleveland Clinic: A
History of Innovation a Death Sentence

11 Prostate Cancer: Not 49 I Just Found a Lump.

38 HealthWatchMD: Men 52 Know Your Specialist

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To test or not to test: Blood glucose monitoring for patients with type 2 diabetes
CHAPEL HILL, N.C. The Patient-Centered Outcomes Research Institute (PCORI) has approved a $2 million research award to the University of North Carolina School of Medicine to study the role of glucose monitoring in patients with type 2 diabetes using oral medications. The three-year project will focus on assessing the impact of three different types of blood sugar or glucose home testing approaches on outcomes important to patients with type 2 diabetes treated in a community-based clinic setting. Katrina Donahue, MD, MPH, associate professor of family medicine, and Laura Young, MD, PhD, assistant professor of medicine, will lead the research project. Both are members of the North Carolina Clinical and Translational Institute, academic home of the National Institute of Healths Clinical and Translational Science Awards (CTSA). John Buse, MD, PhD, professor of medicine and deputy director of the CTSA, will lead the stakeholder advisory team comprising patients and community members as well as representatives from industry, advocacy groups and state government. The contract from PCORI is for $2,090,699.80. Given the time and resource-intensive nature of glucose self-monitoring, to test or not to test is a critically important question facing the millions of patients living with non-insulin-treated type 2 diabetes, said
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study leaders Drs. Donahue and Young in a written statement. Patients often receive mixed messages about blood glucose self-monitoring. We are excited that PCORI has recognized the lack of consensus around the utility of glucose monitoring in patients with type 2 diabetes not treated with insulin. The researchers said this important, patientcentered project will help patients and those that care for them make better, evidence-based decisions about whether or not blood glucose monitoring can improve the outcomes they value most. They also said that the results will shape future decisionmaking in diabetes-care practice and guidelines.

in the first place. But once they do, the pathway that we describe is relevant in causing their cancers to be more aggressive and more likely to spread.

Discovery helps show how breast cancer spreads

ST. LOUIS. Researchers at Washington University School of Medicine in St. Louis have discovered why breast cancer patients with dense breasts are more likely than others to develop aggressive tumors that spread. The finding opens the door to drug treatments that prevent metastasis. It has long been known that women with denser breasts are at higher risk for breast cancer. This greater density is caused by an excess of a structural protein called collagen. We have shown how increased collagen in the breasts could increase the chances of breast tumors spreading and becoming more invasive, says Gregory D. Longmore, MD, professor of medicine. It doesnt explain why women with dense breasts get cancer

The results appear online May 5 in Nature Cell Biology. Working in mouse models of breast cancer and breast tumor samples from patients, Longmore and his colleagues showed that a protein that sits on the surface of tumor cells, called DDR2, binds to collagen and activates a multistep pathway that encourages tumor cells to spread. We had no idea DDR2 would do this, says Longmore, also professor of cell biology and physiology. The functions of DDR2 are not well understood, and it has not been implicated in cancer and certainly not in breast cancer until now.

Smoke-free subsidized housing would save $521 million a year

ATLANTA The estimated annual cost savings from eliminating smoking in all U.S. subsidized housing would be $521 million, according to a new study from the Centers for Disease Control and Prevention. This is the first study to estimate the costs that could be saved by prohibiting smoking in subsidized housing, including public housing and other rental assistance programs. The bulk of those annual savings $341 million would come from reduced health care expenditures related to secondhand smoke. The study also estimates savings of $108 million in annual renovation expenses and $72 million in annual smoking-related fire loses. Many of the more than 7 million Americans living in subsidized housing in the United States are children, the elderly or disabled, said Tim McAfee, M.D., M.P.H., director of the Office on Smoking and Health at CDC. These are people who are most sensitive to being exposed to secondhand smoke. This report shows that there are substantial financial benefits to implementing smoke-free policies, in addition to the health benefits those policies bring. The study also estimated the cost savings associated with prohibiting smoking in all U.S. public housing, which is a portion of subsidized housing managed by public housing authorities. The total annual savings for public housing would be about $154 million a year, including $101 million from health care costs related to secondhand smoke exposure, $32 million from renovation expenses, and $21 million from smoking-attributable fire losses. Studies have shown that people who live in multiunit housing can be particularly affected by unwanted secondhand smoke exposure. Other studies have shown that most people who live in subsidized housing favor smoke-free policies. Secondhand smoke enters nearby apartments from common areas and apartments where smoking is

occurring, said Brian King Ph.D., an epidemiologist with CDCs Office on Smoking and Health and lead author of the report. Opening windows and installing ventilation systems will not fully eliminate exposure to secondhand smoke. Implementing smoke-free policies in all areas is the most effective way to fully protect all residents, visitors, and employees from the harmful effects of secondhand smoke. Secondhand smoke is responsible for about 50,000 deaths a year in the United States. The 2006 Surgeon Generals Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, concluded that secondhand smoke is also known to cause numerous health problems in infants and children, including more frequent and severe asthma attacks, respiratory infections, ear infections, and sudden infant death syndrome. In the same report, the Surgeon General concluded that there is no safe level of exposure to secondhand smoke, and that only 100 percent smoke-free indoor policies can fully protect people from secondhand smoke dangers.
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Teen girls less successful than boys at quitting meth according to UCLA study
LOS ANGELES. A UCLA-led study of adolescents receiving treatment for methamphetamine dependence has found that girls are more likely to continue using the drug during treatment than boys, suggesting that new approaches are needed for treating meth abuse among teen girls. Results from the study, conducted by the UCLA Center for Behavioral and Addiction Medicine and the community-based substance abuse treatment program Behavioral Health Services Inc., are published in the April edition of the Journal of Adolescent Health. "The greater severity of methamphetamine problems in adolescent girls compared to boys, combined with results of studies in adults that also found women to be more susceptible to methamphetamine than men, suggests that the gender differences in methamphetamine addiction observed in adults may actually begin in adolescence," said the study's lead author, Dr. Keith Heinzerling, a health sciences assistant clinical professor of family medicine at the David Geffen School of Medicine at UCLA. The clinical trial focused on use of the antidepressant bupropion for treating methamphetamine addiction. Nineteen adolescents nine boys and 10 girls with meth addiction who were receiving counseling at Behavioral Health Services were given either bupropion or placebo pills. The average age of participants was approximately 17.5 years. The researchers found that the study subjects who received the antidepressant provided significantly fewer meth-free urine samples than did those who were given placebos, suggesting that bupropion was an ineffective treatment for addiction in this small sample. Overall, boys in both groups provided more than twice as many meth-free urine drug tests during treatment as girls in both groups. While the results did not support continued research into the use of bupropion for methamphetamine addiction, they did suggest the need for research to develop new interventions to improve the outcomes of treatment for addiction in adolescent girls, the researchers said. Heinzerling noted the importance of collaborations such as the one between UCLA and Behavioral Health Services. "It shows that partnerships between researchers and community organizations are critical to insuring that research is translated into improvements in the health of real people," he said.

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Physical activity extends lives, reduces cancer risk

COLLEGE STATION, Texas Even mild physical activity is associated with longer life expectancy, regardless of body weight. According to a recent study funded by the National Cancer Institute, people who engaged in leisure time physical activity had life expectancy gains of as much as 4.5 years. Physical activity is one of the best things you can do for yourself to stay healthy, says Regents and Distinguished Professor Marcia Ory, Ph.D., M.P.H., of the Texas A&M Health Science Center (TAMHSC) School of Rural Public Health and a leading researcher in cancer survivorship and aging. Yet, today only about 31 percent of U.S. adults say they engage in any kind of regular physical activity. When it comes to practical tips for moving more, weve all heard to take the stairs, not the elevator. According to Dr. Ory, its still good advice, but there are many more ways to get physically active breaks in your day:

Buzz me active Set a timer on your phone or your computer to remind you every 40-60 minutes that its time to stand up, stretch and take a brief walk, outside if possible. Walk with me Need to have a quick chat with a family member or a coworker? Instead of sending a text or an email, suggest going for a walk. Stand to talk Standing desks are great, but if you dont have one, you can always stand up every time you answer the phone. If the cord is long enough or you have a speakerphone, you can walk around, do deep knee bends and stretch while talking on the phone. Stay webinar fit Hour-long webinars are great times for stretch breaks. You can attend to business while stretching or using weights. Keep a flexibility stretch band or a pair of hand weights at your desk for use during webinars and long conference calls. Park to walk When you are shopping or at an off-site meeting, park your car at the furthest edge of the lot. Enjoy the opportunity for an outdoor physical activity break.
Think of exercise as medicine, Dr. Ory says. Regular exercise can reduce the need for medications and costly health care treatments. There are many different types of exercise, chose one that you enjoy this will help you stay active for life.
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Please Dont Wake Me: One Million People to Be Screened for Risky Sleep Disorder.
AMSTERDAM, The Netherlands. Snore much? Beware: its one of the key signs of a disorder that may lead to serious chronic diseases, including diabetes or heart disease. In an effort to help obstructive sleep apnea (OSA) sufferers identify and combat the disorder, Royal Philips Electronics announced it will screen one million people worldwide for OSA over the next five years. Philips program will include screening across North America, Europe and Asia. The program uses an online risk assessment on its World Sleep Day website. Individuals who have symptoms or believe they may be at-risk are encouraged to take the online risk assessment test. Upon completion, it will provide their risk level for OSA and encourage follow up with their health care provider. "Obstructive sleep apnea steals health from its sufferers and put them on a path to potentially lifethreatening diseases, said Brent Shafer, CEO, Philips Home Healthcare Solutions. It is our goal to use our innovative solutions to help OSA sufferers identify and combat this very serious disorder." Obstructive sleep apnea is one of the most common sleep disorders, and affects approximately five to six percent of the adult population1. It is characterized by a narrowing or closing of the upper airway, which hinders breathing during sleep. Sleep is often labeled as the third pillar of good health, along with diet and exercise. Philips research suggests that more than two-thirds of all people with sleep apnea are not diagnosed. The most common cause of obstructive sleep apnea is weight gain. Other signs and symptoms of sleep apnea include:

* * * *

Frequent loud snoring Pauses in breathing or gasping for breath Obesity Regularly falling asleep in situations, such as reading, watching TV or driving * High blood pressure
There are three important steps to helping individuals with OSA: awareness, diagnosis and treatment. Each is integral to improving the sleep quality and overall health of individuals around the world, said Dr. Lee-Chiong, chief medical liaison for Philips Home Healthcare Solutions. Philips pledge helps individuals take the first step to make them aware of their risk for OSA. To find out if youre at risk for obstructive sleep apnea or for more information about World Sleep Day 2013 and whats happening in your local area, visit www.philips.com/worldsleepday.

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Five sudden symptoms of stroke: Recognizing these could save a life even a young life
LOS ANGELES. Stroke is the fourth-leading cause of death in the United States. Each year an estimated 795,000 people in this country experience a stroke. Stroke is also the No. 1 cause of adult disability and it is no longer a disease only of the elderly. Nearly 20 percent of strokes occur in people younger than age 55, and over the past decade, the average age at stroke occurrence has dropped from 71 to 69. The good news, says Patrick D. Lyden, MD, chair of Neurology and director of the Stroke Program at Cedars-Sinai Medical Center, is that quickly recognizing the signs of stroke and seeking immediate medical care from stroke specialists can minimize the effects of the disease or even save a life. And just as important as knowing the symptoms is the knowledge that regardless of an individuals age, those symptoms need to be treated as the emergency that they are.

If you see any one of these Five Sudden, Severe Symptoms, call 911 regardless of the victims age. Sudden numbness or weakness of the face, arm or leg on one side of the body. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing on one side. Sudden, severe difficulty walking, dizziness, loss of balance or coordination. Sudden, severe headache with no known cause.
It is important to emphasize the words sudden and severe and the number one. Any of these symptoms can occur in a mild, fleeting way and not be worrisome, but if any one of them comes on suddenly and is quite severe, it could signal the onset of a stroke, which increasingly is described as a brain attack, because like a heart attack, a stroke requires immediate action to improve the odds against disability and death.

Obsessing over your appearance could mean your brain is wired abnormally
LOS ANGELES Body dysmorphic disorder (BDD) is a disabling but often misunderstood psychiatric condition in which people perceive themselves to be disfigured and ugly, even though they look normal to others. New research at UCLA shows these individuals have abnormalities in the underlying connections in their brains. Dr. Jamie Feusner, the study's senior author and a UCLA associate professor of psychiatry, said individuals with BDD have, in essence, global "bad wiring" in their brains that is, there are abnormal network-wiring patterns across the brain as a whole. And in line with earlier UCLA research showing that people with BDD process visual information abnormally, the study discovered abnormal connections between regions of the brain involved in visual and emotional processing. The findings suggest these patterns in the brain may relate to impaired information processing. "We found a strong correlation between low efficiency of connections across the whole brain and the severity of BDD," Feusner said. "The less efficient patients' brain connections, the worse the symptoms, particularly for compulsive behaviors such, as checking mirrors." People suffering from BDD tend to fixate on minute details, such as a single blemish on their face or body, rather than viewing themselves in their entirety. They become so distressed with their appearance that they often can't lead normal lives, are fearful of leaving their homes and occasionally even commit suicide. Patients frequently have to be hospitalized. BDD affects approximately 2 percent of the population and is more prevalent than schizophrenia or bipolar disorder. Despite its prevalence and severity, scientists know relatively little about the neurobiology of BDD. "How their brain regions are connected in order to communicate about what they see and how they feel is disturbed," said Feusner, who also directs the
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Adult Obsessive-Compulsive Disorder Program and the Body Dysmorphic Disorder Research Program at UCLA. "Their brains seem to be fine-tuned to be very sensitive to process minute details, but this pattern may not allow their brains to be well-synchronized across regions with different functions," he said. "This could affect how they perceive their physical appearance and may also result in them getting caught up in the details of other thoughts and cognitive processes."

WHAT DOCTORS KNOW

And you should, too!
Special Thanks To:
Published by What Doctors Know, LLC Publisher and Chairman Steve Porter, MD Editorial Advisory Board Vicki J. Lyons, MD, Chairman Editorial and Design Director Bonnie Jean Thomas Senior Designer Suki Xiao Design Associate Raulin Huang Executive Director, Marketing Larry Myers Production Kai Xiao, Vice President IT Manager Eric Lu

For more information on ad placement or contributing an article, please email submit@whatdoctorsknow.com, or call (801) 825-4600. For information on subscriptions, please visit www.whatdoctorsknow.com

Corporate Office What Doctors Know 1755 E Legend Hills Dr., Suite 100, Clearfield, UT 84015 (801) 825-4600

Calling All Doctors. Our readers want to hear from you. What healthcare issues do you want to address? What do you want to tell patients all over the country? Whats new in your practice, in your specialty? Drop us a line and let us know about any healthcare topic you want to address in What Doctors Know. Remember, we want to inform and educate our readers. We know, an informed reader has the opportunity to live longer and happier. You can be part of that healing process. Our readers look forward to hearing from you.

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Copyright 2013 by What Doctors Know, LLC. All rights reserved. Reproduction of this magazine, in whole, or in part is prohibited unless authorized by the publisher or its advertisers. The Advertising space provided in What Doctors Know is purchased and paid for by the advertisers. Products and services are not necessarily endorsed by What Doctors Know,LLC.
10 whatdoctorsknow.com

men diagnosed with lowerrisk forms of the disease. The researchers examined causes of death among prostate cancer cases recorded in the U.S. Surveillance, Epidemiology, and End Results Program (over 490,000 men from 1973 to 2008) and the nationwide Swedish Cancer and Cause of Death registries (over 210,000 men from 1961 to 2008). The results showed that during the study period, prostate cancer accounted for 52% of all reported deaths in Sweden and 30% of reported deaths in the United States among men with prostate cancer; however, only 35% of Swedish men and 16% of U.S. men diagnosed with prostate cancer died from this disease. In both populations, the risk of prostate cancer-specific death declined, while the risk of death from heart disease and non-prostate cancer remained constant. The five-year cumulative incidence of death from prostate cancer was 29% in Sweden and 11% in the United States. Death rates from prostate cancer varied by age and calendar year of diagnosis, with the highest number of deaths from the disease among men diagnosed at older ages and those diagnosed in the earlier years of the surveys (especially in the years before the introduction of PSA screening). Our study shows that lifestyle changes such as losing weight, increasing physical activity, and quitting smoking, may indeed have a greater impact on patients survival than the treatment they receive for their prostate cancer, said senior author Hans-Olov Adami, professor of epidemiology at HSPH. -This information provided courtesy of Harvard School of Public Health

Prostate Cancer:

Not a Death Sentence

en diagnosed with prostate cancer are less likely to die from the disease than from largely preventable conditions such as heart disease, according to a new study from Harvard School of Public Health (HSPH). It is the largest study to date that looks at causes of death among men with prostate cancer, and suggests that encouraging healthy lifestyle changes should play an important role in prostate cancer management. Our results are relevant for several million men living with prostate cancer in the United States, said first author Mara Epstein, a postdoctoral researcher at HSPH. We hope this study will encourage physicians to use a prostate cancer diagnosis as a teachable moment

to encourage a healthier lifestyle, which could improve the overall health of men with prostate cancer, increasing both the duration and quality of their life. The study was published July 25, 2012 in the Advance Access online Journal of the National Cancer Institute. Prostate cancer is the most frequently diagnosed form of cancer, affecting one in six men during their lifetime. While incidence of prostate cancer has greatly increased in the United States, Sweden, and other Western countries in recent decades, the likelihood that a newly diagnosed man in these countries will die from the disease has declined. The researchers attribute this to the widespread use of the prostatespecific antigen (PSA) test, which has resulted in a higher proportion of

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11

Cleveland Clinic

A History of Innovation

I
12

nnovation has been one of Cleveland Clinics cornerstone values since its inception. Founded in 1921 by four renowned physicians, Cleveland Clinic broke with traditional medicine by pioneering the idea of multi-specialty group practice. While this vision would revolutionize patient care, the founders knew this type of collaborative structure would also generate new and game-changing ideas that would continue to improve patient care into the future. Innovative from the very beginning, Cleveland Clinics breakthrough medical inventions include co-founder George Criles novel carotid and forceps clamps, as well as coronary artery bypass surgery and the first face transplant in the United States. Not only has innovation come from physicians looking to improve patient care, but ideas have also been generated from nurses and operations staff to advance the overall delivery of care. With an overflowing pipeline of new ideas, Cleveland Clinic Innovations was created to keep pace with the bulging innovation pipeline.

Innovations, the corporate venturing arm of Cleveland Clinic, accelerates the adoption process and encourages even more ideas from the entire healthcare community. Within the ever-changing healthcare environment, Innovations has become a model of driving medical innovation. Cleveland Clinic Innovations seeks to improve the lives of patients by turning the ideas and breakthroughs of Cleveland Clinics physician inventors into medical products that create new companies, jobs and economic opportunities. Over more than a decade, Innovations has filed 1,600 patents, has more than 400 active licenses and has 55 spin-off companies that have received nearly $700 million in equity investment. Nearly 1,000 jobs have been generated as a result of Cleveland Clinic Innovations and its spin-offs, having a significant impact on the economic growth in Northeast Ohio. Leaders from Cleveland Clinic Innovations actively meet with physicians and researchers to encourage them to think of themselves as innovators and to keep the innovation process top of mind.

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Innovation Summit
Cleveland Clinic Innovations hosts the annual Medical Innovation Summit, which convenes more than 1,000 great thinkers and leaders for a candid exchange on new medical technology, its future, recent breakthroughs and continuing challenges. Many regard the meeting as among the premier healthcare gatherings in the United States. The Summit is built around CEOs of major corporations, government executives and top investors. The Summit has welcomed attendees and speakers from around the world to come learn, share and collaborate on a vast platform of innovation. The 2013 Medical Innovation Summit Finding Balance through Innovation: Obesity, Diabetes & the Metabolic Crisis will take an in-depth look at one of the nations most troubling healthcare issues. This years Summit will take place Oct. 14-16 and mark the opening of the Global Center for Health Innovation, Clevelands newest medical showplace. The Medical Innovation Summit provides an unrivaled perspective on the newest medical innovations and the financial drivers behind those innovations. It is recognized for providing singular insights, networking opportunities and actionable take away for all participants.

vote. The two panels then vote on the combined lists and establish the Top 10 Medical Innovations.

Spin-offs
A look at several Cleveland Clinic Innovations spin-off companies that are having an impact on healthcare today. Explorys: Explorys was co-founded in 2009 with the Clinic to provide leading-edge enterprise performance management for the healthcare industry. Explorys platform has been adopted by 14 major integrated healthcare systems with nearly 100 billion data elements, 31 million patients, 200 hospitals, and over 100,000 providers. In addition, Trinity Health just announced it will implement the entire suite of Explorys cloud-based big data analytics solutions across its 47 acute-care hospitals, 432 outpatient facilities, 33 longterm care facilities, and numerous home health offices and hospice programs spanning 10 states in order to continue improving its care of patients, residents and communities. Juventas: Juventas Therapeutics is taking regenerative medicine to the next level. Juventas was spun-off from Cleveland Clinic in 2007 to cultivate and commercialize a pipeline of regenerative therapies that can treat lifethreatening diseases. Since its launch, Juventas has transitioned its therapeutic platform from concept into Phase II clinical trials for heart failure and critical limb ischemia. The company's lead product, JVS-100, has been shown to protect and repair tissue and organ damage in a broad range of pre-clinical disease models. ImageIQ: In a time when medical research is often clouded by high costs, long timelines, and subjective analyses, ImageIQ brings clarity. Spun out of Cleveland Clinic in February of 2011, ImageIQ is helping companies and institutions draw definitive, objective conclusions in their research by extracting quantitative data from a wide array of images. For nearly 10 years, ImageIQs unique expertise was refined inside Cleveland Clinic by providing imaging analysis for the Clinics various research efforts. As the Clinics Biomedical Imaging and Analysis Centers capabilities grew and image data became more important in clinical and preclinical trials, the Clinic launched ImageIQ to respond to analytical challenges across the medical industry. Cleveland HeartLab: Cleveland HeartLab, Inc.s mission is to lead in the pursuit of the identification and prevention of chronic disease through innovation. Launched by Cleveland Clinic in 2009, Cleveland HeartLab now offers an array of reliable and affordable biomarkers that provide insight into an individuals risk for heart disease and cardiac events. Its unique profile of tests focuses on managing and reducing inflammation, and offers an assortment of standard and advanced tests that doctors can choose from.

Annual Top 10 list

Each year the Summit concludes with the presentation of Cleveland Clinic Innovations annual Top 10 list of the up-and-coming technologies that will have the biggest impact on health care in the next year. Cleveland Clinics culture of innovation naturally fosters a good deal of discussion about new game changing technologies. The passion of Cleveland Clinics clinicians and researchers for getting the best care for patients drives a continuous dialogue on what state-of-the art medical technologies are just over the horizon. A rigorous process is used to gather the opinions of Cleveland Clinic physicians and researchers, create a field of nominated innovative technologies for consideration, and develop a consensus perspective of what will be the Top 10 Medical Innovations for the next year. More than 110 Cleveland Clinic experts are interviewed to elicit their nominations. The primary question is, What innovations are game changers in your field? In all, these interviews yield nearly 150 nominations of emerging technologies. A team prepares research on each technology and then presents a final list of over 55 up-and-coming technologies and their data profiles to two independent panels of leading Cleveland Clinic physicians. In late August, each panel meets to discuss, debate, and

Health Information
For more innovative health information geared to what you want to know, visit health.clevelandclinic.org
whatdoctorsknow.com 13

Platelet-rich Plasma

May Benefit Early Knee OA

Although questionnaires used in the study the visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) are validated tools routinely used to assess pain and function in people with OA, they are subjective. An MRI, on the other hand provides an objective picture of changes in the joint. Seventeen patients completed the study and full MRI data was available for 15. For the majority of patients, clinical outcomes were encouraging. On the VAS pain scale, pain was reduced 56.2 percent at 6 months and nearly 60 percent at one year. WOMAC scores showed similar reductions in pain and stiffness. Activities of daily living (ADL) scores also improved significantly: 46.8 percent at 6 months and 55.7 percent at one year. What's more, most study participants showed no further cartilage loss a year after the PRP injection. Previous studies have found that people with knee OA tend to lose around 5 percent of cartilage per year.

latelet-rich plasma (PRP), a therapy used to help heal surgical wounds and tendon injuries, may also relieve symptoms of early knee osteoarthritis (OA), according to a new study out of the Hospital for Special Surgery (HSS) in New York. Researchers there say patients with knee OA reported significantly improved pain and function for 12 months after a single PRP injection. The findings, published online in Clinical Journal of Sports Medicine, also suggest that PRP may slow joint damage if administered early in the course of the disease. "The results are very exciting," says Brian Halpern, MD, chief of the Primary Care Sports Medicine Service at HSS and lead author of the study. "This suggests that PRP may have the potential not only to relieve symptoms but also to delay progression of OA, although we don't know if that will continue year after year." Dr. Halpern is also a clinical associate professor at Weill Cornell Medical College in New York. PRP is a preparation of platelets derived from a person's own blood. It's obtained by spinning a small amount of blood in a centrifuge to separate the platelets from red and white blood cells. The concentrated platelets are then injected into problem areas where they are thought to release growth factors and stimulate the healing process. In the HSS study, researchers injected 22 patients with 6 milliliters of PRP and followed them for one year. All participants had diagnosed knee OA and had arthritisrelated pain for an average of 14 months. The patients were clinically evaluated at baseline and periodically throughout the year for knee pain, function, stiffness and the ability to perform tasks of daily living, such as climbing stairs. Study participants also underwent magnetic resonance imaging (MRI) to evaluate joint cartilage at baseline and at one year something not done in previous PRP studies.
14 whatdoctorsknow.com

Dr. Halpern stresses that the positive results occurred in people with early OA. "You're not going to be able to do a lot in the regenerative sense for people with bone-onbone arthritis. By then, the horse is already out of the barn," he says. "But in the earlier stages, you can improve symptoms and the environmental milieu enough to delay or maybe even prevent knee replacement. But that's a long way off and we need to look at a lot more numbers [before we can say that with certainty]." Still, Dr. Halpern says the study results have prompted HSS to create a registry that will track future osteoarthritis patients over time. Researchers will be able to compare outcomes for various OA treatments, such as exercise, weight control, bracing and hyaluronic acid injections as well as PRP. And for the first time, imaging tests will be used to detect changes in joint cartilage.

It's hoped that the HSS data will help answer some of the many questions that arise as PRP treatments become more common. "Many more folks are doing it now, especially sports medicine orthopaedists, and they are learning more about why it can and can't work," says Dr. Halpern, noting that he has injected more than 400 patients with PRP over the last five years and all had outcomes consistent with the study results. "One example is that it appears the platelet concentration has an effect on efficacy, but we don't know what the optimum [level] is right now. That's another thing that has to be explored, he says. By definition, PRP formulations have to be two to five times greater than the platelet concentration in the blood. But it seems that if platelet concentration gets as high as eight times greater, it can actually have a deleterious effect." Dr. Halpern stresses that PRP is not a panacea. "It certainly won't help everybody with everything," he notes. "This is an evolving field, and we need to learn much more." Eric L. Matteson, MD, chair of rheumatology at the Mayo Clinic in Rochester, Minnesota, agrees that PRP needs more study. "The real issue from a biological standpoint is whether PRP contains factors that can somehow stimulate cartilage and in so doing improve arthritis. There has to be some demonstration of actual effect. If there is improvement in cartilage, we should be able to see it, but this study didn't show that, says Dr. Matteson. And if MRI didn't show an improvement, then what accounts for the decrease in pain? Perhaps the placebo effect. We really have no idea. We need studies that show the biological plausibility of this treatment." Orthopaedic surgeon Jason Scopp, MD, director of the Joint Preservation Center at Peninsula Orthopaedic Associates in Salisbury, Md., says that in addition to failing to show biological plausibility, the HSS study has other shortcomings. "This is a very small sample size, which means the study is underpowered, and there is no control group for comparison. Other studies of PRP have enrolled more patients, are better powered and compare PRP to viscosupplementation [hyaluronic acid injections]," he notes. Still, despite what he sees as the limitations of this study, Dr. Scopp is a fan of PRP. "PRP is a great product, and several studies have shown it to be superior to cortisone and even viscosupplementation, but there is still no consensus on the best preparation, best volume of injections and number of injections," he says. Dr. Matteson agrees that PRP procedures need to be standardized. "There is a whole conglomeration of stuff out there," Dr. Matteson says, "and we need to sort out what may or may not have a biological effect." -This information provided courtesy of Weill Cornell Medical College
whatdoctorsknow.com 15

Gaining weight was easy. Losing it's a lot harder...

but very much worth the effort.

You have to work at losing weight. Every day. But with every step, you lower your risk for type 2 diabetes and heart disease. Because many of the nearly one million deaths each year from type 2 diabetes, heart disease and stroke could be prevented with a few lifestyle changes, including weight loss, regular physical activity and healthier food choices.

Its not easy. But it is worth it.

Learn how you can help stop diabetes by losing weight, eating healthy and staying active. Visit checkupamerica.org or call 1-800-DIABETES.

One Step at a Time 7x10 V5a.indd1 1

7/13/10 8:46:09 PM

Prescription Painkiller Overdoses

1 in 3
Methadone contributed to nearly 1 in 3 prescription painkiller deaths in 2009.

Use and abuse of methadone as a painkiller

Prescription painkiller overdoses* were responsible for more than 15,500 deaths in 2009. While all prescription painkillers have contributed to an increase in overdose deaths over the last decade, methadone has played a central role in the epidemic. More than 30% of prescription painkiller deaths involve methadone, even though only 2% of painkiller prescriptions are for this drug. Six times as many people died of methadone overdoses in 2009 than a decade before. Methadone has been used safely and effectively to treat drug addiction for decades. It has been prescribed increasingly as a painkiller because it is a generic drug that can provide long-lasting pain relief. But as methadones use for pain has increased, so has nonmedical use of the drug and the number of overdoses.
* Prescription painkiller overdoses refers to deaths from using harmful amounts of opioid or narcotic pain relievers, including drugs such as Vicodin (hydrocodone), OxyContin (oxycodone), Opana (oxymorphone), and methadone.

5,000

About 5,000 people die every year of overdoses related to methadone.

Six times as many people died of methadone overdoses in 2009 than a decade before.

6x


Want to learn more? Visit

www

http://www.cdc.gov/vitalsigns

National Center for Injury Prevention and Control Division of Unintentional Injury Prevention

Problem

Methadone use poses risks

Methadones risks include: The difference between appropriate prescribed doses and dangerous doses of methadone is small. Methadone has special risks as a painkiller. For example, taking it more than 3 times a day can cause the drug to build up in a persons body, leading to dangerously slowed breathing. Methadone can seriously disrupt the hearts rhythm. Methadone can be particularly risky when used with tranquilizers or other prescription painkillers. In one study, four in ten overdose deaths involving single prescription painkillers involved methadone, twice as many as any other prescription painkiller.

Methadone is frequently prescribed for pain. Methadone, like other painkillers, is commonly prescribed for chronic problems like back pain even though it might not help these problems in the long run. More than 4 million methadone prescriptions were written for pain in 2009, despite US Food and Drug Administration warnings about the risks associated with methadone. Methadone is available as a low-cost generic drug. It is often listed as a preferred drug by insurance companies.

Why have methadone overdoses increased?

As methadone prescriptions have increased, so have the number of methadone overdoses. But many people who die of painkiller overdoses dont have a prescription. How can this be? Its because some of these prescriptions are illegally sold or given to people who use them for nonmedical reasons. This is known as diversion. Diversion is a major factor in the prescription drug abuse epidemic. More careful prescribing will help reduce diversion and save lives.

Rx

Diversion

Growth of methadone use for pain and methadone overdoses

Methadone use for pain (kg/100,000 people) Methadone-related overdose deaths per 100,000 people 3.0 Rate per 100,000 people 2.5 2.0 1.5 1.0 0.5 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Sources: National Vital Statistics System, 1999-2009; Drug Enforcement Administration Automation of Reports and Consolidated Orders System (ARCOS), 1999-2010.

Death rate from overdoses caused by a single prescription painkiller

12 Rate per 100 kilograms 10 8 6 4 2 0 Buprenorphine Hydromorphone Hydrocodone Oxycodone Fentanyl Morphine Methadone

Source: Substance Abuse and Mental Health Services Administration, Center for Behavioral Statistics and Quality, Drug Abuse Warning Network Medical Examiner Component, 2009.

Methadones share of prescription painkillers dispensed in each state

AK OR ID HI NV UT CA CO WY NE KS OK IA IL MO TN MS TX
Source: Drug Enforcement Administration Automation of Reports and Consolidated Orders System (ARCOS), 2010 Numbers account for differences in drug strength.

WA MT ND MN SD WI MI PA IN OH WV KY SC AL GA VA NY VT ME NH MA RI CT NJ DE MD DC

NC

AZ

NM

AR LA

Percentage 4.4 - 6.6 6.7 - 8.5

FL

8.6 - 11.4 11.5 - 18.5

What Can Be Done

The US government is
Enforcing federal laws to prevent nonmedical use of methadone. Educating health care providers and consumers about the correct use of methadone. Tracking prescription drug overdose trends and the impact of efforts to stop overdoses.

Health insurers can

Evaluate methadones place on preferred drug lists. Consider strategies to ensure that pain treatment with any dose higher than 30 mg of methadone a day (the recommended maximum daily starting dose) is appropriate.

Individuals can
Use methadone only as directed by a health care provider. Make sure they are the only ones to use their methadone and never sell or share it with others. Store methadone in a secure place and dispose of it properly. See www.cdc.gov/ HomeandRecreationalSafety/Poisoning/ preventiontips.htm for correct storage and disposal of medications. Get help for substance abuse problems 1-800-662-HELP or www.samhsa.gov/treatment/.

States can
Develop and promote the use of safe prescribing guidelines for methadone. Support the use of methadone as a treatment for opioid dependence in opioid treatment programs. Use prescription drug monitoring programs to identify patients who are using methadone or other prescription painkillers for nonmedical purposes.

Health care providers can

Follow guidelines for prescribing methadone and other prescription painkillers correctly, including  Screening and monitoring for substance abuse and mental health problems.  Prescribing only the quantity needed based on the expected length of pain.  Using prescription drug monitoring programs to identify patients who are misusing or abusing methadone or other prescription painkillers.  Monitor patients on high doses for heart rhythm problems.  Educating patients on how to safely use, store, and dispose of methadone and how to prevent and recognize overdoses.

For more information, please contact

Telephone: 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov

Web: www.cdc.gov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Publication date: 07/03/2012

www www

http://www.cdc.gov/vitalsigns http://www.cdc.gov/mmwr

CS232209-B

When to See A Physician

for Your Headache

here are times when headaches or uncharacteristic migraine symptoms are indications of something that needs medical attention. Some individuals are reluctant to call their doctors or go to an Emergency Department because they dont want to arrive only to learn that nothing out of the ordinary is wrong. Please, dont be concerned about that; get medical attention if you think you fit the following criteria.

You have more than the occasional headache Your headaches are severe or come on quickly Your headache is accompanied by any of the following: (And you have not discussed these symptoms with your doctor before) Confusion Dizziness Fever Numbness Persistent vomiting Shortness of breath Slurred speech Stiff neck Unpredicted symptoms affecting your ears, nose, throat pr eyes Unrelenting diarrhea Vision loss Weakness

Your have a headache that persists, and continues to get worse or wont stop Your headaches interfere with your normal activities of daily life You find yourself taking pain relievers more than two days a week You take over-the-counter medications for headache relief but the recommended dosage is not adequate Coughing, sneezing, bending over, exercise or sexual activity cause headaches You have headaches that continue and that began after a head injury, or other trauma The characteristics of your headaches change The symptoms of your migraine attacks change See your Physician Immediately or Go to an Emergency Department if: You are having the worst headache ever You are having your worst migraine attack ever Your headache is accompanied by the following symptoms: Unresolved loss of vision Loss of consciousness Uncontrollable vomiting The pain of your headache lasts more than 72 hours with less than a solid four-hour pain-free period while awake You experience a headache or a migraine attack that presents unusual symptoms that are abnormal for you and frightening
-This information provided courtesy of the National Headache Foundation. headaches.org
whatdoctorsknow.com 21

Your Microbes and You

The Good, Bad and Ugly

icroscopic creaturesincluding bacteria, fungi and virusescan make you ill. But what you may not realize is that trillions of microbes are living in and on your body right now. Most dont harm you at all. In fact, they help you digest food, protect against infection and even maintain your reproductive health. We tend to focus on destroying bad microbes. But taking care of good ones may be even more important. You might be surprised to learn that your microbes actually outnumber your own cells by 10 to 1. The current estimate is that humans have 10 trillion human cells and about 100 trillion bacterial cells, says Dr. Martin J. Blaser at the New York University School of Medicine. New techniques allow scientists to study these rich microbial communities and their genesthe microbiome. In 2007, NIH launched the Human Microbiome Project to study microbes in and on the body. Earlier this year, researchers from almost 80 institutions published a landmark series of reports. They found that more than 10,000 different species occupy the human body. The microbiome actually provides more genes that contribute to human survival than the human genome itself (8 million vs. 22,000). Humans need bacteria and their genes more than most of us thought. One of the most important things microbes do for us is to help with digestion. The mix of microbes in your gut can affect how well you use and store energy from food. In laboratory experiments, transferring bacteria from certain obese mice to normal ones led to increased fat in the normal mice. Blaser and his colleagues are concerned that changes in our microbiome early in life may contribute to weight problems later. Were in the middle of an
22 whatdoctorsknow.com

epidemic of obesity that is very severe, Blaser says. Its relatively recent, its widespread across the United States and across the world, and increased calories and decreased exercise seem insufficient to explain this. We might be changing our microbiome for the worse, he says, by using antibiotics too often. In a recent NIH-funded study, Blasers team found that lowdose antibiotic therapy affected the gut microbiomes of young mice. Antibiotics also altered how the mice used sugars and fats. After 7 weeks, treated mice had up to 15% more fat than untreated mice. This and other studies suggest that gut bacteria can affect both appetite and how you use energy in food. In related work, Dr. Leonardo Trasande, Blaser and colleagues analyzed data from more than 11,000 children. Although the results werent conclusive, they suggest that infants given antibiotics might be at increased risk of becoming overweight. More work will be needed to confirm this connection. Microbes in our intestines may play critical roles in how we absorb calories, Trasande says. Exposure to antibiotics, especially early in life, may kill off healthy bacteria that influence how we absorb nutrients into our bodies, and would otherwise keep us lean. Microbes are also important for your skin, one of the bodys first lines of defense against illness and injury. Skin health depends on the delicate balance between your own cells and the microbes that live on its surface.

Basically, the healthy bacteria are filling all those little niches so that the more dangerous bacteria cant get a foothold onto the skin, says Dr. Julie Segre of NIH. Segre and other NIH researchers looked at skin microbes collected from different body regions on healthy volunteers. They found that body location has a huge effect on which types of bacteria live. For example, bacteria living under your arms likely are more similar to those under another persons arm than to the bacteria on your own forearm. Microbes are also important to the bodys infectionfighting immune system. In one recent study, NIH scientists examined special mice that were born and raised to be germ-free. These mice seemed to have weak immune function. In contrast, normal mice have vibrant bacterial communities and a rich variety of immune cells and molecules on their skin. The germ-free mice were exposed to Staphylococcus epidermidis, one of the most common bacteria on human skin. Adding this one species of bacteria boosted immune function in the mouse skin. The mice with S. epidermidis were able to defend against a parasite, whereas the bacteria-free mice werent. We often have a sense that the bacteria that live on our skin are harmful, Segre says. But in this study we show that these bacteria can play an important role in promoting health by preventing skin infections from becoming more prolonged, pronounced and more serious.

Theres strong evidence that the microbes in the female reproductive tract affect reproductive health and help protect against disease. A recent study also found a diverse community of microbes in the male urinary tract and on the penis. NIH-funded researchers are investigating other positive roles for microbes. One major area of research concerns allergy-related conditions, including childhood asthma, skin allergies, hay fever and eczema. So what can you do to protect against microbes that cause infection but take care of the ones that help you? We know that washing our hands is important for removing harmful microbesfor example, before eating or after using the bathroom. Other less obvious things can affect your skin microbes, Segre says. The lotions and creams you use can provide a barrier to protect your skins moisture, Segre points out, but in fact youre also putting a fertilizer onto the microbial garden. Youre really changing the food source for the bacteria that live on your skin. Theres not one right answer about which skin products are best for you, she says. Experiment to see how different ones affect your skin. Many researchers worry that some people are trying to get too clean. Blaser thinks that people are using sanitizers and antibiotic products too often these days. Obviously, there are many bad germs, but I think weve gone overboard and it looks like trying to get rid of the bad guys has had a collateral effect on the good guys. Youre never alone when it comes to your microbes. But dont get squeamish about it. Just remember how much you need them. -Source: NIH News in Health, November 2012, published by the National Institutes of Health and the Department of Health and Human Services. For more information go to www.newsinhealth.nih.gov

Protect Your Microbes

Dont be scared of microbes. Most actually help you. Dont pressure your doctor to give you antibiotics. They may cause more harm than good. Know when to wash your handsfor example, when preparing food and before eating. To learn more, visit www.cdc.gov/handwashing. Dont use antibacterial products you dont need. Antibacterial soaps have little or no health benefit. And antibacterial versions of household products (like phones and staplers) have not been shown to reduce your risk of infection. Dont go overboard with hand sanitizers. Theyre useful in health care settings, but hand washing is a better option in most situations. Experiment with different skin moisturizers to see which work best for you. Theres no conclusive evidence that so-called probiotic products have health benefits.

whatdoctorsknow.com

23

High Blood Pressure, Afib and Your Risk of Stroke

What do blood pressure and the rhythm of your heart have to do with stroke risk? Plenty.

C
24 whatdoctorsknow.com

onsider this: About three out of four people who have a stroke for the first time have high blood pressure. And an irregular atrial heart rhythm a condition called atrial fibrillation is present in about one out of five strokes. Stroke is the nations No. 4 killer. It happens when a blood vessel that supplies blood to the brain is blocked or bursts. Nearly 800,000 Americans suffer a stroke each year.

High blood pressure is the chief culprit, and atrial fibrillation isnt far behind. Yet theres good news you can easily do something about them. Your best defense is to avoid these heart conditions through a heart-healthy lifestyle. But even if youre living with atrial fibrillation or high blood pressure, theres still a lot you can do to lower your risk of stroke.

The Stroke Connection

The brain needs blood and oxygen. When that doesnt happen and that crucial nourishment cant reach the brain either because of a clogged artery or a burst vessel brain cells start to die. For people with high blood pressure, the force of blood pushing against the arteries as the heart pumps blood is too high. That causes gradual damage to the arteries, including those to the brain. A weakened blood vessel may rupture in or near the brain, or scarred arteries may become blocked by a clot or plaque buildup. Then theres atrial fibrillation. Thats when stroke risk increases because the rapid heartbeat allows blood to pool in the heart, which can cause clots to form and travel to the brain. High blood pressure is generally considered the most common controllable risk factor for stroke, but atrial fibrillation is the most powerful, said Ralph L. Sacco, M.D., professor and chairman of neurology at the Miller School of Medicine at the University of Miami and past president of the American Heart Association. Somebody with high blood pressure has almost twice the risk of stroke than somebody without high blood pressure, he said. But someone with atrial fibrillation has more than five times the risk of stroke. More than 76 million Americans have high blood pressure. Atrial fibrillation, on the other hand, affects far fewer Americans an estimated 2.7 million. Because high blood pressure is so frequent, affecting tens of millions of people, it has a bigger impact on the number of strokes attributed to it, Dr. Sacco said. But atrial fibrillation is a more potent risk factor. The two risk factors are also related to each other: High blood pressure is a risk factor for atrial fibrillation. Middleaged men and women with high blood pressure are at increased risk for atrial fibrillation later in life. Then it becomes a double whammy, where you have high blood pressure as well as atrial fibrillation increasing your stroke risk, Dr. Sacco said.

Dont smoke. Get regular physical activity. Maintain a healthy weight. Limit alcohol to no more than two drinks a day for men or one drink a day for women. Eat a healthy diet that is high in fruits, vegetables, and whole grains, include low-fat dairy products and limit salt, saturated fat, trans fat and cholesterol. Monitor your blood pressure and work to keep it at your goal. Take your medication as prescribed if you have high blood pressure or atrial fibrillation.
Stroke prevention is often the focus of doctorpatient conversations in atrial fibrillation, Dr. Sacco said. But for people with high blood pressure, busy physicians dont always rank discussions about preventing stroke as high as wed like, he said. We have so many very effective medicines to treat high blood pressure and atrial fibrillation. If more patients with high blood pressure and atrial fibrillation are properly treated, were optimistic the number of projected strokes will go down. For more information on high blood pressure, atrial fibrillation and stroke, please visit the American Heart Associations websites: www. heart.org/hbp, www.heart.org/afib and www. strokeassociation.org. -This information provided courtesy of the American Heart Association

How to Reduce Stroke Risk

Stroke is not inevitable, even if you are among the millions with high blood pressure or atrial fibrillation. Preventing or controlling high blood pressure and atrial fibrillation can greatly lower your chances of having a stroke. Heres how:
whatdoctorsknow.com 25

Get the Facts about

Cystic Fibrosis

C
26 whatdoctorsknow.com

ystic fibrosis (CF) is an inherited disease characterized by an abnormality in the glands that produce sweat and mucus. It is chronic, progressive, and is usually fatal. Due to improved treatments, people with CF, on average, live into their mid to late 30s. Cystic fibrosis affects various systems in children and young adults, including the following:

How does CF affect the respiratory system?

The basis for the problem with CF lies in an abnormal gene. The result of this gene defect is an atypical electrolyte transport system within the cells of the body. The abnormal transport system causes the cells in the respiratory system, especially the lungs, to absorb too much sodium and water. This causes the normal thin secretions in our lungs to become very thick and hard to remove. These thick secretions put the child with CF at risk for constant infection. The high risk of infection in the respiratory system leads to damage in the lungs, lungs that do not work properly, and eventually death of the cells in the lungs. The most common causes for infection in the lungs of the CF patient are the following bacteria:

Respiratory system Digestive system Reproductive system

There are about 30,000 people in the US who are affected with the disease, and about 1,000 babies are diagnosed with it each year. It occurs mainly in Caucasians, who have a northern European heredity, although it also occurs in African-Americans, Asian Americans, and Native Americans. Approximately one in 31 people in the US are carriers of the cystic fibrosis gene. These people are not affected by the disease and usually do not know that they are carriers.

Staphylococcus aureus Haemophilus influenzae Pseudomonas aeruginosa (PA)

Over a period of time, PA becomes the most common bacteria that causes infection and becomes difficult to fight. A large percentage of respiratory infections in the CF patient are due to PA.

As a result of the high rate of infection in the lower respiratory tract, people with CF may develop a chronic cough, blood in the sputum, and sometimes can even have a collapsed lung. The cough is usually worse in the morning or after activity. People with CF also have involvement of the upper respiratory tract. Some patients have nasal polyps that need surgical removal. Nasal polyps are small protrusions of tissue from the lining of the nose that go into the nasal cavity. Children also have a high rate of sinus infections.

How does CF affect the reproductive system?

Most males with CF have obstruction of the sperm canal known as congenital bilateral absence of the vas deferens (CBAVD). This results from the abnormal electrolyte transport system in the cells, causing the secretions to become thick and lead to an obstruction and infertility. Women also have an increase in thick cervical mucus that may lead to a decrease in fertility, although many women with CF have children.

What are the symptoms of cystic fibrosis?

Symptoms for cystic fibrosis may include:

How does CF affect the gastrointestinal (GI) system?

The organ primarily affected is the pancreas, which secretes substances that aid digestion and help control blood-glucose levels. As a result of the abnormal electrolyte transport system in the cells, the secretions from the pancreas become thick and lead to an obstruction of the ducts of the pancreas. This obstruction then causes a decrease in the secretion of enzymes from the pancreas that normally help to digest food. A person with CF has difficulty absorbing proteins, fats, and vitamins A, D, E, and K. The problems with the pancreas can become so severe that some of the cells in the pancreas can become destroyed. This may lead to glucose intolerance and insulin-dependent diabetes. About 35 percent of CF patients develop this type of diabetes in their 20s and 43 percent develop the disease after 30 years of age. The symptoms that may be present due to the involvement with the GI tract include the following:

Bulky, greasy stools Rectal prolapse--a condition in which the end part of the bowels comes out of the anus. Delayed puberty Fat in the stools Stomach pain Bloody diarrhea
The liver may also be affected. A small number of patients may actually develop liver disease. Symptoms of liver disease may include:

Abnormalities in the glands that produce sweat and mucus This may cause a loss of salt. A loss of salt may cause an upset in the balance of minerals in the blood, abnormal heart rhythms, and, possibly, shock. Thick mucus that accumulates in the lungs and intestines This may cause malnutrition, poor growth, frequent respiratory infections, breathing difficulties, and/or lung disease. Other medical problems, such as: Sinusitis Nasal polyps Clubbing of fingers and toes--a condition marked by the ends of the fingers and toes become enlarged; more prevalent in the fingers. Pneumothorax--the presence of air or gas in the pleural cavity causing the lung to collapse. Hemoptysis--coughing blood. Cor pulmonale--enlargement of right side of heart. Abdominal pain Gas in the intestines Rectal prolapse Liver disease Diabetes Pancreatitis Gallstones Congenital bilateral absence of the vas deferens (CBAVD) in males
The symptoms of CF differ for each person. Infants born with CF usually show symptoms by age two. Some children may not show symptoms until later in life. When infants have the following suspicious signs of CF, they should be tested for the disease:

Enlarged liver Swollen abdomen Yellow color to the skin Vomiting of blood

Diarrhea that does not go away Foul-smelling stools Greasy stools Frequent episodes of wheezing Frequent episodes of pneumonia or other lung infections Persistent cough Skin tastes like salt Poor growth despite a good appetite
The symptoms of cystic fibrosis may resemble other conditions or medical problems. Therefore its always best to consult a physician for a diagnosis to be sure.
whatdoctorsknow.com 27

How is cystic fibrosis diagnosed?

Most cases of cystic fibrosis are now identified with newborn screening. In addition to a complete medical history and physical examination, diagnostic procedures for cystic fibrosis include a sweat test to measure the amount of sodium chloride (salt) present. Higher than normal amounts of sodium and chloride suggest cystic fibrosis. Other diagnostic procedures include:

There is no cure for CF. A cure would call for gene therapy at an early age and this has not been developed yet, although research is being done in this direction. The gene that causes CF has been identified and there are hopes that this will lead to an increased understanding of the disease. Also being researched are different drug regimens to help stop CF. Goals of treatment are to ease severity of symptoms and slow the progress of the disease. Treatment may include:

Chemical tests Chest X-rays Lung function tests Sputum cultures Stool evaluations
For babies, who do not produce enough sweat, blood tests may be used.

Treatment for cystic fibrosis

Specific treatment for cystic fibrosis will be determined by the physician based on:

Age, overall health, and medical history Extent of the disease Expectations for the course of the disease Tolerance for specific medications, procedures, or therapies The patient opinion or preference

Management of problems that cause lung obstruction, which may involve: Physical therapy Exercise to loosen mucus, stimulate coughing, and improve overall physical condition Medications to reduce mucus and help breathing Antibiotics to treat infections Anti-inflammatories Management of digestive problems, which may involve: Appropriate diet Pancreatic enzymes to aid digestion Vitamin supplements Treatments for intestinal obstructions
Newer therapies include lung transplantation for patients with end-stage lung disease. The type of transplant done is usually a heart-lung transplant, or a double lung transplant. Not everyone is a candidate for a lung transplant. Discuss this with your physician.

28 whatdoctorsknow.com

The genetics of cystic fibrosis

Cystic fibrosis (CF) is a genetic disease which means CF is inherited. A person will be born with CF only if two CF genes are inherited - one from the mother and one from the father. A person who has only one CF gene is healthy and said to be a "carrier" of the disease. A carrier has an increased chance of having a child with CF. This type of inheritance is called "autosomal recessive." "Autosomal" means that the gene is on one of the first 22 pairs of chromosomes which do not determine gender, so that the disease equally affects males and females. "Recessive" means that two copies of the gene, one inherited from each parent, are necessary to have the condition. Once parents have had a child with CF, there is a one in four, or 25 percent chance with each subsequent pregnancy, for another child to be born with CF. This means that there is a three out of four, or 75 percent chance, for another child to not have CF. The birth of a child with CF is often a total surprise to a family, since most of the time (in eight out of 10 families) there is no previous family history of CF. Many autosomal recessive conditions occur this way. Since both parents are healthy, they had no prior knowledge that they carried the gene, nor that they passed the gene to the pregnancy at the same time. Genes are founds on structures in the cells of our body called chromosomes. There are normally 46 total, or 23 pairs of chromosomes in each cell of our body. The seventh pair of chromosomes contains a gene called the CFTR (cystic fibrosis transmembrane regulator) gene. Mutations or errors in this gene are what cause CF. This gene is quite large and complex. Over 1,000 different mutations in this gene have been found which cause CF. The risk for having a mutation in the gene for CF depends on your ethnic background (for persons without a family history of CF):
Ethnic Background Caucasian Hispanic African-American Asian Risk of CF Mutation 1 in 29 1 in 46 1 in 65 1 in 90 Risk of Child with CF 1 in 2,500-3,500 1 in 4,000-10,000 1 in 15,000-20,000 1 in 100,000

Testing for the CF gene can be done from a small blood sample or from a cheek swab, which is a brush rubbed against the inside of your cheek to obtain cells for testing. Laboratories generally test for the most common mutations. There are many people with CF whose mutations have not been identified. In other words, all of the genetic errors that cause the disease have not been discovered. Because not all mutations are detectable, a person can still be a CF carrier even if no mutations were found by carrier testing. Testing for the CF gene is recommended for anyone who has a family member with the disease, or whose partner is a known carrier of CF or affected with CF. -This information provided courtesy of The Ohio State Wexner Medical Center
whatdoctorsknow.com 29

STROKES ARE THE NUMBER-THREE KILLER

IN THIS COUNTRY, YET MANY PEOPLE DONT EVEN

KNOW WHAT THEY ARE. THEY DONT KNOW THAT MORE

OF THE BRAIN CAN BE SAVED IF A STROKE IS DETECTED AND

TREATMENT IS RECEIVED IMMEDIATELY. STROKES BEGIN WHEN A

W I T H A S T R O K E , T I M E L O S T I S B R A I N L O S T.
BLOOD VESSEL IN THE BRAIN BECOMES BLOCKED OR BURSTS. BLOOD FLOW

IS CUT OFF. TISSUE IS STARVED FOR OXYGEN, AND PARTS OF THE BRAIN DIE.

IF NOT TREATED QUICKLY, ABILITIES AND PRODUCTIVE LIFE CAN BE

LOST. YOUR BRAIN IS YOUR MOST PRIZED POSSESSION.

GUARD IT WITH YOUR LIFE.

If you suddenly have or see any of these symptoms, call 9-1-1 immediately: Numbness or weakness of the face, arm or leg, especially on one side of the body Confusion, trouble speaking or understanding Difficulty seeing in one or both eyes Trouble walking, dizziness, loss of balance or coordination Severe headache with no known cause

Learn more at StrokeAssociation.or g or 1-888-4-STROKE.

2004 American Heart Association Made possible in part by a generous grant from The Bugher Foundation.

Itchy, Runny Nose...

...what's to blame, allergy or the weather?

s the weather takes the country on a temperature roller coaster ridefrom seasonal bone-chilling cold to springlike warmth and then back again many people find themselves reaching for pain relievers or other remedies to deal with runny noses and other symptoms associated with sinus and allergy problems. John Fahrenholz, M.D., assistant professor of Medicine who practices at the Vanderbilt Asthma, Sinus and Allergy Program, says that such whipsawing temperatures can be a real challenge for people with allergiesand with the rest of us, too. People who know they have allergies should make sure to take their allergy medications daily during such times, he said. But even those of us who dont suffer from allergies can develop a runny nose when the temperature and humidity are changing rapidly. Rhinitisa swollen, itchy nose can occur in the midst of rapidly changing weather that many parts of the U.S. continue to experience this year. Since simply experiencing the weather can cause an itchy, runny nose, it can be a challenge to figure out who is experiencing allergy symptoms and who is not.

Here are a few guidelines from Fahrenholz to help you and your nosethrough crazy changeable weather:

If temperature changes bring on an itchy, runny nose, try using an over-the-counter salt water nose spray or nasal sinus rinses. These can also be helpful in dealing with cold, dry air in winter. If symptoms persist even when the temperatures level out, you may have allergies. Dont blame changing weather for your cold or flutheres no evidence that cycles of cold and warm days make your immune system any more likely to pick up a virus. People with a tendency toward ongoing allergy symptoms during the winter months should make sure to take their regular allergy medications. Colder air is dry which can cause irritation to the nasal tissues leading to increased nasal allergy symptoms. If regular use of over-the-counter antihistamines or other allergy products are not controlling symptoms, the allergy sufferer should make an appointment to see a health care professional to see if prescription medications, such as nasal steroids, may help.
-This information provided courtesy of Vanderbilt University Medical Center
whatdoctorsknow.com 31

10
Taking Charge in

Ten Steps for Better Communication

panel of leading headache specialists recently convened to identify specific steps migraine patients can take to better communicate with their healthcare providers and obtain a successful treatment program. Effective physician/ patient communication is increasingly important given today's time constraints for office visits and the variety of new treatment options available.

1. 2.

Seek help. Be a self-advocate. You owe it to yourself. Let go of the biases and guilt--there is no need for you to endure headache pain. Understand that migraine is a disease, and deserves the same attention and care as any health condition. Educate yourself about migraine so you will know what to communicate to a physician. Attend support groups and join resource organizations such as the National Headache Foundation (NHF); 1-888-NHF-5552. Pay attention to newspaper, magazine, television and radio coverage of migraine and ask your physician about what you've seen or heard.

3.

Visit a doctor specifically about your headaches. Search for a physician who is interested in treating headaches and make an appointment about your migraine. Find out if your primary care physician (family physician, internists or OB/GYN) treats migraine. Consider seeing a headache specialist or neurologist. Call the NHF for a state-bystate list of member physicians.

4.

Prepare for a dialogue with your physician. Keep a headache diary. Be organized, specific, direct and ready to talk details. Be prepared to provide information on your headache history and general medical history. Track your attacks and how you treat them. Note the date, length of each migraine, severity, symptoms, triggers and impact on your life (i.e., how many days lost from work, how many family/social activities missed). Track medication taken, when, for how long and effectiveness in relieving pain and symptoms. Get to know your migraine patterns and triggers so you feel more "in control."
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8. 9.

Ask for detailed instructions for taking medication--and follow them. Ask for specific instructions on taking prescribed medication; i.e., how often, with meals or on an empty stomach, what to do if a dose is missed, side effects, and what to do if pain and symptoms persist.

Partner with your physician for treatment success. Enter into a partnership with your physician and bridge the communication gap. See your physician on a regular basis and develop a relationship -- treatment is a process that works better with in-person visits.

10. 5.
Have reasonable expectations about treatment. Understand there is no cure for migraine; however, the disease can be managed with an effective treatment program. Be patient and give treatment time to work. Realize that treatment success will ebb and flow. Be willing to listen to your physician and to yourself. Be flexible, open-minded, and prepared to modify your treatment as necessary.

Follow-up regularly with your physician. Your treatment program will only be as good as the time you invest. Schedule a follow-up appointment as you conclude each physician visit. Physicians say three months is usually a reasonable time period to evaluate the effectiveness of a treatment program. -This information provided courtesy of the National Headache Foundation. headaches.org

6. 7.

Be honest about all current medications and other medical conditions. Tell your doctor about all your current therapies, including prescription, over-the-counter and natural remedies (b ecause certain medications interfere with each other). Share any psychological history or "emotional disturbances" and medications taken for those now or in the past.

Focus on solutions. Be positive. Don't blame yourself; headaches are not your fault. Focus on finding the best treatment options by working with your physician to find solutions.

Online:Are My Medicines Safe?

hen it comes to buying prescription medicines online, it's better to be safe than sorry.

BeSafeRx: Know Your Online Pharmacy, a new public education campaign by the U.S. Food and Drug Administration (FDA), is aimed at helping consumers understand and minimize the risks of buying medicines online. In a recent FDA survey of Internet users, 29 percent of participants reported they are unsure how to safely buy medicines online. Still, more than 20 percent of respondents reported using the Internet to buy prescription medicines. The Internet makes it easier for fraudulent and illegal online pharmacies to sell medicines to American consumers outside the system of federal and state safeguards that protect patients from inappropriate or unsafe medicines. Medicines you purchase from fraudulent online pharmacies may put your health, or the health of your family, at risk. "Many online consumers may not realize that they're buying from a fraudulent, illegal online pharmacy and that the medicines they may receive could be counterfeit, contaminated, contain the wrong active ingredient, or not approved by FDA," says FDA pharmacist, Connie Jung, RPh., Ph.D. Medicines purchased from fraudulent online pharmacies may contain no active ingredient. (The active ingredients in medicines are responsible for their effects.) It's also possible that they'll have too much or too little of the active ingredient or the wrong ingredient entirely. These medicines may also be contaminated with harmful substances, or be past their expiration dates. As a result, says Jung, you may not receive the therapy you need. And, you may experience unexpected side effects and possibly get worse.
34 whatdoctorsknow.com

Some Red Flags

According to the National Association of Boards of Pharmacy (NABP), the professional organization that represents the state boards of pharmacy (or equivalent state agencies) that are responsible for licensing pharmacies, only 3 percent of online websites reviewed appear to meet state and federal pharmacy laws. It's sometimes hard to tell that a website isn't trustworthy, says Jung. Many fraudulent online sellers use convincing marketing efforts and develop websites that look legitimate. Even careful consumers may be fooled. FDA is providing information through its BeSafeRx campaign to help consumers identify and avoid fraudulent pharmacy websites. FDA Commissioner Margaret Hamburg, M.D., says, "Fraudulent online pharmacies often offer deep discounts. If the low prices seem too good to be true, they probably are. BeSafeRx is designed to help patients learn how to avoid these risks and safely buy medicine online." Jung also warns consumers not to be tempted by the much lower prices than those charged for prescription drugs by a legitimate pharmacy. "They are a sure sign of a fraudulent, illegal online pharmacy, and the medicines you are getting could be harmful," Jung says.

are the risks of purchasing What from a fake online pharmacy?

Buying prescription medicine from fraudulent online pharmacies can be dangerous, or even deadly. At best, counterfeit medicines are fakes of approved drugs and should be considered unsafe and ineffective. These medicines may be less effective or have unexpected side effects. In addition to health risks, most fraudulent online pharmacies may put your personal and financial information at risk. Some intentionally misuse the information you provide. These sites may infect your computer with viruses, and they may sell your information to other illegal websites and Internet scams. are some of the warning signs What of a fake online pharmacy?

are consumers increasingly turning to Why online pharmacies for their medicines?

The Internet provides consumers with instant access to information and services, including online pharmacies for prescription medicines. Health insurance plans are encouraging home delivery of maintenance medications and use of pharmacy services online. As the cost of prescription medicine continues to increase, consumers may look for cost savings from online pharmacies to afford their medicines. In addition, many consumers value the convenience and privacy of purchasing their medicines online. For those consumers that may be considering purchasing from online sources that are not associated with health insurance plans or local pharmacy, these consumers need to know the risks of buying from fraudulent online pharmacies.

Avoid online pharmacies that: 1. Allow you to buy drugs without a prescription or by completing an online questionnaire 2. Offer discounts or cheap prices that seem too good to be true 3. Send unsolicited email or other spam offering cheap medicine 4. Ship prescription drugs worldwide 5. State that the drugs will be shipped from a foreign country 6. Are located outside of the United States 7. Are not licensed by a state board of pharmacy in the United States (or equivalent state health authority) are some tips to identify What safe online pharmacies?

-This information provided courtesy of the U.S. Food and Drug Administration

To identify a safe online pharmacy, make sure that the online pharmacy: 1. Requires a valid prescription 2. Provides a physical address in the United States 3. Is licensed by the state board of pharmacy in your state and the state where the pharmacy is operating 4. Has a state-licensed pharmacist to answer your question it okay to buy prescription medicine Is online from other countries?

FDA does not have jurisdiction of prescription medication from other countries; therefore, FDA cannot guarantee the safety or effectiveness of those medication. Medicines approved in other countries may have slight variations, or different ingredients, that could cause you to develop a resistance to your medicine or result in a misdiagnosis by your doctor. If you take more than one medicine, these differences could also cancel out the effects of your medicines or cause harmful interactions. Additionally, many of these illegal pharmacies use fake storefronts to make consumers think they come from countries with high safety standards, but the medicines could have been made anywhere. most online pharmacies safe and legal? Arent No. Only 3 percent of online pharmacies reviewed by the National Association of Boards of Pharmacy are in compliance with U.S. pharmacy laws and practice standards. it obvious which online pharmacies Isnt are fake and which are legitimate?

A survey of more than adults who have made online purchases revealed these patterns:
say they've purchased prescription medicine 2 3% online. Of those, almost 1 in 5 chose sites not associated with a local pharmacy or health insurance plan.

6,000

of those who reported buying 2 1% from an online pharmacy reported using one based outside the U.S. of all respondents would consider 1 5% purchasing from an online pharmacy based outside the U.S. of those who reported buying from an pharmacy 47%oronline pharmacy not associated with a local health insurance plan searched online for comments and ratings before making the purchase.

No, it may not be obvious that an online pharmacy is fake. Many illegal online pharmacies use fake storefronts to make you think they are real pharmacies. Fraudulent sellers run fake online pharmacy scams to exploit American consumers by pretending to be legitimate pharmacies offering prescription medicines for sale. However, the products they provide may be fake, expired and otherwise unsafe. In fact, many online pharmacy scams are so sophisticated that even health care professionals can have a hard time detecting illegal sites at first glance

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36 whatdoctorsknow.com

HighTech Dieting

he most difficult thing about a diet is being honest about exercise and eating right. And even when you are being honest, translating the results of diet and exercise can be little more than a guess.

Weight Watchers has teamed up with Philips technology to give its members a hightech means to accurately track activity and diet with a nifty new device called ActiveLink.

values I earned just by dancing and singing! ActiveLink has made me look at activity in a whole new way, said Weight Watchers Ambassador Jennifer Hudson of Chicago. I always track what I eat, but now seeing the results of also tracking my activity each day is challenging me to set higher goals. Plus, its helping me earn activity PointsPlus values, which for me means more chocolate!

ActiveLink Technology
The ActiveLink monitor is a three-way accelerometer that tracks body motion and provides a measure of acceleration. When combined with ones age, gender, height, and weight, it calculates how many activity PointsPlus values a person earns while wearing it. ActiveLink subscribers can then plug the ActiveLink monitor into their computer to upload the information onto their dashboard and receive customized challenges that will gradually increase over time plus activity tips to keep them moving and motivated. At Philips, our goal is to improve peoples lives through meaningful innovation, said Gopi Koteeswaran, General Manager at Philips. Working together on ActiveLink, Weight Watchers and Philips are delivering an innovative behavioral change experience that seamlessly integrates activity into the Weight Watchers approach. By translating movement into activity PointsPlus values a language that Weight Watchers members speak and a lifestyle they live every day were helping people to take control of a healthy lifestyle in a fun and engaging way. The ActiveLink monitor is available exclusively to Weight Watchers members with eTools and Weight Watchers Online subscribers, and can be purchased at participating Weight Watchers locations or via the eCommerce store at www.weightwatchers. com, and requires an additional monthly ActiveLink subscription. To learn more about ActiveLink, go to www.weightwatchers. com/getactivelink. -This information provided courtesy of Weight Watchers
whatdoctorsknow.com 37

ActiveLink, is the first and only activity monitor and web experience that translates movements to activity into a point monitoring system Weight Watchers calls PointsPlus. ActiveLink is available exclusively to Weight Watchers members and Weight Watchers Online Subscribers. Most of us tend to underestimate the amount of food we eat, and overestimate how much activity we get. We rarely exercise enough to burn off that cheeseburger or dessert like we planned, said Stacy Gordon, Senior Vice President, Products, Licensing & Publishing, Weight Watchers North America. ActiveLink takes the guess work out of it by more accurately estimating our activity level, and motivates us to set that bar even higher by getting more active. While activity has always been a key component of the Weight Watchers approach, ActiveLink provides members with eTools and Online subscribers a more accurate account of their current activity levels, which in turn motivates the user to make increased activity a healthy habit they develop for a lifetime. Powered by Philips technology, ActiveLink allows users to set personalized goals, seamlessly track their activity routines from walking the dog to hitting the gym to help them reach their goal of becoming more active over time. It aligns with Weight Watchers integrated approach to successful weight loss, which combines smarter eating, healthy habits, activity and a supportive environment. I wore my ActiveLink monitor during a recent performance and couldnt believe how many activity PointsPlus

HealthWatchMD
with Dr. Randy Martin

Provided courtesy of Piedmont Healthcare

Men Looking for Youth Plastic Surgery on the Rise

Dr. Randy Martin: According to 2010 statistics from the American Society of Plastic Surgeons, men are increasingly having plastic surgery procedures done. Lets find out what theyre getting and why.
38 whatdoctorsknow.com

n its 2010 statistics release, the American Society of Plastic Surgeons (ASPS) revealed a 14 percent increase in the number of facelifts among men and an 11 percent increase in number of plastic surgical procedures on mens ears. In fact, procedures in males, including both minimally invasive (such as Botox injections) and surgical procedures, accounted for almost 10 percent of all procedures for the year. The numbers for the men are definitely increasing, says Joseph Woods, M.D., chief of plastic surgery for Piedmont Hospital. Ten years ago, my practice in cosmetic surgery was 99 percent women. And today, I would say it is 90 percent women. Men are now realizing plastic surgery is not just for their wives. So why are men having plastic surgery? Often its for marketability in the workplace. According to the ASPS statistics, men and women between the ages of 40 and

54 are getting the majority of cosmetic procedures. These older men are typically looking for ways to bridge the gap between themselves and younger men who are job hunting. Dr. Woods reports seeing many men requesting facial types of procedures and those for the torso, either breast reductions or tightening of areas men arent able to tone to their satisfaction. If youre debating a tightening option but arent quite ready for a facelift, Dr. Woods says Botox or fillers can help for a good five or six years. For invasion-free help for your skinwhether youre male or female, adopt healthy eating habits and an exercise regimen, stay out of the sun, and do not smoke one of the top ways to age your face, Dr. Woods suggests. Also, hydrate your skin with a moisturizer, use sunscreen, and apply a topical, mild acid like alpha hydroxy acid (glycolic acid), which is found in many skincare products.
whatdoctorsknow.com 39

What

is Testicular Cancer?
40 whatdoctorsknow.com

hat are the testicles?

The testicles are male sex glands that produce sperm and the hormone testosterone. The testicles are two walnut-shaped glands inside the scrotum. The scrotum is the sac of skin that lies below the penis.

What is testicular cancer?

Testicular cancer is a disease that occurs when cancerous (malignant) cells develop in the tissues of a testicle. The development of cancerous cells in both testicles can occur, but is very rare. Testicular cancer is the most common cancer in men aged 20 to 35. The disease usually is curable.

What are the risk factors for developing testicular cancer?

Risk factors for developing testicular cancer include:

Testiscular cancer is usually diagnosed after the man notices a lump or other change in a testicle. When an abnormality is suspected, an ultrasound is usually ordered, which is a painless medical test that helps the doctor to see whether there are abnormalities in the testicle. If the ultrasound shows evidence of cancer, then surgery is performed to remove the testicle and it is examined under a microscope to see whether cancer is present and, if so, what type of cancer. Thus, testicular cancer is only diagnosed after the testicle is removed and examined. Biopsies, which involve the removal of a small amount of tissue using a needle or other medical tool, are NOT performed on testicles because penetrating the testicle can make it more difficult to treat a cancer if one is discovered.

* Undescended testicle(s) This is when one or both testicles do not move down into the scrotum before birth. * Klinefelters syndrome This is a disorder in which males are born with an extra X chromosome in all or most of their cells. Certain other genetic syndromes are also associated with higher risk. * Race Non-Hispanic, white men are more likely to develop this cancer than are men of other races and ethnicities. * Personal or family history Men with a brother or father who had testis cancer have an increased risk of developing testis cancer themselves. Men who have had testis cancer themselves in one testicle are at increased risk of developing a second cancer in the other testicle. What are the symptoms of testicular cancer?
The following symptoms can be signs of testicular cancer or of another condition. Consult a doctor if you have any of these symptoms:

* * * * * *

Swelling in the scrotum Lump or swelling in either testicle Build-up of fluid on the scrotum Dull ache in the groin or lower abdomen Pain or discomfort in the scrotum or a testicle How is testicular cancer diagnosed?

Tests to help diagnose testicular cancer can include: * Ultrasound This is a procedure that uses high-energy sound waves to form pictures of body tissues. * A physical exam and history A physical exam and medical history can help the doctor look for problems that might be related to testicular cancer. * A serum tumor marker test This procedure examines a blood sample to measure the amounts of certain substances linked to specific types of cancers. These substances are called tumor markers. The tumor markers that are often elevated in testicular cancer are alpha-fetoprotein (AFP), human chorionic gonadotrophin (HCG or beta-HCG) and lactate dehydrongenase (LDH). * Inguinal orchiectomy and biopsy This procedure involves the removal of the entire testicle through an incision in the groin. A tissue sample from the testicle is then checked for cancer cells. * CT scans and X-rays A CT scan is a medical test that uses x-rays to form pictures of the inside of the body. When a cancer is diagnosed or suspected, a CT scan (also referred to as a CAT scan) is performed to see whether cancer can be seen elsewhere in the body. In testis cancer, a CT scan is performed of the abdomen and pelvis. Images of the chest are taken using either a CT scan or a regular X-ray.
whatdoctorsknow.com 41

Stage II - This stage consists of Stage IIA, Stage IIB, and Stage IIC and refers to patients whose cancer has spread to the lymph nodes in the back of the abdomen (this part of the body is referred to as the retroperitoneum) but not to anywhere else. If patients with cancer in their lymph nodes have moderately or highly elevated tumor markers, then they are stage III rather than stage II. In Stage IIA, the cancer has spread to a maximum of five lymph nodes in the abdomen. None of the lymph nodes is larger than 2 centimeters in size. Tumor markers must be either normal or only mildly elevated. In stage IIB, the cancer has spread to more than 5 nodes, none of which is larger than 5 centimeters, or the cancer has spread to 5 or fewer nodes and there is a lymph node mass measuring between 2 and 5 centimeters. Tumor markers must be either normal or mildly elevated.

What are the stages of testicular cancer?

Stage 0 Abnormal cells have developed but are still confined within the tubules where sperm cells start to develop. Stage I - This stage consists of the stages IA, IB, and IS. In Stage IA, the cancer is confined to the testicle and the epididymis, and all tumor marker levels are normal. The cancer has not spread to the outer layer of the double membrane that surrounds the testicle and has not grown into the blood or lymph vessels. In Stage IB, at least one of the following applies: The cancer invades into the blood vessels or lymphatics within the testicle; the cancer has spread to the outer layer of the membrane around the testicle; and/or the cancer invades into the spermatic cord or the scrotum. In stage IB, all tumor marker levels are normal. In Stage IS, the cancer is anywhere within the testicle, spermatic cord, or scrotum and one or more of the tumor markers is elevated.
42 whatdoctorsknow.com

In Stage IIC, the cancer has spread to at least one lymph node in the abdomen that is larger than 5 cm diameter. Tumor markers must be either normal or only mildly elevated. Stage III - This stage is divided into Stage IIIA, Stage IIIB, and Stage IIIC and is determined after an inguinal orchiectomy (removal of a testicle through an incision in the groin) is performed. In Stage IIIA, the cancer has spread to lymph nodes beyond the abdomen (such as lymph nodes in the chest) and/or to the lungs. Tumor markers must be normal or only mildly elevated. In stage IIIB, the cancer has spread to lymph nodes in the abdomen or elsewhere (such as lymph nodes in the chest) and/or to the lungs and the tumor markers are moderately elevated. In stage IIIC, either the cancer has spread to an organ other than the lungs (such as the liver, the bones, or the brain) or the tumor markers are highly elevated and the cancer has spread to at least one lymph node or organ.

How is testicular cancer treated at each stage?

Nearly all testicular cancers start in the germ cells (those that become sperm or eggs). The main types of testicular germ cell tumors are seminomas and non-seminomas. Non-seminomas tend to grow and spread faster than do seminomas. Seminomas are more sensitive to radiation, and both kinds are very sensitive to chemotherapy. If a testicular tumor has both seminoma and nonseminoma cells, it is treated as a non-seminoma. The three main kinds of treatment for testicular cancer are: Surgical treatment - This treatment can include removing the testicle (orchiectomy) and removing associated lymph nodes (lymphadenectomy). Usually, orchiectomy is performed for both seminoma and non-seminoma testicular cancers, whereas lymph node removal is used only for non-seminomas. Surgery may also be performed in certain situations to remove tumors from the lungs or liver if they have not disappeared following chemotherapy. Radiation therapy - This treatment uses highdose X-rays. Radiation might be used after surgery for patients with seminomas to prevent the tumor from returning. Usually, radiation is limited to the treatment of seminomas.

Chemotherapy - This treatment uses drugs such as cisplatin, bleomycin, and etoposide to kill cancer cells. Chemotherapy has improved the survival rate for people with both seminomas and non-seminomas.

Treatment by stage for testicular cancer

In Stage I, the treatment is usually surgery to remove the testicle. For stage I seminomas, the standard treatment is observation, carboplatin chemotherapy, or radiation to the lymph nodes in the abdomen. For non-seminomas, management consists of observation, chemotherapy with bleomycin, etoposide, and cisplatin, or surgery to remove lymph nodes in the abdomen. In Stage II, seminoma tumors are divided into bulky and non-bulky disease. Bulky disease is generally defined as tumors greater than 5 centimeters. For nonbulky disease, the treatment of stage II seminomas includes surgery to remove the testicle, followed by radiation to the lymph nodes or chemotherapy using nine weeks (three 21-day cycles) of bleomycin, etoposide, and cisplatin, or 12 weeks (four 21-day cycles) of etoposide and cisplatin. . In cases of bulky disease, the treatment involves surgery to remove the testicle, followed by chemotherapy using nine weeks (three 21-day cycles) of bleomycin, etoposide, and cisplatin, or 12 weeks (four 21-day cycles) of etoposide and cisplatin without bleomycin.
whatdoctorsknow.com 43

The treatment of Stage II non-seminomas is similarly divided into bulky and nonbulky disease, but the cutoff is lower at 2 centimeters. For nonbulky disease, treatment is usually surgery to remove the testicle followed by either surveillance with CT scans or surgery to remove the lymph nodes in the back of the abdomen (the retroperitoneum). If cancer is found in the lymph nodes that are removed, then six weeks of chemotherapy using cisplatin and etoposide (either with or without bleomycin) is often recommended. For bulky disease, surgery is performed to remove the testicle, followed by chemotherapy (the same chemotherapy as defined above for seminoma). After chemotherapy, surgery should be performed to remove the lymph nodes in the back of the abdomen if there are any remaining enlarged nodes. In Stage III, the treatment is surgery to remove the testicle followed by multi-drug chemotherapy. Treatment is the same for Stage III seminomas and non-seminomas, except that after chemotherapy, surgery is often performed to remove any residual tumors in non-seminomas. In seminomas, residual tumors usually do not require any additional treatment. Chemotherapy typically consists of nine weeks of bleomycin, etoposide, and cisplatin, or 12 weeks of etoposide plus cisplatin for patients with favorable risk factors and 12 weeks of bleomycin, etoposide, and cisplatin for patients with unfavorable risk factors. Unfavorable risk factors include highly elevated tumor markers in the blood and tumors in organs other than the lungs, such as the liver, bones, or brain.

If the cancer is a recurrence of a previous testicular cancer, the treatment usually consists of chemotherapy using combinations of different medicines, such as ifosfamide, cisplatin, etoposide, vinblastine, or paclitaxel. This treatment sometimes is followed by an autologous bone marrow or peripheral stem-cell transplant. Recurrences occurring more than two years after initial treatment are usually treated surgically.

What is the prognosis (chance of recovery) for men with testicular cancer?
The prognosis is good for most men with testicular cancer. This form of cancer is treated successfully in more than 95 percent of cases. Even men with unfavorable risk factors have, on average, a 50 percent chance of being cured.

Can testicular cancer be prevented?

There is no way to prevent testicular cancer, but early detection is important. Men should perform testicular self-examination (TSE) on a monthly basis. If you are a male over 15 years old who has not been informed about how to perform TSE, ask your doctor to show you how to do this. If a man notices any change in his testicles (lumps or nodules, hardness, persistent pain, or a testicle becoming bigger or smaller), he should notify his doctor right away so that the testicles can be evaluated. -This information provided courtesy of Cleveland Clinic

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Kaylas got different plans.

St. Jude patient Kayla: California Girl

2012 ALSAC/St. Jude Childrens Research Hospital

(10991)

But at this moment, shes fighting cancer.

Thats why St. Jude Childrens Research Hospital spends every moment changing the way the world treats children with pioneering research and exceptional care. And no family ever pays St. Jude for anything. Dont wait. Join St. Jude in finding cures and saving children like Kayla. Because at this moment, she should be biking, hiking and hanging out with her three-legged cat, Kramer.

Help them live. Visit stjude.org.

Re-examining
Chemotherapy Drugs
Powerful Help in Prostate Cancer Treatment

he power of taxane-based chemotherapy drugs are misunderstood and potentially underestimated, according to researchers at Weill Cornell Medical College in the September 15, 2012 issue of the journal Cancer Research.

Most physicians and investigators believe that taxane chemotherapy (paclitaxel, docetaxel and cabazitaxel) just does one thing stop a cancer cell from dividing but the team of Weill Cornell scientists have revealed it acts much more powerfully and broadly, especially against prostate cancer. "Taxanes are one of the best class of chemotherapy drugs that we can use to treat our cancer patients, but while they are effective against a wide range of tumors, they don't work in all of them, and often patients become resistant," says the study's senior investigator, Dr. Paraskevi Giannakakou, an associate professor of pharmacology in medicine and pharmacology and director of laboratory research for the Division of

Hematology and Medical Oncology at Weill Cornell. "However, our new understanding of the precise action of taxanes in a cancer cell may help us overcome drug insensitivity or acquired resistance to the drugs and design therapies that can be used in combination with them to improve cancer control." In their study, the researchers stress that investigators must shift their attention away from taxane's function during cell division to the drugs' effects on halting the everyday movement of proteins and protein-to-protein communication within cancer cells and to understanding how and why a cancer cell can still survive. Researchers suggest that cancers that are insensitive to taxanes or those that have become resistant to them may, for example, switch to alternate forms of "transportation" to shuttle proteins within cells in a way that does not depend on the cell's skeletal structure which is the target of taxane therapy. Researchers showed in the study that the androgen receptor (AR), which is a driving force in prostate cancer growth and metastasis, "moves" along microtubules to be transported to the nucleus. When a taxane binds microtubules, it stops AR from traveling, thus inhibiting its activity. Taxane chemotherapy drugs such as paclitaxel, docetaxel and cabazitaxel work by binding tubulin, a protein that makes up microtubules.

46 whatdoctorsknow.com

Microtubules are the rope-like channels that provide both a skeletal structure to cells as well as provide "highways" along which molecules, such as proteins, RNA complexes and vesicles, can travel from one part of the cell to another and interact with each other. "Microtubules are the highly dynamic network of wires within cells, and when taxanes are used, the network stops moving," says Dr. Giannakakou. This is best observed when cancer cells attempt to divide, she says. "It is easy to see in the laboratory, that prostate cancer cells double every 30-48 hours, and taxane stops them from doing that, which pushes these cells to die. This leads everyone to think that this is exclusively how taxanes work they stop cells from dividing." But Dr. Giannakakou and her research team point out in their new study that patients have significantly lower rates of cell division in their tumors than do cancer cells growing in the lab. In fact, cancer cells in prostate cancer patients only divide every 33-577 days, she says. "Thus, the therapeutic benefit of taxanes on microtubules depends on more than just stopping cell division." The new insights provided by this study about the action of taxanes on AR trafficking helps explain the clinical activity of these drugs in the treatment of prostate cancer while at the same time can help researchers better understand why an individual patient might respond or not to taxane therapy. Such insights are critical for future chemotherapy customization, according to researchers. The drug that was later named Taxol (pacilitaxel) was isolated from the bark of a Pacific yew tree by federal researchers in 1967 and was later synthesized. It 1993 it was approved for use in ovarian cancer, and has since been used for lung, breast, head and neck and other cancers. Taxotere (docetaxel), synthesized from chemicals extracted from the European yew tree, was developed as an alternative to Taxol, and is used for the treatment of many of the same cancer types. Cabazitaxel, the newest taxane, is a semi-synthetic paclitaxel analog and is used to treat patients with prostate cancer who have failed prior docetaxel chemotherapy. "In the 20 years since Taxol was approved, hundreds of labs worldwide are trying to understand how taxanes work to stop cell division in cancer," Dr. Giannakakou says. "However, we think they need to now take a fresh approach and look at what these drugs do during the normal life cycle of a cancer cell and target the newly revealed underlying mechanisms and modes of movement with novel therapies, in combination with taxane therapy, to provide life-saving therapy for patients who don't benefit from taxanes." -This information provided courtesy of Weill Cornell Medical College

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Can Men Get Breast Cancer?

hen is the last time your husband performed a breast exam on himself? What about your father or even your son? Most likely it hasnt been recently, probably not frequently, and in fact he may have never performed an exam more than once in his life. Even though men do not have breasts like women, they do have a small amount of breast tissue and can develop breast cancer. Breast cancer in men accounts for only about one percent of all breast cancers. This is possibly due to their smaller amount of breast tissue and the fact that men produce smaller amounts of hormones such as estrogen that are known to affect breast cancers in women. A lower percentage does not mean that men who develop breast cancer have a better, more treatable or more positive outcome. Doctors used to think that breast cancer in men was a more severe disease than in women, but it now seems that for comparably advance breast cancers, men and women have similar outcomes.

Unfortunately, breast cancer in men is often diagnosed later than breast cancer in women, possibly because men are less likely to be suspicious of an abnormality in their breast area.

The clearest risks for developing breast cancer in men are: * Men who have had an abnormal enlargement of their breasts (called gynecomastia) * Drug or hormone treatments that cause the breasts to enlarge Infections or contact with certain poisons * Obesity * Individuals with Klinefelters syndrome, a rare genetic disease
Remind your father, husband or son about doing a regular breast exam. The conversation may be uncomfortable at first, but its a conversation that just might save their life. -This information provided courtesy of Cleveland Clinic Health Hub

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I Just Found a Lump.

Is It Testicular Cancer?

t can be an embarrassing thing for a guy to call his doctor about a lump or swelling on his testicles, but its important to do.

Whether its painful or not, a mass on the testicle is the most common early signal of testicular cancer, and should prompt an immediate call to the doctor. It often strikes young men most commonly between the ages of 15 and 45 who dont even suspect it might be cancer. Too often, neither do their primary care physicians. Its usually interpreted as an infection by the patient and the physician so theyll start a long course of antibiotics, says urologist Andrew Stephenson, MD, who specializes in cancers of the prostate, bladder and testis. They might wait four to six weeks to see if he responds to the antibiotics, but for a rapidly growing cancer like testicular cancer, those four to six weeks can be very important.

Thats not the only possible warning sign. Since testicular cancer generates the female hormone hCG, it can cause swelling or tenderness of a mans breasts. If the cancer has started to spread, Dr. Stephenson says, men might have abdominal or back pain or even a swelling in the neck. Guys who were born with an undescended testicle are among those at greatest risk, so Dr. Stephenson encourages parents to talk with their sons about the warning signs of testicular cancer as soon as they hit puberty.

Easy diagnosis, highly curable

Diagnosing testicular cancer is as easy as doing an ultrasound, and results are nearly immediate. Treatment is straightforward as well removal of the testicle and is usually enough to cure the disease. Losing a testicle is something no man wants to have happen, but theres functionally no important consequence of removal, he says. Their fertility potential is unaffected, their male sex hormone levels are unaffected, and about half of men have a testicle prosthesis so they have the appearance of two. -This information provided courtesy of Cleveland Clinic Health Hub

What to watch for

Its actually pretty uncommon for an otherwise healthy man of that age to develop a testis infection, Dr. Stephenson says. If I find a firm mass on the testes in a man whos 15 to 45, I consider that to be testicular cancer until proven otherwise.

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A Link Between Atherosclerosis and Macular Degeneration?

A
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new study raises the intriguing possibility that drugs prescribed to lower cholesterol may be effective against macular degeneration, a blinding eye disease. Researchers at Washington University School of Medicine in St. Louis have found that agerelated macular degeneration, the leading cause of vision loss in Americans over 50, shares a common link with atherosclerosis. Both problems have the same underlying defect: the inability to remove a buildup of fat and cholesterol.

Beneath the retina of a patient with macular degeneration, the small light dots against the orange background are cholesterol deposits, and as cholesterol builds up, the area becomes inflamed, spurring the development of abnormal blood vessels that can lead to loss of vision.

Working in mice and in human cells, the researchers shed new light on how deposits of cholesterol contribute to macular degeneration and atherosclerosis and even blood vessel growth in some types of cancer. Patients who have atherosclerosis often are prescribed medications to lower cholesterol and keep arteries clear. This study suggests that some of those same drugs could be evaluated in patients with macular degeneration. Based on our findings, we need to investigate whether vision loss caused by macular degeneration could be prevented with cholesterol-lowering eye drops or other medications that might prevent the buildup of lipids beneath the retina, says senior investigator Rajendra S. Apte, MD, PhD. The new research centers on macrophages, key immune cells that remove cholesterol and fats from tissues. In macular degeneration, the excessive buildup of cholesterol begins to occur as we age, and our macrophages begin to malfunction. In the dry form of age-related macular degeneration, doctors examining the eye can see lipid deposits beneath the retina. As those deposits become larger and more numerous, they slowly begin to destroy the central part of the eye, interfering with the vision needed to read a book or drive a car. As aging macrophages clear fewer fat deposits beneath the retina, the macrophage cells themselves can become bloated with cholesterol, creating an inflammatory process that leads to the formation of new blood vessels that can cause further damage. Those vessels characterize the later wet form of the disease. Ultimately, that inflammation creates a toxic mix of things that leads to new blood vessel growth, Apte explains. Most of the vision loss from wet macular degeneration is the result of bleeding and scar-tissue formation related to abnormal vessel growth. As part of their research, the scientists identified a protein that macrophages need to clear fats and cholesterol. As mice and humans age, they make less of the protein, and macrophages become less effective at engulfing and removing fat and cholesterol. Apte and his team found that macrophages, from old mice and in patients with macular degeneration, have inadequate levels of the protein, called ABCA1, which transports cholesterol out of cells. As a result, the old macrophages accumulated high levels of cholesterol and couldnt inhibit the growth of the damaging blood vessels that characterize the wet form of the disorder. But when the researchers treated the macrophages with a substance that helped restore levels of ABCA1,

the cells could remove cholesterol more effectively, and the development of new blood vessels was slowed. We were able to deliver the drug, called an LXR agonist, in eye drops, says first author Abdoulaye Sene, PhD, a post-doctoral fellow in the Apte lab. And we found that we could reverse the macular degeneration in the eye of an old mouse. Thats exciting because if we could use eye drops to deliver drugs that fight macular degeneration, we could focus therapy only on the eyes, and we likely could limit the side effects of drugs taken orally. Sene and Apte also say that since macrophages are important in atherosclerosis and in the formation of new blood vessels around certain types of cancerous tumors, the same pathway also might provide a target for more effective therapies for those diseases. We have shown that we can reverse the disease cascade in mice by improving macrophage function, either with eye drops or with systemic treatments, Apte says. Some of the therapies already being used to treat atherosclerosis target this same pathway, so we may be able to modify drugs that already are available and use them to deliver treatment to the eye. -This information provided courtesy of Washington University School of Medicine in St. Louis

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KNOW YOUR SPECIALIST

Urologist

U
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rology focuses on surgical and medical diseases of the male and female urinary tract system and the male reproductive organs. Organs under the care of a urologist include the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs (testes, epididymis, vas deferens, seminal vesicles, prostate and penis). Urologic surgeons, or urologists, undergo a rigorous post-graduate surgical training period for a minimum of five years, of which 12 months must be training in general surgery and 36 months training in clinical urology. The remaining 12 months are spent in general surgery, urology or other clinical disciplines relevant to urology. Upon successful completion of a residency program, some urologists choose to undergo further advanced training in a sub-specialty area of expertise through a fellowship lasting an additional 12 to 36 months. Urology combines the management of medical (i.e., non-surgical) conditions such as urinary tract

infections and benign prostatic hyperplasia, with the management of surgical conditions such as bladder or prostate cancer, kidney stones, congenital abnormalities, traumatic injury, and stress incontinence. Urology has traditionally been on the cutting-edge of surgical technology in the field of medicine. Urologists are well-trained in minimally-invasive techniques, employing real-time ultrasound guidance, fiberoptic endoscopic equipment, and various lasers in the treatment of multiple benign and malignant conditions. Urologists have been pioneers in the use of robotics in laparoscopic surgery. And because urology is closely related to such medical fields as oncology, nephrology, gynecology, andrology, pediatric surgery, colorectal surgery, gastroenterology, andendocrinology, urologists often collaborate with other medical professionals.

Subdisciplines
As a medical discipline involving the care of many organs and physiological systems, urology can be broken down into several subdisciplines. Urologists often specialize within a particular subdiscipline of urology.

Endourology
Endourology is the branch of urology dealing with the closed manipulation of the urinary tract. It has lately grown to include all urologic minimally invasive surgical procedures. As opposed to open surgery, endourology is performed using small cameras and instruments inserted into the urinary tract. Transurethral surgery has been the cornerstone of endourology. Most of the urinary tract can be reached via the urethra, enabling prostate surgery, surgery of tumors of the urothelium, stone surgery, and simple urethral and ureteral procedures. Recently, the addition of laparoscopy and robotics has further subdivided this branch of urology.

(undescended testes), congenital abnormalities of the genitourinary tract, enuresis, underdeveloped genitalia (due to delayed growth or delayed puberty, often an endocrinological problem), and vesicoureteral reflux.

Andrology
Andrology focuses on the male reproductive system. It is mainly concerned with male infertility, erectile dysfunction and ejaculatory disorders. Since male sexuality is largely controlled by hormones, andrology overlaps with endocrinology. Surgery in this field includes fertilization procedures, vasectomy reversals, and the implantation of penile prostheses. Vasectomies may also be included here, although most urologists perform this procedure.

Laparoscopy
Laparoscopy is a rapidly evolving branch of urology and has replaced some open surgical procedures. Robotassisted surgery of the prostate, kidney, and ureter has been expanding this field. Today, many prostatectomies in the United States are done by robotic assistance.

Reconstructive urology
Reconstructive urology is a highly specialized field of urology that restores both structure and function to the genitourinary tract. Prostate procedures, full or partial hysterectomies, trauma (auto accidents, gunshot wounds, industrial accidents, straddle injuries, etc.), disease, obstructions, blockages (e.g., urethral strictures), and occasionally, childbirth, can necessitate require reconstructive surgery. The urinary bladder, ureters (the tubes that lead from the kidneys to the urinary bladder) and genitalia are other examples of reconstructive urology.

Urologic oncology
Urologic oncology centers on the surgical treatment of malignant genitourinary diseases such as cancer of the prostate, adrenal glands, bladder, kidneys, ureters, testicles, and penis. The treatment of genitourinary cancer is managed by either a urologist or an oncologist, depending on the treatment type (surgical or medical). Most urologic oncologists in western countries use minimally invasive techniques (laparoscopy or endourology, robotic-assisted surgery) to manage urologic cancers amenable to surgical management.

Urogynecology
Urogynecology is a branch dealing with overactive bladder, pelvic organ prolapse, and urinary incontinence. Thorough knowledge of the female pelvic floor together with urodynamic skills are necessary to diagnose and treat these disorders. Depending on the cause of the individual problem, a medical or surgical treatment can be the solution.

Neurourology
Neurourology focuses on the nervous system control of the genitourinary system, and of conditions causing abnormal urination. Neurological diseases and disorders such as a stroke,multiple sclerosis, Parkinson's disease, and spinal cord injury can disrupt the lower urinary tract and result in conditions such as urinary incontinence, detrusor overactivity, urinary retention, and detrusor sphincter dyssynergia. Urodynamic studies play an important diagnostic role in neurourology. Therapy for nervous system disorders includes clean intermittent self-catheterization of the bladder, anticholinergic drugs, injection of Botulinum toxin into the bladder wall and advanced and less commonly used therapies such as sacralneuromodulation. Less marked neurological abnormalities can cause urological disorders as wellfor example, abnormalities of the sensory nervous system are thought by many researchers to play a role in disorders of painful or frequent urination (e.g. painful bladder syndrome also known as interstitial cystitis).

Pediatric urology
Pediatric urology concerns urologic disorders in children. Such disorders include cryptorchidism

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Zit-Face?
Why some people get zits and others don't

he bacteria that cause acne live on everyone's skin, yet one in five people is lucky enough to develop only an occasional pimple over a lifetime. What's their secret?

lead to a myriad of new therapies to prevent and treat the disfiguring skin disorder. "We learned that not all acne bacteria trigger pimples one strain actually may help keep skin healthy," explained lead author Huiying Li, an assistant professor of molecular and medical pharmacology at the David Geffen School of Medicine at UCLA. "We hope to apply our findings to develop new strategies that stop blemishes before they start, and enable dermatologists to customize treatment to each patient's unique cocktail of skin bacteria." The scientists looked at a tiny microbe with a big name: Propionibacterium acnes, bacteria that

In a boon for teenagers everywhere, a UCLA study conducted with researchers at Washington University in St. Louis and the Los Angeles Biomedical Research Institute has discovered that acne bacteria contain "bad" strains associated with pimples and "good" strains that may protect the skin. The findings, published in the Feb. 28 edition of the Journal of Investigative Dermatology, could
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scientists sequenced the genomes of 66 of the P. acnes strains, enabling UCLA co-first author Shuta Tomida to zero in on genes unique to each strain. "We were interested to learn that the bacterial strains looked very different when taken from diseased skin, compared to healthy skin," said co-author Dr. Noah Craft, a dermatologist and director of the Center for Immunotherapeutics Research at LA BioMed at HarborUCLA Medical Center. "Two unique strains of P. acnes appeared in one out of five volunteers with acne but rarely occurred in clear-skinned people." The biggest discovery was still to come. "We were extremely excited to uncover a third strain of P. acnes that's common in healthy skin yet rarely found when acne is present," said Li, who is also a member of UCLA's Crump Institute for Molecular Imaging. "We suspect that this strain contains a natural defense mechanism that enables it to recognize attackers and destroy them before they infect the bacterial cell." Offering new hope to acne sufferers, the researchers believe that increasing the body's friendly strain of P. acnes through the use of a simple cream or lotion may help calm spotty complexions. "This P. acnes strain may protect the skin, much like yogurt's live bacteria help defend the gut from harmful bugs," Li said. "Our next step will be to investigate whether a probiotic cream can block bad bacteria from invading the skin and prevent pimples before they start." Additional studies will focus on exploring new drugs that kill bad strains of P. acnes while preserving the good ones; the use of viruses to kill acne-related bacteria; and a simple skin test to predict whether a person will develop aggressive acne in the future. "Our research underscores the importance of strain-level analysis of the world of human microbes to define the role of bacteria in health and disease," said co-author George Weinstock, associate director of the Genome Institute and professor of genetics at Washington University in St. Louis. "This type of analysis has a much higher resolution than prior studies that relied on bacterial cultures or only made distinctions between bacterial species." Acne affects 80 percent of Americans at some point in their lives, yet scientists know little about what causes the disorder and have made limited progress in developing new strategies for treating it. Dermatologists' arsenal of anti-acne tools benzoyl peroxide, antibiotics and Accutane (isotretinoin) hasn't expanded in decades. Most severe cases of acne don't respond to antibiotics, and Accutane can produce serious side effects. -This information provided courtesy of UCLA Health Systems and Washington University in St. Louis.
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thrive in the oily depths of our pores. When the bacteria aggravate the immune system, they cause the swollen, red bumps associated with acne. Using over-the-counter pore-cleansing strips, LA BioMed and UCLA researchers lifted P. acnes bacteria from the noses of 49 pimply and 52 clear-skinned volunteers. After extracting the microbial DNA from the strips, Li's laboratory tracked a genetic marker to identify the bacterial strains in each volunteer's pores and recorded whether the person suffered from acne. Next, Li's lab cultured the bacteria from the strips to isolate more than 1,000 strains. Washington University

Hes one more reason air standards matter.

Big polluters and their allies cant ignore the facts: more pollution from power plants means more childhood asthma attacks. Mercury, arsenic, dioxin and other deadly toxics threaten the air we breathe and the health of our children. Theres technology that makes the air cleaner, but too many plants dont use it. We cant waitEPA must update power plant standards to protect our kids.