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Type 2 diabetes steals the lives we cherish most.
Nearly a quarter million a year. But it can be prevented. Nearly 80 million Americans have prediabetes. But because prediabetes doesnt always have symptoms, nine out of ten people who have it dont even know it. Know your risk before its too late. Especially if youre over 45 or overweight. More importantly, do something about it. Eat better, stay active and lose weight.
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On Call with Dr. Porter

WHO IS CARRYING THE LOADED GUN?
It was a little more than twelve years ago when I walked outside and saw my two-year old daughter in the cab of a friends pick-up truck with sunglasses on, a pacifier in her mouth and a loaded 9mm Glock pistol in her hand. There are no words to express what went through my mind. How did she get the gun? Who was responsible for leaving the gun unattended? Where was the accountability? In 2010, there were approximately 600 accidental gun related deaths reported in the United States. As a father it was disturbing to hear how many people died, when a little caution and responsibility could have prevented so many tragedies. However, as a physician, I am outraged that approximately 106,000 people die every year from prescription drugs while nearly 34,000 people died from traffic related accidents according to 2009 statistics, the most current data available. It gets worse. Prescription drug abuse leads cocaine and heroine in overdose deaths. And, in 2010, prescription pain killer abuse landed 306,000 Americans in the Emergency room. Who is responsible? Who is accountable? Who has the loaded gun? Some of the blame can be placed on the American society. We like things fixed, and we like them fixed quickly. While drugs can only mask the symptom and not treat the disease, we still scream for immediate fix and too often, that fix is a drug. Some blame can be placed on the doctor. A recent report listed the five most important impacts on Americas health as: stress, lack of exercise, high calorie intake, highly processed foods and environmental toxin exposure. Any, or all of these contribute to poor health. Instead of doctors treating the causes of poor health, such as recommending a diet and exercise regimen, out comes the prescription pad with a drug to cover the symptoms. What makes all this even more senseless, is that our societys quest for medications only opens up the possibility for some deadly cocktails medicines, when combined can kill. As a physician, I will admit I believe in medicines when they are absolutely necessary. I do not believe in medicines as a stopgap or a mask. The body is an amazing machine and when given the opportunity it can perform some mini miracles. In this months issue, I have written an article about an infamous drug related legal case that opened up the eyes of the medical and legal community. The case of Libby Zion started out as a wrongful death case against a doctor who acted on information he had at hand not knowing the patient was withholding critical facts about drugs she was taking. The withholding of information caused her death but because her case was tried in the press before all the facts surfaced, the Libby Zion case became an indictment of medical training in the United States. The impact of the Libby Zion case loaded another gun for our society. I urge you to read my story this month entitled: Prescription Drugs. Societys Loaded Gun. The drugs are obviously the loaded gun. Heres the question: Is the baby the patient or the doctor?
Steve Porter, MD Publisher and Chairman
The government spends approximately $30 billion a year on homeland security. Since 2001, 2,996 people in the United States have died from terrorism all as a result of the 9/11 attacks. In that same period of time, 490,000 people have died from prescription drugs. That means prescription drugs in this country are at least 16,400 percent deadlier than terrorism.
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WHAT DOCTORS KNOW

And you should, too!
IN THE TRUNK
15 Fatigue and Pregnancy 16 Do These Gene Make
Me Look Fat?
18 Masked Heart
Problems in Men Laryngeal Reflux
20 The Fiery Details of
P12
HEADlines
6
Categories of Headache
10 The Beginning of MS Revealed? 12 Attention Cataract Patients
P20
P26
BELOW THE BELT

22 HealthWatchMD: Avoiding
Your Colonoscopy?
On The Cover
28 Prescription Drugs. Society's Loaded Gun. 36 Celebrating 50 Years 42 St. Jude Dream Home Giveaway 44 The Community Believes in St. Jude
24 Lets Talk Hernia 26 You Want To Do What?
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Vol. 1 Issue 5
Contents
TECHNOLOGY & YOUR HEALTH
56 Potential Stroke Victims Arent Calling 911 58 Intensity Modulated Radiation
Therapy and Prostate Cancer
59 High-Tech High-Touch 64 Migraine Pain Relief with

Electrical Brain Stimulation in Your Esophagus
66 It Could Be Allergy Season
P54
MIND, BODY, AND SOUL

45 Garlic 46 Acetaminophen: Are You Taking Too Much? 49 Get the Facts on Hands-Only CPR 50 Is My Child on Target? 52 Unraveling Calorie Count Confusion 54 Screening Tests That Can Save a Mans Life
P64
In Every Issue
01 On Call With Dr. Porter 05 Meet Our Doctors 22 HealthWatchMD: Avoiding Your Colonoscopy?
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Meet Our Doctors
Steven Porter, MD
Founder and publisher of What Doctors Know, Dr. Porter is recognized as one of the top gastroenterologists in the country. He is the medical director of the endoscopy lab at a leading hospital in Ogden, Utah and has been practicing for more than 25 years. Contact Dr. Porter at (801)387-2550.
Timothy J. Sullivan, MD
Contributing editorial advisory board member of What Doctors Know, Dr. Sullivan spent 25 years in full-time academic medicine at Washington University, University of Texas Southwestern Medical School, and Emory University. He currently has a fulltime allergy and immunology practice in Atlanta, Georgia and is a clinical professor at the Medical College of Georgia. Contact Dr. Sullivan at (404)255-2918 or www.trittbreatheandsleep.com.
LeGrandBelnap, MD, FACS

A member of several medical societies including the American College of Surgeons, the American Society for Bariatric Surgery and The American Society of Transplant Surgeons. Dr. Belnap is a board certified general surgeon who has received extensive training at the University of Utah, University of Minnesota, University of California and the University of Pittsburgh. He is currently a clinical professor of surgery at Utah-LDS Hospital.
Vicki Lyons, MD
Founding member and chairman of the editorial advisory board of What Doctors Know, Dr. Lyons is a board certified and fellowship trained allergist and immunologist practicing in Ogden, Utah. She has been practicing for 20 years. Contact Dr. Lyons at (801)387-4850 or www.vicki-lyonsmd.com.
Phillips Kirk Labor, MD

Internationally known for his work in refractive surgery and cataract expertise for more than 20 years. Dr. Kirk Labor is a board certified ophthalmologist in the Dallas, Texas area with affiliations to the American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American College of Eye Surgeons, and Society for Excellence in Eye Care. Contact Dr. Labor at (817)410-2030 or www.eyectexas.com.
Aaron Michelfelder, MD
Director of Medical Student Education at the Department of Family Medicine, Loyola University Chicago, Stritch School of Medicine, Dr. Michelfelder practices family medicine at the Loyola Family Practice Center in Illinois. He has been honored with the Mead Johnson Award from the American Academy of Family Physicians as one of the top 20 Family Medicine residents in the country.
Nadim Bikhazi, MD
Board President of a healthcare facility in Northern Utah, Dr. Bikhazi is an Otolaryngologist with specialty training in the ear nose and throat (ENT). Contact Dr. Bikhazi at (801)476-3000 or www.ogdenclinic.com
Copyright 2012 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.
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WHAT DOCTORS KNOW

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Special Thanks To:
Published by What Doctors Know, LLC Publisher and Chairman Steve Porter, MD Editorial Advisory Board Vicki J. Lyons, MD, Chairman Timothy J. Sullivan, MD Editorial and Design Director Bonnie Jean Myers Senior Designer Suki Xiao Design Associate Cayden Chan Executive Director, Marketing Larry Myers Production Kai Xiao, Vice President IT Manager Eric Lu
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Categories of
Headache
P
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rimary or benign headaches are not due to an organic underlying condition. However, these common headaches are legitimate biological disorders, not psychological conditions. Science is rapidly progressing to better understand the cause of primary headaches.
Tension-Type
Approximately 78% of adults experience a tension-type headache at some point in their lives. There appears to be a slightly higher prevalence of this type of headache among women and more women than men seek treatment. Tension-type headache, the most common form of headache, is a nonspecific headache, which is not vascular or migrainous, and is not related to organic disease. The underlying cause of tension-type headache is likely due to chemical and neuronal imbalances in the brain and may be related to muscle tightening in the back of the neck and/or scalp. The pain is pressing or tightening, of mild to moderate intensity, and occurs on both sides of the head. Some sufferers describe a bandlike sensation around the neck and/or head which is a "vice-like" ache located in the forehead, temples or the back of the head and/or neck. The pain is not aggravated
by routine physical activity. Rarely are there associated symptoms such as nausea or sensitivity to light or noise. Tension-type headache is divided into 3 categories, based on the frequency of attacks.
Episodic
Episodic tension-type headache occurs less than once per month and is usually triggered by temporary stress, anxiety, fatigue or anger. They are what most of us consider "stress headaches." It may disappear with the use of over-the-counter analgesics, withdrawal from the source of stress or a relatively brief period of relaxation. For this type of headache, over-the-counter drugs of choice are aspirin, acetaminophen, ibuprofen or naproxen sodium. Combination products with caffeine can enhance the action of the analgesics.
headache. It is often a daily or continuous headache, which may have some variability in the intensity of the pain during a 24-hour cycle. If a sufferer is taking pain medication daily or almost daily and is receiving little or no relief from the pain, then a physician should be seen for diagnosis and treatment. Chronic daily tension-type headache is often associated with depression or other emotional problems. Changes in sleep patterns or insomnia, early morning or late day occurrence of headache, feelings or guilt, weight loss, dizziness, poor concentration, ongoing fatigue and nausea commonly occur. Sufferers usually awaken in the morning with the headache and frequently have an accompanying sleep disorder. One should seek professional diagnosis for proper treatment if these symptoms exist. This type should be treated preventively to avoid becoming dependent on pain relieving drugs. The primary drug of choice for chronic tensiontype headache is amitriptyline or some of the other tricyclic antidepressants taken daily. Antidepressant drugs have analgesic actions, which can provide relief for headache sufferers even if the patient is not depressed. Biofeedback techniques can also be helpful in treating tension-type headaches. For the patient with chronic tension-type headaches, habituating analgesics must be strictly avoided.
Frequent
Occurring 1-15 days per month, this type of headache often co-exists with migraine. Sufferers should be cautious to avoid overusing analgesics due to the high frequency of this headache type.
Chronic
Chronic tension-type headache occurs 15 or more days per month and evolves over time from episodic
Migraine
More than just a bad headache, migraine pain and associated symptoms affect 29.5 million Americans, equivalent to 13% of the population, and one in every four U.S. households has a migraine sufferer. Migraine is characterized by throbbing head pain, usually located on one side of the head, often accompanied by nausea and sensitivity to light and sound. The combination of disabling pain and associated symptoms often prevents sufferers from
performing daily activities. Symptoms, incidence and severity vary by individual. Attacks can last anywhere from four to 72 hours and tend to occur in three phases: pre-headache, the headache itself, and postheadache. The pre-headache and post-headache phases can last for hours to days with symptoms such as muscle tenderness, fatigue and mood changes. Less than one-third of sufferers experience what is known as "aura." They may see light flashes, blind spots, zigzag lines, and shimmering lights or experience
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numbness and tingling in the arm and face prior to the head pain and other symptoms. Aura symptoms last less than one hour and typically resolve before the head pain begins. Aura may occur with some, but not all attacks. Migraine afflicts both women and men, although three times more women experience migraine. Nearly 13 million women in the U.S. suffer from menstrual migraines. It seems clear that certain hormonal changes that occur during puberty in girls, and remain throughout adulthood, are implicated in the triggering and frequency of migraine attacks in women. The finding that 60% of women sufferers related attacks to their menstrual cycle supports this link between female hormone changes and migraine headaches. Attacks may occur several days before or during the woman's menstrual period. There are women who also get the headache mid-cycle, at the time of ovulation. Estrogen levels fluctuate throughout the menstrual cycle. The headaches typically occur in association with drops in the estrogen level. Few women (less than 10%) have headaches only with menses. Therefore, in most women, hormones are just one of many migraine triggers. As women near menopause, the estrogen levels may fluctuate more and trigger an increase in migraines. Daily preventive therapy may again be necessary if the headaches are frequent and the periods are unpredictable. Women who go through natural menopause may have fewer headache problems than women having hysterectomies. In menopause, the use of continuous estrogen replacement without any days off helps to minimize migraine for many women. Peak prevalence for migraine is between 20 - 45 years old for both genders. Migraine is often hereditary. Onset can occur in childhood. If both parents have them, there is a 75 percent chance their children will have them; when only one parent is a migraine sufferer, there is a 50 percent chance the child will be afflicted. If even a distant relative has migraine headaches, a 20 percent chance exists that any offspring will be prone to migraine headaches. Many things may trigger a migraine. Triggers are not the same for everyone and what causes a migraine in one person may relieve it in another. Triggers may be cumulative with exposure to multiple triggers migraine may be more likely to occur. Triggers may include one or more of the following categories: diet, activity, environment, emotions, medications and hormones. While there are no definite answers to the causes of migraine, healthcare professionals are gaining an understanding of what happens when a migraine attack is in progress. Current theory suggests that migraines are triggered from within the brain itself. Once an attack begins, the pain and other symptoms of migraine arise from an inflammatory process resulting from an interaction between the trigeminal nerve and blood
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vessels in the coverings of the brain. Serotonin (or 5-hydroxytryptamine or 5-HT), a naturally occurring chemical in the brain, has been implicated in this inflammatory process. Pain signals are sent from the blood vessels along the trigeminal nerve into the brainstem. Here, pain processing centers can become sensitized or overloaded by the incoming pain signals and begin to spontaneously fire. This can result in skin sensitivity on the head/scalp. Patients may note that my hair hurts, or that they have to take off glasses or jewelry during a migraine. Once these symptoms occur, medication may not be as effective as it would be if taken earlier in the attack. Repeated pain signaling over time may be responsible for chronic (daily) migraine. Migraine sufferers may experience a variety of headache presentations including sinus pain, neck tension, menstrual migraine or have aura without headache. Most migraine occurs episodically; however, 10 million Americans have chronic headache (15 or more days per month). Many of these people experienced episodic migraine that evolved over time to chronic migraine. Migraine can be effectively managed. With the help of a healthcare provider, patients can identify and alleviate their symptoms with an appropriate treatment regimen. Medications generally fall into two categories:
Preventive - Taken on a daily basis, preventive medications can help reduce the number of attacks in patients who experience more than two migraines per month. Acute - Acute therapy treats the symptoms of migraine after the attack begins. Many medications available to treat an acute attack must be taken as soon as the attack occurs, otherwise they may be less effective.
Non-drug treatments can be effective, especially when used in conjunction with medication. Strategies include relaxation techniques, proper sleep and diet habits, exercise, and avoidance of behaviors or situations that may trigger an attack. Biofeedback has also been used successfully, as have acupuncture, massage, and simple heat and cold applications.
Cluster
There are an estimated one million cluster headache sufferers in the United States; about 90 percent of the sufferers are male. Cluster is one of the least common types of headache, and the cause is unknown. Similar to migraine, the pain is related to the inflammatory process resulting from an interaction between the trigeminal nerve and blood vessels in the coverings of the brain. Abnormalities in the hypothalamus, a deep area of the brain that controls circadian rhythms, may be responsible for the pattern of cluster headaches. Cluster headache refers to the characteristic grouping or clustering of attacks. Cluster headaches may also be known as histamine headache, red migraine, Horton's
headache, cephalalgia or spenopalatine neuralgia. The headache periods can last several weeks or months, and then disappear completely for months or years leaving considerable amounts of pain-free intervals between series. Sufferers are generally affected in the spring or autumn, and, due to their seasonal nature, cluster headaches are often mistakenly associated with allergies or business stress. Cluster headache starts suddenly, and a minimal type of warning of the oncoming headache may occur, including a feeling of discomfort or a mild one-sided burning sensation. The pain is of short duration, generally 30 to 45 minutes. However, the headache may last anywhere from a few minutes to several hours and will disappear only to recur later that day. Most sufferers get one to four headaches per day during a cluster period. They occur regularly, generally at the same time, often awakening the sufferer during the night. With typical cluster headaches, the pain is almost always one-sided and remains on the same side during a series, but pain can occur on the opposite side when a new series starts. Usually pain is localized behind the eye or in the eye region and may radiate on the same side to the face or neck. The affected eye may become swollen or droop and the pupil may contract. The nostril on the affected side is often congested and nasal discharge and tearing of the eye is on the same side as the pain. Sufferers may also experience excessive sweating, and the face may become flushed on the affected side. Cluster sufferers report that even small amounts of alcohol will precipitate an attack during a cluster cycle but not during cluster-
free times. Few other triggers have been identified. About 20% of cluster sufferers' attacks are chronic, occurring throughout the year, thus making the control of these headaches more difficult. Because chronic cluster headache periods are continuous, the patients do not respond to conventional forms of cluster therapy. The patient with cluster headaches should be started on preventive therapy as early as possible in the cycle in order to curtail the length of the cluster period and decrease the severity of the headaches. Because of the brief duration of an acute cluster attack, the acute treatment of these headaches is difficult. Histamine desensitization and surgical intervention may be considered for chronic cluster headache patients who have not responded to other forms of standard therapy. Oxygen inhalation by facial mask has been successful in aborting an acute cluster headache.
Secondary Headaches
Organically Caused An organically caused headache is not a disease itself; rather it is a symptom of another disease or disorder. Organically caused headaches are evidence of tumors, infection, high blood pressure, diseases of the brain, eye, ear and nose, blood clots, and aneurysms to name a few. These conditions can be lifethreatening so immediate evaluation by a doctor is recommended. Fortunately, these types of headache are less common than primary headaches. Some signs that the headache is related to a serious disorder include change in headache pattern; headache associated with a medical problem or neurological symptoms such as focal weakness, loss of consciousness or confusion; pain that becomes progressively more severe or is the worst headache ever experienced; or the individual is using prescription or over-thecounter pain relievers every day. -This information provided courtesy of The National Headache Foundation
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ultiple sclerosis (MS) may progress from the outermost layers of the brain to its deep parts, and isn't always an "insideout" process as previously thought, reported a new collaborative study from researchers at the Mayo Clinic and the Cleveland Clinic. The traditional understanding is that the disease begins in the white matter that forms the bulk of the brain's inside, and extends to involve the brain's superficial layers, the cortex. Study findings support an opposite, outside-in process: from the cerebrospinal fluid-filled subarachnoid space, that cushions the outside of the brain and the cortex, into the white matter. The new findings will guide researchers as they seek to further understand and treat the disease. The study was published in the December 8, 2011, issue of the New England Journal of Medicine. Researchers do not know precisely what causes MS, but it is thought to be an autoimmune disease in which the body's immune system attacks and destroys its own myelin. This fatty substance surrounds and protects axons, nerve cell projections that carry information, and its damage slows down or blocks messages between the brain and body, leading to MS symptoms, which can include blindness, numbness, paralysis, and thinking and memory problems. "Our study shows the cortex is involved early in MS and may even be the initial target of disease," says Claudia F. Lucchinetti, M.D., co-lead author of the study and Mayo Clinic neurologist. "Inflammation in the cortex must be considered when investigating the causes and progression of MS", she says. Study authors say current therapeutic options may not even address issues associated with the cortex. Understanding how the cortex is involved, therefore, is critical to creating new therapies for MS. "Measures of cortical damage will enhance enormously the power of clinical trials to determine if new medications address tissue changes of MS in all regions of the brain,"
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says co-lead author Richard Ransohoff, M.D., a Cleveland Clinic neurologist. These measures are important because disease accumulates in the cortex over time, and inflammation in the cortex is a sign the disease has progressed. The research is distinct because it studied brain tissues from patients in the earliest stages of MS. "What's unique about the study is, and the reason the National MS Society funded this international team of researchers, is that it offers a rare view of MS early in the disease," says Timothy Coetzee, Ph.D., Chief Research Officer at the National Multiple Sclerosis Society. "Collaborative studies like this, that deepen our understanding of the sequence of nervous system-damaging events, should offer new opportunities for stopping MS disease progression and improving quality of life for people with MS." The findings support the understanding that MS is primarily a disease of inflammation, not neurodegeneration, as some studies have recently suggested. Co-lead authors Drs. Lucchinetti and Ransohoff conclude that it is "overwhelmingly likely" that MS is fundamentally an inflammatory disease, and not a neurodegenerative Alzheimer-like disease.
How They Did It

The research did not at first focus on the 'outsidein' question, says Dr. Lucchinetti. Instead, the team initially wondered what tissue changes in the cortex of MS patients gave rise to indicators of cortical damage. For the last several years, researchers knew from MRI studies that the cortex was damaged very early after onset of MS, and they knew from autopsy studies that the cortex was demyelinated, as was white matter. What researchers were unable to determine, until completion of the present study, was whether
findings at autopsy (usually after 30-50 years of disease) accurately reflected the indicators of cortical damage from MRI images taken after only a few months of disease. In autopsy MS tissues, cortical lesions show demyelination, but without inflammation-raising the possibility that MS cortex degenerates due to intrinsic tissue defects. Such a process would not be treatable by current MS therapies and could not be explained by present concepts of the causes of MS. Drs. Lucchinetti and Ransohoff determined to see if early-MS cortical lesions were, or were not, inflammatory. To do so, they studied the Mayo resource of white-matter biopsies taken largely from patients with suspected tumors, but eventually proving to have MS. About one-fourth of the biopsies also included tiny fragments of cortex, which formed the focus of study. The primary question was quickly answered: cortical demyelinating lesions of early-MS patients resembled those found at autopsy in every way but one the early lesions were highly inflammatory. These findings were reassuring because they indicated that treatments targeting inflammation in the disease may ameliorate MS effects on both the cortex as well as the white matter. While investigating the cortical changes in the biopsies, researchers were struck by the high frequency of cortical demyelinating lesions. Furthermore, in the white matter biopsies, which contained miniscule
cortical fragments, about 20% showed inflammatory demyelination was contained entirely in the cortex. Researchers also noted inflammation was present in the meninges, the protective membranes that cover the surface of the brain and demarcate the subarachnoid space. Meningeal inflammation and cortical demyelination were highly-associated. Looking at implications of their data, Drs. Lucchinetti and Ransohoff could weave together a proposed pathway for lesion initiation, along with known experimental data from MS animal models, and term this pathway the "outside-in" theory. The research findings also lend urgency to efforts to use MRI to "see" more deeply into the cortical lesions of MS, particularly given that cortical damage is an important correlate of progressive disability and cognitive dysfunction in MS. -This information provided courtesy of Mayo Clinic.
This study was funded by the National MS Society's MS Lesion Project, led by Dr. Lucchinetti, as well as the National Institutes of Health. Other Mayo Clinic study authors include: Bogdan Popescu, M.D.; Reem Bunyan, M.D.; Shanu Roemer, M.D.; Joseph Parisi, M.D.; Bernd Scheithauer, M.D.; Caterina Giannini, M.D.; Stephen Weigand, M.S.; Jay Mandrekar, Ph.D. Additional authors included Hans Lassmann, M.D. from the Center for Brain Research, Medical University of Vienna, Austria; Wolfgang Bruck, M.D. from the Department of Neuropathology, University Medical Center and Institute for MS Research in Gottingen, Germany; and Natalia Moll, M.D, Ph.D. from the Neuroinflammation Research Center and Department of Neurosciences Lerner Research Institute, Cleveland Clinic.
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11
ATTENTION Cataract Patients

Extending vision and possibilities with multifocal lens implants
A
s we enter our 40s and move towards middleage, the fact that most of us will experience problems with our vision is a fact of life. Invariably, the problem is with our ability to see things up close, or focus on important things like reading food or medicine labels, a computer screen, restaurant menu, or the Sunday paper. This can be very frustrating, because its something we were once able to do without a second thought. Its simply a natural consequence of aging called presbyopia, commonly associated with cataracts, the clouding and discoloration of the eyes natural lens.
glasses to view things that are near. This isnt the case with multifocal lenses, however, because they offer a full range of vision, allowing the eye to focus on objects that are near, intermediate, or far away. ReSTOR is the first multifocal lens of its kind. Whereas some artificial lenses are hard and not easily bent, ReSTOR lenses are made of a soft acrylic, making them more flexible. The results of this softer, more flexible material provides a more controlled delivery of the implant for the surgeon. Most importantly, of course, the ReSTOR lens enables patients to see well at all distances. Tecnis is another multifocal IOL that delivers excellent results for the patient. Also an acrylic lens, the Tecnis lens offers a full range of vision, and, in many cases, patients are completely free of the need for spectacles to focus on objects at any distance. In general, ReSTOR offers stronger near vision and good distance vision; Tecnis offers stronger distance vision and better intermediate vision. Both lenses can be effective, and your doctor should discuss their differences in detail to help you make the right choice. Once a lens is chosen, the surgical procedure to remove a cataract is fairly simple and painless. In fact, cataract surgery is one of the safest and most commonly performed surgeries today, with over one million performed worldwide every year, typically on an outpatient basis. The procedure begins with eye drops or a gel to numb the eye, after which a small incision is made at the edge of the cornea. Through this incision the affected lens is washed away and replaced with the multifocal IOL. The entire process takes only 15 to 20 minutes, and the patient is awake the entire time. Following a brief recovery period, the patient is free to return home, usually an hour or
Presbyopia occurs when the natural crystalline lens of the eye becomes less flexible. This built-in flexibility allows the eye to focus clearly on objects at varying distances. Its when the eye loses this flexibility that many people discover they need eyeglasses to see up close, even if theyve never needed them before. But this can be a nuisance and, over time, expensive. Premium multifocal IOLs (intraocular lens implants) may be used to replace the eyes natural lens to correct presbyopia, as in clear lens extraction, or to replace the eyes clouded lens during cataract surgery. Multifocal lenses are an effective, long-term solution to treating presbyopia, and can reduce, or even eliminate, the need for eyeglasses after surgery. The multi in multifocal lenses means that the lens has more than one focal point like a naturally healthy eye. Thats why, in many cases, multifocal IOLs are preferable to monofocal lenses. Monofocal lenses correct for vision at only one distance, usually for far away objects, and require the use of
Intraocular Lens
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13
so after surgery. Patients who receive lens implants can safely resume most of their normal activities within two or three days, but should expect to make a return visit to their doctor for a post-op evaluation. While vision is better after surgery, the final results are not immediate. Vision will continue to improve as time goes by, and the eye re-trains itself to see objects naturally at all distances. This can be reinforced by daily reading designed to help speed up the recovery and restore optimum visual capability. Its also important to point out that because multifocal lenses are considered premium lenses, they are not
covered by insurance. However, most patients who choose this elective procedure experience better results than with standards lenses, which are covered by insurance. In other words, the benefits make it well worth the investment. If you think you might be a candidate for a multifocal lens implant, you should talk to your doctor. He or she can evaluate your vision to determine if a multifocal lens implant is right for you. Remember, its not just about improving your vision; its about making your vision the absolute best it can be. -Part two of a series on premium lenses-Phillips Kirk Labor, MD
Fatigue and
Is That Sleepiness During Pregnancy Normal or a Sign of Sleep Apnea?
Pregnancy
Unfortunately, many pregnant women dont get tested for sleep apnea because the associated symptoms, like snoring and sleepiness, are also common in a normal pregnancy, said Ann Cartwright, MPAS, PS-C, sleep specialist at National Jewish Health. Pregnant women who were overweight before their pregnancy or who have developed high blood pressure or diabetes during their pregnancy should consider getting evaluated for sleep apnea. If you are pregnant and have any of the following symptoms, talk to your doctor about getting tested for sleep apnea:
ost pregnant women complain of being tired. Some of them however, could be suffering more than normal fatigue associated with their pregnancy; they may have developed obstructive sleep apnea (OSA), a periodic cessation of breathing during sleep. If left untreated, OSA poses a variety of health risks to these women, from diabetes to high blood pressure and stroke. Recent studies have also indicated that pregnant women with OSA are at risk for delivering low birthweight or preterm infants. Obstructive sleep apnea (OSA) occurs when a persons airway collapses repeatedly during sleep. This repeated stoppage of airflow causes low bloodoxygen levels and strain on the heart. The person also experiences a brief interruption of sleep when the brain wakes up to start breathing again. Untreated, OSA causes high blood pressure, heart disease, heart attacks, strokes, irregular heart rhythms, diabetes and mental decline. People with untreated sleep apnea are also at higher risk of having a motor vehicle or workplace accident caused from sleep deprivation.
Snoring Unrefreshing sleep Daytime sleepiness Morning headaches Nighttime heartburn Difficulty focusing/concentrating Insomnia Poor memory High blood pressure Diabetes
Continuous positive airway pressure (CPAP) is a safe and effective treatment for sleep apnea during pregnancy. In most cases woman who did not suffer from sleep apnea prior to pregnancy will return to normal sleep after giving birth. -This information is provided courtesy of National Jewish Health.
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15
Do These Genes Make Me
When Diet and Exercise Arent Enough
Look Fat?
S
More than 50% of Americans are overweight. Most of them wont admit it or dont believe they are overweight. And for the most part, those who fall into this group are known as averagely overweight. The extra pounds this group has gained over time can be shed by sensible diet and exercise programs. However, about three to five percent of the population is grossly overweight and this group is genetically destined to stay that way. In fact, studies from the National Institutes of Health (NIH) have found that no diet is effective for some significantly overweight people.
ensible Steps to a Sensible Weight
Health experts, dietitians and doctors agree that for the averagely overweight population, losing weight requires a commitment to lifestyle change. A commitment that can run the gamut from eating less to eating smartalong with becoming more active, which translates to burning calories and perhaps even extending life.
The first step in a weight-loss program if you are averagely overweight is to acknowledge that the pounds have added up and some changes need to be made. Keep in mind that while the changes could be drastic, depending on your situation, you need to make the changes immediately so your body and mind can adjust. One of the easiest ways to start adjusting is to begin eating lessand eating smarter. Take smaller portions the first time around and wait at least 10 minutes before you go for seconds. The time in between may be all you need to talk yourself out of those extra calories.
The next step is to look at what you eat. Past generations grew up on meat and potatoesoften lots of potatoes with gobs of gravy and butter. Today we are smarter and realize that meat and potatoes are just fine, but with a lot less butter and gravy and a lot more emphasis on lean meat or other proteins. Talk to your doctor about a realistic weight-loss program.
Lap band surgery involves placing a constricting plastic band around the upper stomach, making it smaller so, like gastric bypass, a few bites of food makes the patient feel full. This bariatric procedure has proven to be a safe and effective method of surgical weight loss since its worldwide debut in the mid-1990s.
Vertical sleeve gastrectomy (VSG)
When Diets Dont Work, You Still Have Options

Eating less and eating smart might seem doable for the majority of overweight Americans, but many excessively overweight individuals those with a body mass index (BMI) of 35 or greaterhave a 98% failure rate with traditional diet and exercise programs because their genes wont let diets work. For these people, a surgical option may be the only effective means of weight loss. And the number of these surgical procedures is growing each year. The NIH reports that the number of bariatric procedures performed in the United States has grown from 20,000 procedures in 1995 to more than 230,000 procedures in 2007. Today surgeons perform three main procedures to help patients lose weight: gastric bypass, lap band, and vertical sleeve gastrectomy (VSG). The oldest and most popular of the procedures, gastric bypass involves surgically reducing the size of the stomach so patients feel full after only a few bites. The small bowel is divided about 18 inches below the lower stomach outlet, and is rearranged to enable outflow of food from the small upper stomach pouch, via a Roux limb. The Roux limb preserves most of the small bowel, so it can still absorb nutrients. The gastric bypass patient experiences a very quick sense of stomach-fullness, followed by a feeling of growing satiety, or indifference to food, shortly after the start of a meal.
pain, diabetes, heart disease and even cancer. The cancer rate in this group is 200 to 400 times higher compared to the normal weight-bearing population. After one of these three surgical procedures, a patients quality of life can improve dramatically. Patients are out of the hospital in one to two days and the complications are remarkably low. One to four percent of this group has serious complications from a procedure; however, these complications are always correctable. Pain from the procedures is typically moderate and easily controlled with medication. And because these procedures are performed laparoscopically, pain is minimal. Once the procedure is complete, the patient will need to stick with a diet of 75% protein and 25% fruits and vegetables, supplemented with proper vitamins. And of course, as with any diet, exercise is critical for the best long-term results. As far as food restrictions go, one group that doctors and dietitians agree on is DESSERTS. Moderation is always the key. Before you embark on any diet or exercise program, see your doctor. And if diet and exercise hasnt worked for you, talk to your doctor. A surgical procedure may be the answer to a healthier and longer life. -LeGrand P. Belnap, MD, FACS
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The third and latest surgery technique is a gastric sleeve procedure known as vertical sleeve gastrectomy (VSG). The gastric sleeve combines many of the advantages of the laparoscopic gastric bypass and the lap band. This operation consists of removing a greater portion of the stomach and creating a gastric tube.
Choose a Healthier and HappierLife

The co-morbidity rate of morbid obesity is 100%. In laymans terms, being grossly overweight is a death sentence. Ninety-five percent of these patients are at least moderately depressed with low self-esteem, and the vast majority develop sleep apnea, arthritis, low back
Masked Heart Problems in Men Could Lead to Sudden Death

The first manifestation of a heart problem oftentimes is sudden death. So where do the mens heart problems start? Gertler says it can date very early in life. The process of atherosclerosis begins in the teenage years, and takes a long time to develop. That hardening of the arteries is caused in general by years of unhealthy living: smoking, uncontrolled hypertension, obesity, high cholesterol, inactivity; these all tend to accelerate that process, Gertler says. Some risk factors are beyond your control a family history of heart disease, age, or in this case gender but there are things that you can control, and you might want to start now. Heart disease does not discriminate. Men in their 20s and 30s can have heart attacks, Gertler says. Gertler encourages men to be proactive in recognizing their coronary risk factors and work to modify them. Men need to focus on what their appropriate numbers are for blood sugar, blood pressure, cholesterol and body-mass index, Gertler says. Gertler says the increased prevalence of obesity in the past two decades has led to more young men developing diabetes and living a much less active life, and diabetes is linked to heart disease. He says young people need to focus on participating in some form of regular aerobic activity for 30 to 40 minutes, four to five times per week. So, watch your waistline. It should measure less than 40 inches because of the association between abdominal fat and increased risk of coronary artery disease, Gertler says. Talk with your doctor about a riskfactor assessment. Gertler does this with his patients, to better personalize their individual journey to better heart health. We discuss the appropriate diets for them Im a proponent of the Mediterranean diet and we also discuss the importance of regular exercise to achieve their ideal body-mass index, says Gertler. I will give men an idea of what their 10-year risk of having a heart attack is based on their risks using the Framingham risk score. This often hits home with many men, says Gertler. Quitting smoking is one of the hardest changes for men, Gertler says. Well talk about their prognosis if they dont quit. Smoking-cessation is tough because of the nicotine addiction, but its often a wake-up call when they realize they may not be able to watch their kids grow up and graduate, says Gertler. An added bonus for beating the pack? Gertler says if men abstain from smoking for five years, their risk of having a heart event becomes closer to that of someone who never smoked. Gertler says free, valuable sources of information for a healthy lifestyle found on sites such as the American Heart Association at www.heart. org can make it easier to understand the disease and prevent it. Coronary heart disease is mostly preventable, but you have to be motivated. By modifying risk factors you can slow down the progression of plaque formation in the arteries and your chances of disease can all be reduced, Gertler says. -This information provided courtesy of the University of Alabama at Birmingham Medicine.
he healthy heart movement in recent years has focused largely on heart disease as the No. 1 killer of women. But the same statistic is true for men, and the reality is grim: The first sign that a man has coronary heart disease could be death, says one University of Alabama at Birmingham expert. Coronary heart disease is caused by a buildup of plaque in the arteries to your heart, affecting the flow of blood and oxygen to your ticker. More than half of the deaths due to heart disease in 2008 were in men, and coronary heart disease is the most common type of heart disease, according to the Centers for Disease Control and Prevention. Half of the men who die suddenly of coronary heart disease have no previous symptoms, says Alan Gertler, M.D., associate professor of medicine in UABs Division of Cardiovascular Diseases and part of UABs Heart & Vascular Services.
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Laryngeal Reflux
The Details of
Fiery
t is estimated that one out of seven adults complain about reflux at least once a week. Forty percent of these patients have had symptoms for more than 10 years. While most people recognize reflux by its esophageal indicators of heartburn (typical of Gastroesophageal reflux, or GERD), Laryngopharyngeal reflux (LPR), is a much more sinister enemy. Difficult to diagnose and more difficult to treat, LPR requires more frequent medication and longer therapy.
of the acid. Thats why the small amount of acid from the stomach -- which may not be enough to cause esophageal burning (heartburn) -- can still profoundly damage the voice box. Thats why it takes more intensive and more prolonged therapy to heal the larynx once LPR is diagnosed. Any break in therapy could allow harmful acidic secretions to slow the healing process.
How is LPR Different Than GERD?

Patient risk factor profiles differ greatly from LPR patients and those with GERD. For example, obesity is not associated with isolated LPR. However, obesity has a strong association with GERD. Patient complaints also differ for LPR and GERD patients. One landmark study demonstrated that 100% of otolaryngology patients with reflux complained of hoarseness, but only six percent reported heartburn. Most often, LPR indicators are related to the vocal cords. A dry, irritated cough seems to be the most troubling in LPR patients, while it is less common among GERD patients. Also, the symptoms in GERD tend to be worse at nighttime or early in the morning, while LPR symptoms are equally distributed morning and night.
How Do I Know if I Have LPR?

The most common symptoms of LPR include hoarseness, the feeling of having a lump in the throat, throat clearing, difficulty swallowing (dysphagia), chronic cough, and spasm of the vocal cords. Since these symptoms can be confused with allergies or chronic sinus infections, LPR can remain misdiagnosed for years. It is not uncommon for some patients to have symptoms for more than 10 years -- believing the symptoms are related to allergies or some other problem.
But I Don't Have Heartburn.

Many people with LPR dont have symptoms of heartburn, which is why LPR is often called the silent heartburn. Compared to the esophagus, the larynx (voice box) is significantly more sensitive to the effects
Is LPR Dangerous?
In the short term, LPR can have complications of acid going down the wrong way into the windpipe called
Other medications that also can help resolve LPR symptoms include acid blockers (Zantac), mucosal protectants (Carafate), and prokinetic agents (Reglan).
Do Dietary Changes Help Reduce LPR?

In short, yes. While GERD has definite associations with dietary intake causing relaxation of the lower esophageal sphincter (alcohol, peppermint, chocolate, caffeine); LPR may not improve as dramatically. Nevertheless, changes such as not laying down within two hours of dinner, losing weight, elevating the headof-the-bed, and avoiding certain foods can help.
What if Medication Does Not Relieve My Symptoms?

If symptoms relapse after prolonged medical therapy, some patients may be candidates for surgical correction of the esophageal-stomach junction. In these patients, the lower esophageal sphincter inappropriately relaxes allowing acid to not only enter the esophagus, but also travel up into the larynx. A tightening procedure of this area, called Nissen Fundoplication, can provide permanent relief of symptoms. Excellent results have been reported in 85 to 95 percent of reflux cases. In other patients who fail medical therapy, close evaluation is necessary to re-think the original diagnosis and rule out other possible conditions such as chronic sinusitis, chronic allergy/asthma, neuropathic cough, and pulmonary conditions that could be irritating the lungs. Diagnosing LPR is now in the forefront of most physicians minds. Simple attention to symptoms such as cough, vocal irritation, and fullness in the throat, combined with accurate diagnosis and effective treatment can minimize the fire burning within. -Nadim Bikhazi, MD
aspiration. Long-term complications can include: laryngeal inflammatory damage, scarring with obstruction of breathing and even laryngeal cancer. Cancer develops through the effect of continuing inflammation on the laryngeal tissue causing mutations and abnormal cell generation. Early diagnosis and treatment of LPR can prevent these sequellae from developing. LPR has also been associated with sinus infections as a contributing factor.
How is LPR Diagnosed?

Its best to have an Otolaryngologist (ENT physician) diagnose LPR because it is difficult to get a good look of the vocal cords without a flexible nasal scope used in an in-office procedure. This way, findings such as redness behind the vocal cords, swelling, and inflammatory tissue can be detected. Many times, a normal voice box is seen and the findings can be subtle. If this case, the physician may perform a more reliable diagnostic test involving a 24 hr pH probe (a small probe placed in the nose). This test can provide a great deal of information regarding the number of reflux events and the severity of acid contacting the vocal cords.
My Physician Tells Me I May LPR, Now What?

Once diagnosed, LPR can be a very challenging disorder to treat, partly because it has gone undiagnosed and untreated for many months/ years. During this time damage has been caused to the delicate lining of the larynx. As a result, higher doses of proton pump inihibitors (PPIs) may be required to reduce acidity of acid secretions 24 hours/day. Often, twice-a-day dosing is initiated for 3 months with hopes to slow down the treatment as time goes on. Because of the prolonged need of PPI (more than several months), caution needs to be exercised because long term use creates the possibility of osteoporosis.
HealthWatchMD
with Dr. Randy Martin
Provided courtesy of Piedmont Healthcare
Avoiding your Colonoscopy?

"Don't!" says former Falcons quarterback and colorectal cancer survivor.
Dr. Randy Martin: I recently sat down with former Atlanta Falcons quarterback Steve Bartkowski to discuss his battle against colon cancer. Read on to learn more about his journey, why he says his football background helped him fight cancer and the advice he gives to everyone regarding early detection.
teve Bartkowski has had many successes in his life. He was a consensus AllAmerican during his senior season at the University of California at Berkeley and was the first overall pick in the 1975 Draft. He later became one of only eight quarterbacks in history to have 30-touchdown passing seasons consecutively. But, as he will tell you, the best victory he ever won was in his battle with cancer. In June 2005, then 53-year-old Bartkowski was at a backyard barbeque when a friend mentioned he didnt look well. Bartkowski explained that he had not been himself lately and that he had noticed some blood in his stool. His friend immediately introduced him to Piedmont Hospital gastroenterologist Dr. Booker H. Dalton, Jr., who was also a guest at the party. They agreed that Bartkowski would come in first thing Monday morning for a colonoscopy. After undergoing a colonoscopy, Bartkowski remembers waking up and knowing something was wrong. I said, Booker, you found something, didnt you? he explains. Booker said, Yes sir, I did, and its something we need to jump on right away. He immediately sent me to Jay Singh, a colorectal surgeon [at Piedmont Hospital]. Dr. Singh shrunk and resected the tumor in November 2005 and Bartkowski went through chemotherapy and radiation treatments. Ive been clean as a whistle ever since, he says.
When Bartkowski was first diagnosed, the cancer was stage II and the tumor was too large to operate on, so doctors put him in concurrent chemotherapy and radiation treatments to target and kill the cancer cells and shrink the tumor. I had a little bit of a tough time the first two weeks into [chemotherapy], Bartkowski says. But after that, the four pills in the morning and four pills at night got to be a fairly simple routine. [The treatment] didnt really upset my stomach more than just the first week in, and it was just a godsend. He admits that the radiation treatment was tougher to take than chemotherapy. I did it five mornings a week for about six weeks, he explains. But it was a necessary hill that I had to climb and I certainly was happy to do whatever I could to ensure I would get through it. He credits his football experience for helping him through his fight against cancer.
I think we [as men] are all goaloriented, Bartkowski says. Guys are just like that. You need something you can plug into. When there is a well-defined goal at the end of the dayI think we have that collective, internal commitment to it. Prevention is crucial and Bartkowski is committed to spreading this message. Diet is a big [part of cancer prevention], he says. Certainly exercise, which we all know we need. Early detection is the key to beat this dreaded disease. Pay attention to what your body is telling you. If you have a history of [colon cancer], start [colonoscopies] at 40. If there is no history, 50 should be that magical date. [My tumor] would have been a polyp at age 50. A polyp is a benign growth on the colon or rectum wall. A polyp can become a cancerous tumor. As a preventative measure, they may be removed and tested to determine if they are cancerous.
Dr. Randy Martin: Steve shares a great message and I thank him for taking time to tell his story. As he notes, prevention and early detection is crucial, so talk with your doctor about any symptoms or concerns you have it may just save your life.
Early Detection Saves Lives

Bartkowski was 53 when he was diagnosed with colon cancer, but had never had a colonoscopy. Experts recommend that people begin colon cancer screenings at age 50, or age 40 if they have a family history. I knew I needed one and knew I was a couple years overdue, but you know how it is, he says. As guys, we just think that sort of thing happens to other people.
Hernias
W
hat is a hiatal hernia?
Any time an internal body part pushes beyond a confining wall into an area where it doesn't belong, it is called a hernia. The hiatus is an opening in the diaphragm -- the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus (food pipe) goes through the hiatus to drain into the stomach. In a hiatal hernia (also called hiatus hernia) the stomach bulges up into the chest through that opening.
Let's Talk
Hiatal Hernia (Also Called 'Paraesophageal Hernia', 'Sliding Hernia')

Who is at risk for hiatal hernia?
Hiatal hernias occur more often in people over the age of 50, in overweight people (especially women), and in smokers.
What are the symptoms of a hiatal hernia?

Many people do not experience any symptoms related to their hiatal hernia. When symptoms occur, they may be related to gastroesophageal reflux and include heartburn, bitter or sour taste in the back of the throat, bloating and belching, or discomfort or pain in the stomach or esophagus. Some people with a hiatal hernia may experience chest pain that can easily be confused with the pain of a heart attack. It's important to undergo testing to be properly diagnosed and treated. If you have been diagnosed with a hiatal hernia, and you have nausea or vomiting; or you are unable to have a bowel movement or pass gas, you may have a strangulated hernia or an obstruction. These are medical emergencies and you should call your doctor immediately.
There are two main types of hiatal hernias: A sliding hiatal hernia, the junction of the stomach and the esophagus herniate (slide) up into the chest through the hiatus. This is the most common type of hiatal hernia. A Paraesophageal hernia is less common, but is more cause for concern. A larger part of the exophagus and stomach squeeze through the hiatus with a Paraesophageal hernia. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become "strangled," which means its blood supply is cut off.
Often, people with a hiatal hernia also have heartburn or gastroesophageal reflux disease (GERD). Although there is a link, one condition does not necessarily cause the other, because some people can have a hiatal hernia without having GERD, and vice versa.
How is a hiatal hernia diagnosed?

A hiatal hernia can be diagnosed with a barium study, a special X-ray that allows visualization of the esophagus, or with esophagoscopy, a procedure in which the upper digestive system is examined with an endoscope (long-thin flexible instrument).
What causes a hiatal hernia?

In most patients, the cause is not known, but a hiatal hernia is usually the result of many factors. Some people develop a hiatal hernia after sustaining an injury to that area of the body; others are born with a weakness or an especially large hiatus. Some experts suspect that increased pressure in the abdomen from coughing, straining during bowel movements, pregnancy and delivery, or substantial weight gain may contribute to the development of a hiatal hernia.
How are hiatal hernias treated?

Many people do not experience any symptoms related to their hiatal hernia, so no treatment is necessary. When mild symptoms occur -- such as heartburn, bloating or stomach discomfort -- a hiatal
hernia may be successfully treated by making these lifestyle changes:
Losing weight if you are overweight, and maintaining a healthy weight Having a common sense approach to eating, such as eating moderate to small portions of foods; and limiting fatty foods, acidic foods (such as tomatoes and citrus fruits or juices), foods containing caffeine, and alcoholic beverages Eating meals at least 3-4 hours before lying down, and avoiding bedtime snacks Elevating the head of your bed by 6 inches (this helps allow gravity to keep the stomach's contents in the stomach) Not smoking Taking medications, such as over-the-counter antacids, Gaviscon, or H2 blockers (such as Pepcid AC or Zantac). If you take over-thecounter medications for longer than two weeks without any improvement, see your physician. Your physician may prescribe a stronger medication to manage your symptoms.
If the hiatal hernia is complicated by severe symptoms of GERD or if the symptoms and tests suggest that a paraesophageal hernia (part of the stomach squeezes through the hiatus) may be present, surgery may be recommended.
When is surgery necessary?

Surgery is indicated in patients with a symptomatic hiatal hernia that is present along with these conditions:
Gastroesophageal reflux or GERD symptoms include heartburn, regurgitation, dysphagia (difficulty swallowing) that has not been successfully treated with medications Strangulated hernia or obstruction symptoms include abdominal pain, chest pain, early satiety (filling up fast), pain with eating, nausea or vomiting, or inability to have a bowel movement or pass gas.
Hiatal hernia surgery can sometimes be performed with a laparoscopic approach, which is a less-invasive procedure with a faster recovery than traditional hiatal hernia surgery. After the surgery, there is no guarantee that the hernia will not return, but avoiding abdominal stressors such as heavy lifting and straining, and minimizing weight gain, will reduce the risk of recurrence. -This information provided courtesy of Cleveland Clinic.
You Want To
Do What?
ll joking aside, prostate cancer is the most commonly diagnosed cancer in men, and second only to lung cancer in the number of cancer deaths. In 2007 (the most recent year for which statistics are available), 223,307 men were diagnosed with prostate cancer, and 29,093 men died from it.* The CDC provides men, doctors, and policymakers with the latest information about prostate cancer.
Cancer is a disease in which abnormal cells in the body grow out of control. When cancer starts in the prostate, it is called prostate cancer. The prostate is a walnut-sized organ located just below the bladder and in front of the rectum in men. It produces fluid that makes up a part of semen.
Symptoms
Different people have different symptoms for prostate cancer. Some men do not have symptoms at all. Some symptoms of prostate cancer are
Difficulty in starting urination. Weak or interrupted flow of urine. Frequent urination, especially at night. Difficulty in emptying the bladder completely. Pain or burning during urination. Blood in the urine or semen. Pain in the back, hips, or pelvis that doesn't go away. Painful ejaculation.
If you have any symptoms that worry you, be sure to see your doctor right away. These symptoms may be caused by conditions other than prostate cancer.
screening. CDC supports informed decision making, which encourages men to talk with their doctors to learn the nature and risk of prostate cancer, understand the benefits and risks of the screening tests, and make decisions consistent with their preferences and values. Tests that are commonly used to screen for prostate cancer are
Risk Factors
There is no way to know for sure if you will get prostate cancer. Men have a greater chance of getting prostate cancer if they are 50 years old or older, are African-American, or have a father, brother, or son who has had prostate cancer.
Screening for Prostate Cancer

Not all medical experts agree that screening for prostate cancer will save lives. Currently, there is not enough credible evidence to decide if the potential benefit of prostate cancer screening outweighs the potential risks. The potential benefit of prostate cancer screening is early detection of cancer, which may make treatment more effective. Potential risks include false positive test results (the test says you have cancer when you do not), treatment of prostate cancers that may never affect your health, and mild to serious side effects from treatment of prostate cancer. Most organizations recommend that men discuss with their doctors the benefits and risks of prostate cancer
Digital rectal exam (DRE): A doctor, nurse, or other health care professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Prostate specific antigen test (PSA): PSA is a substance made by the prostate. The PSA test measures the level of PSA in the blood, which may be higher in men who have prostate cancer. However, other conditions such as an enlarged prostate, prostate infections, and certain medical procedures also may increase PSA levels.
Is prostate cancer screening right for you? The decision is yours. To help men aged 50 years or older understand both sides of the issue, CDC has developed several helpful guides to assist you with making an informed decision. Visit cdc.gov/Features/ ProstateCancer/ to find downloadable guides and fact sheets. -This information provided courtesy of the Centers for Disease Control and Prevention.
* Data source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 19992007 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2010. Available at: http://www.cdc.gov/uscs
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Prescription Drugs
That Shot Medical Education.

Gun
Societys Loaded
octors dont listen. Patients dont understand. The Reality? Both statements are true and reversible. Maybe thats the reason more than 100,000 people die every year in the United States from prescription drug errors, while only about 600 die from accidental gun shootings, and nearly 34,000 die from traffic accidents.
(an essential part of Parkinson's treatment) and serotonin (used in the treatment of depression). At normal blood levels, they are good medicines. If the blood levels get too high, they can cause serotonin syndrome and spiral into potentially fatal NMS (neuroleptic malignant syndrome). These are sound and safe medications, but when they interact with other medications -- including 160 of the top 200 prescribed medications in the country -- the result can be NMS, and death. The goal then, is to avoid these drug interactions -- a hefty goal considering there are 160 drugs to avoid. MAOIs are eliminated mainly by the liver. It turns out 160 of the top 200 drugs can block or delay the reaction. Major precipitating classes of drugs include the proton pump inhibitors (reflux meds), the tricyclics (depression, chronic pain, IBS), stimulants, and recreational drugs such as cocaine. MAOIs became infamous 29 years ago and were the epicenter of a very controversial medical malpractice case that started in 1983 and ended in 1995.
Why the concern?

We are seeing the reintroduction of a class of drugs used to treat Parkinsons disease and depression. These drugs are called Monoamine Oxidase Inhibitors (MAOIs). On the surface, these drugs pose little or no problem. But 30 years ago, an MAOI was at the center of a legal case that changed the course of medical education. Before discussing the case and its affect on the medical world, its important to give a little background on how this class of drugs works. Monoamines are chemicals derived from the essential amino acid tryptophan, which is converted by enzyme into serotonin or dopamine. Monoamine oxidases are enzymes in the nervous system functioning to break down dopamine and serotonin. As the name implies, MAOIs inhibit the breakdown enzyme, thereby increasing nervous system levels of dopamine,
The sad, but not isolated, case of Libby Zion

In 1983, an 18 year-old female patient was taking a medication called phenelzine, which is a MAOI.
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The patient was admitted to the hospital and given Demerol, which in combination with phenelzine can result in NMS. In the case of Libby Zion, it proved fatal. Nobody knew at the time that Libby was using cocaine along with the phenelzine and the combination played a major role in her fate. More importantly, the patient and her family failed to tell the physicians about the cocaine or the MAOI. Her drug use was never mentioned in the 12-year plus media trial. The case was popular discussion at the time, even without all of the facts. Unfortunately, it went on to impact medical training beginning well before the trial started and before all the facts surfaced. The basis of the legal case was that the intern in the Zion case was overworked and overtired, directly leading to the death of the patient. The media trial made much of the overworked intern and caused a complete restructuring of the medical training system in the United States. The case served to indict the entire structure of medical residency training based on the failure of a residents ability to pick up a drug reaction that 85 percent of wide-awake doctors wouldnt catch. Picking up on adverse drug reactions requires knowledge of the medication being started (in this case Demerol) and knowledge of any drugs in the patients system. The family didnt win the lawsuit because of their failure to inform the attending physicians about the cocaine. Cocaine can cause NMS through its own action in the nervous system, but it also can increase the effect of MAOIs. Libby Zions death was probably the result of NMS. However, without more information, malignant hyperthermia cant be ruled out, given the mixture of medications and her seizure-like symtoms including a fever of 107. In either case, the medical team was wrong to treat with Demerol. Demerol is contraindicated in NMS, but is recommended for malignant hyperthermia. Even without the Demerol, this young lady might have died from what was in her system. Recommended treatment for her symptoms would be a benzodiazepine like Valium, which would be indicated in the treatment of NMS. A 1999 study (four years after the trial) showed that 85 percent of physicians were unaware of this possible drug interaction.
or every third night depending upon the rotation, starting at 8:00 in the morning and going to 8:00 the next morning. We didnt go home at 8:00 in the morning to sleep because we were expected to stay until about 5 or 6:00 in the evening. We would sign out to the on call resident the following evening before going home to sleep for 12 hours, before doing another 36-hour stretch. The joke at the time was: "Whats wrong with being on call every other night" the answer was " you miss half of the interesting cases". The down side was we interns were tired much of the time. The up side was we weren't really making lifeand-death decisions. Every night, on call, there was a junior resident, a senior resident and an attending physician. They were not in the same sleep deprived rotation as us. We were intimately involved in the care process and were learning massive amounts through experience. The junior and senior residents were better rested, overseeing all of the decision making process with final oversight from the attending physician. The end of the internship year was historically a celebratory time, because it meant that life would be considerably easier for the next two years. Those next two years were a time to oversee the new interns and to consolidate knowledge base, interacting with the care team -- particularly the professors from different specialties on the various rotations. This all started to come unraveled at the end of my internship year because of the Libby Zion case publicity. My second year as a junior admitting resident went from being a celebration of some slight improvement in quality of life to a surreal sentencing. Since there was no money and no mechanism to add residents, the answer to the problem of the internship overwork was to make life hell for second year residents by taking up much of the workload for the interns so they would be sufficiently rested. Their call was slashed dramatically and placed on our shoulders, and we did it fairly quietly. The unfairness became quickly apparent near the end of our second year, when it was decided it really wasn't fair for third year residents to not share the load, leaving all the work for the poor second year residents. This resulted in another realignment of the workload just in time for our third year, so we were able to assume much of the workload for the second year residents. Rather than be appreciative, and consistent with human nature, the new first and second year residents were jubilant and mocking about the rolling tsunami of misfortune my poor group suffered. I was excited to start my Fellowship in Gastroenterology because my quality of life was finally going to change. Unfortunately, the other first year Fellow came down with an autoimmune illness, which meant I had to be on call every day for 365 continuous days. I didnt see
The Past
There is a Chinese expression: "in pursuit of perfection man often ruins that which if left alone would suffice ". Doctors trained at or around the same time as I, went through medical school about 30 years ago, started residency about 25 years ago and their practices between 20 and 22 years ago. We were actually in training during the transition of this case. What I mean by the transition is this. When I began my internship in Internal Medicine, the internship year was extremely difficult. On call was every other night
my first daughter until a few days after her birth. I have read the book "The House of God" and my only response is that he had nothing to complain about. Those of us riding the wave of misfortune probably set the world record for being on call during medical training. Ultimately, we received better training because of the time we spent in the hospital taking care of patients. My question is, who is the loser in this cascade of events? Not the heavily burdened residents of my time.
I would say the loser is every intern that had an easier path through training and the patients in their care.
Outcomes Medicine
Another interesting phenomenon developing in the same place at the same time was a medical practice called Outcomes Medicine. In my opinion, Outcomes Medicine has damaged medical education. My training institution was pioneering the field while these other changes were happening and it became
a bizarre act being carried out in front of us. This was the result of the well-intended effort of trying to eliminate anecdotal medical training and replace it with statistical analysis of outcomes, culminating in the announcement of an outcome service. The service would be taking call and would be available to help us with difficult decision making. We residents found this comical, especially when put into practice. We would purposely call the "outcomes expert" in the middle of the night with difficult
medical management questions. We would spend 20-30 minutes on the phone giving all of the facts to the expert, usually on a conference call with the other residents listening and biting their tongues while we were told they would have an answer for us in 48-72 hours. We would hang up the phone and look at each other in disbelief. Everybody knew difficult decision-making occurs on-thefly, in life-and-death situations with the apparent exception of the head of the medicine department
and his new minion (known to us affectionately as flying monkeys). Nobody doubted that outcomes assessment would play a valuable role as a part of the armament in medical practice. The problem we had, and still have, is the attempt to make it the essence of medical practice rather than a small tool. The result is a dependency on cookbook medicine. Outcomes did take hold and began to replace in-depth knowledge of genetics, embryology, cellular biology and biochemistry along with physiology, anatomy and pharmacology. When we were in training there was an exhaustive consolidation of everything we had learned. The basic sciences and medicine were being applied in a setting of living human patients, explained by academic specialists who spent most of their time educating residents. This conflicted at the same time with another growing social phenomenon started in 1990 with the election of Bill Clinton to the presidency and concern that his wife was going to socialize medicine, leading to the advent of forprofit medicine which further disrupted medical education. As medical centers became business models, simply educating was no longer considered a viable business position. These erudite professors with their accumulated knowledge were expected to begin seeing patients and begin performing procedures at a much higher rate to pay their own salaries and generate income in this new for profit business model.
complications and I do not see an improved knowledge base in most physicians practicing today. It is my opinion, and the opinion of older physicians, and frankly the opinion of most nurses and most patients, the current situation is not an improvement over the past. We have two possible choices. The first is to ignore the facts and proceed forward with the current learning model, or to take a step backward. There is simply no way to teach the same amount in one-third of the time. Because of this time problem, shortcuts have developed and we need to re-explore the question of how do we step back to a more difficult learning model. In other words, once tremendous liberties have been granted it is very difficult to take them back. My suggestion would be to simply acknowledge bad things happen. Not everyone in the world taking care of patients should be doing so. In the hands of most doctors, and without the knowledge of the cocaine use, Libby Zion would have died in a great many different medical centers around the country or around the world. Most importantly, would she be more likely to die in the hospital today because of the changes, or more than 20 years ago before the changes? Patients die from medication errors, most of them however, do not have a father who is an attorney and writes for the New York Times. I dont mean to diminish the grief of the family, but I have to ask if redirection of medical training provoked by the combination of the Zion case along with the advent of outcomes medicine and the need for forprofit medicine has not brought us in the search for improvement to an actual degradation of medical education. If we fail to ask these difficult questions because of political sensitivities we are doomed to forever " throw the baby out with the bath water". I often open an article with some lame joke, but because of the seriousness of the subject, I will close with a joke instead. A young gastroenterologist has just finished his training and is coming to join his fathers practice. After all the arrangements have been made, the young doctor says to his father: "Dad we really haven't talked about the call situation." The father responds, "I have given this considerable thought and I think that the only fair way to do it is to split the call 50-50." The son replies, "I'm so glad to hear that you have such a reasonable attitude about it." The father smiles and says, "The way I see it, I have been on call for the last 25 years, why don't you take the next 25? That joke wasnt great so I will add one more; we Cajuns would call it lagniappe (a little something extra). Whats wrong with never being on call? Of course there is no punch line. It hasnt been written yet. -Steve Porter, MD
The Present
We have now arrived at a point in which we see young doctors in training being treated like interns in any other business doing basically shiftwork. Meaning if they are on call at night, they're sleeping the next day. They're still doing the same number of years in training, but present in the hospital only about one third of the time expected in the past. Medical education is now leaning heavily towards outcomes assessment, instead of an intertwined deeper knowledge of disease processes. Doctors currently training are not expected to understand the biochemistry or physiology as much as to remember the list of what diagnosis goes with what symptoms. Anyone can see the downside in that it takes away the ability to reason through a problem rather than relying on the regurgitation of information. Couple these with the disappearance of the academic instructors from the hospital floor, putting them into the clinic or procedure room and replacing them with a young hospitalist hired to carry out the teaching role without specialty insight. In an assessment of the present situation I would also point out that I spend much of my time with patients going through their list of medications and making changes because of contraindications that although perhaps not as immediately lethal as in the Zion case, they certainly can have major
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Celebrating
St. Jude Children's Research HospitalChanging Childhood Cancer Treatment
50 Years
t. Jude Childrens Research Hospital is celebrating its 50th anniversary this year. But it was more than 20 years before that when Danny Thomas put faith in his faith and faith in people and made the commitment to build St. Jude. The journey to build one of the most recognized childrens research hospitals in the world today, was far from easy. As a struggling young actor with a baby on the way, Thomas sat in a Detroit church and donated the last $7 he had on him at the time. Realizing what he had done, remorse hit him. His last $7. Left with nothing but prayer, Thomas reached out to the deity for help in paying hospital bills. The next day, he landed a small part paying him 10 times what he had donated the day before. Having achieved moderate success in the next two years, Thomas wanted to reach the next level. Again he turned to his church, but this time he made a commitment. Praying to St. Jude Thaddeus, the patron saint of hopeless causes, Thomas asked for help. Help me find my way and I will build you a shrine. St. Jude must have been listening. Thomas career blossomed. He moved his family to Chicago and at another turning point in his life;
he once again visited a church remembering his pledge to St. Jude. He repeated his pledge to build a shrine, but asked for guidance. In the years that followed, Thomas career flourished in television and film. All the while he never forgot his pledge to St. Jude. At the pinnacle of his success, Thomas knew it was time to make good on his pledge
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Research Hospital. Today, ALSAC is one of the nations largest health-care charities and is supported by more than one million volunteers nationwide. With funding and organization firmly in place, in 1962, St. Jude Childrens Research Hospital opened its doors. There was fanfare and there was debate about how to treat childhood cancer. In those days, few children with the most common form of childhood cancer survived. It didnt help that most physicians believed treatment was futile. Following the Danny Thomas lead to put faith in people, St. Jude physicians and researchers took a radically different approach to treatment. These efforts proved pivotal in changing the way the world treats childhood cancer today. St. Jude is recognized for playing a significant role in improving overall survival rates for childhood cancer, which have increased from a lowly 20 percent in 1962 to a much more impressive 80 percent today. Recognizing the St. Jude impact on childhood cancer treatment, Tennessee Gov. Bill Haslam declared February St. Jude Month in the state of Tennessee. In the nearly four decades Ive been at St. Jude, Ive had the privilege of watching the organization grow from one star-shaped building to a sprawling campus of about 2.5 million square feet of research, clinical and administrative space, said Dr. William E. Evans, St. Jude director and CEO. When I started, there were a few hundred people on staff. Now we have more than 3,700 employees. Driven by our patients, and thanks to our employees, our colleagues at ALSAC and the public support they generate, St. Jude will only continue to grow and flourish in the years to come. The history of St. Jude is marked with milestones in the treatment of pediatric cancer and other childhood illnesses. In 1971, St. Jude investigators showed the combination of chemotherapy and radiation cured at least half of all children with acute lymphoblastic leukemia (ALL). The most common
to St. Jude. After consulting with friends, the idea of a childrens hospital in Memphis, Tennessee began to evolve. In the 1950s, Thomas started fund raising efforts for the hospital. By 1955, local business leaders who had joined his cause began fundraising efforts to help. Meanwhile, Thomas was crisscrossing the country going to benefits and meetings raising money for his dream. Scores of stars came to Memphis to perform and help the fundraising efforts. By this time, a milestone had been reached but another problem had been created. How do you fund the yearly operation of a research hospital? Thomas put his faith in people. Being of Lebanese decent, Thomas turned to other Americans of Arabic heritage. He felt these Americans should thank the United States for the freedom it gave this groups parents. Supporting St. Jude, he thought, would be a good way to honor his immigrant forefathers who had come to America. The Arabic community agreed with Thomas. In 1957, 100 representatives of the Arab-American community met in Chicago to form ALSAC with the sole purpose of raising funds for the support of St. Jude Childrens
form of childhood cancer, ALL, was previously considered almost universally fatal. Today, St. Jude patients with ALL have a 94 percent survival rate. In 1984, a St. Jude patient with sickle cell disease was the first to be cured with a bone marrow transplant. St. Jude is currently engaged in the largest effort in the world to do whole genome sequencing of pediatric cancer tumors. The St. Jude Childrens Research Hospital Washington University Pediatric Cancer Genome Project collaboration has already produced significant new findings related to aggressive forms of pediatric leukemia, eye tumors and brain tumors. St. Jude has a legacy of taking on the toughest of pediatric cancer questions, and that focus wont change, said James R. Downing, M.D., scientific director and deputy director at St. Jude. Were uniquely positioned as an institution to move research and treatment ahead. From the genetic data we collect from the genome project, were creating the foundation of knowledge to deliver the next decades childhood cancer discoveries and treatments.
Throughout its five decades, St. Jude research has included work in cancer biology and genomics, pharmacogenomics, gene therapy, bone marrow transplant, drug discovery, radiation treatment, blood diseases and infectious diseases, integrated into a long series of innovative clinical trials. According to Joseph Laver, M.D., St. Jude clinical director, the unsurpassed family-centered care that is provided at St. Jude stems from the multidisciplinary team approach that has been a hallmark of St. Jude since the doors opened in 1962. Looking toward the future, St. Jude is a national resource with a global mission and will continue to enhance its leadership as a resource for children with cancer and other catastrophic diseases, Evans said. Even though weve grown significantly, our mission has never wavered. Weve created a collaborative culture whose team members demonstrate unceasing compassion for our patients and families, innovation in our treatment and research, and quality in everything we do.
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1986
St. Jude Childrens Research Hospital has always combined pioneering treatments with compassionate care for patients. From the first 126 children treated at St. Jude in 1962 to the 7,800 patients currently seen each year, St. Jude truly provides world-class care for families. Thanks to the support of donors, no family ever pays St. Jude for anything. We cover all costs of treatment as well as transportation, lodging and food. Dr. Ching-Hon Pui, chair of the Department of Oncology at St. Jude, is pictured here with St. Jude patients past and present. Dr. Pui, who joined the hospital in 1977, won the 2011 Henry M. Stratton Medal from the American Society of Hematology (ASH) in recognition of the progress he has made in the fight against leukemia during the past three decades.
2010
Memphis Grizzlies center Marc Gasol hosts a tea party with St. Jude patients Ellen and Jakayla, on his most recent visit to the Memphis Grizzlies House at St. Jude. He was helping raise awareness of the Hoops For St. Jude Week, a fundraising event in partnership with the NBA.
MEMPHIS GRIZZLIES HOUSE HELPING MAKE THE ST. JUDE STAY A LITTLE EASIER
Life is difficult enough for a parent when youre told your child has cancer. Being told the best treatment is miles away, just adds more to the burden. Where to stay, how much is it going to cost and what do I need to bring? Thanks to the Memphis Grizzlies, parents whose children are being treated at St. Jude Childrens Research Hospital have one less worry. The first step in a commitment to help the children of St. Jude was a $5 million contribution to a $10 million state of the art oncampus housing facility for child and family. The second step was for the Memphis Grizzlies to partner with the NBA for an on-going awareness program for St. Jude and all it does in the fight against childhood cancer. Furnished with the essentials the on-campus facility also features a fitness room, secured parking, laundry facilities, a playground and of course, an outside half-court basketball facility for those future stars to hone their NBA games. Just as St. Jude never charges patients for treatment, the Memphis Grizzlies House is free of charge for the children and parents. Stays are limited to short term one to seven days. The Memphis Grizzlies House was designed by The Renaissance Group from Memphis, Tennessee and is managed by Wilson Hotel Management Company, Inc., a division of Kemmons Wilson Companies. Chances are you wont see any of the Grizzlies in a pick-up game at the Grizzlies House, but you might find a player stopping by to host a tea party.
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St. Jude Dream Home Giveaway homes valued between $300,000 and $700,000
St. Jude Dream Home Giveaway

Supermodel and style expert Cindy Crawford partners with St. Jude Children's Research Hospital to give away 28 Dream Homes
Crawford Home), but she also lost her younger brother to acute lymphoblastic leukemia (ALL), the most common form of childhood cancer, when she was just nine years old. I know firsthand what its like to lose a family member to this terrible disease, which is why Im so committed to St. Judes mission, said Crawford. I just love the connection to what Im doing in my life right now with the home goods business that is all about creating a home for your family. The St. Jude Dream Home Giveaway gives families a wonderful opportunity to win their dream home while helping other families battling cancer at St. Jude. When Crawfords brother passed away, the survival rate for ALL was around 50 percent. Today, thanks to the pioneering research and care of St. Jude, the survival rate for ALL is 94 percent. No family ever pays St. Jude for anything. Seventy-five percent of the operating costs of St. Jude are covered by public donations like the money raised through the St. Jude Dream Home Giveaway. St. Jude is a home away from home for children and families during one of the most difficult times in their lives, said Richard Shadyac Jr., CEO of ALSAC/St. Jude Childrens Research Hospital. By purchasing a St. Jude Dream Home ticket, you can help St. Jude continue its commitment to providing the highest quality of care for kids battling deadly diseases like cancer while ensuring that no family ever pays St. Jude for anything. By purchasing a $100 ticket, participants are entered to win a newly-constructed home in their select market, while also helping support the lifesaving mission of St. Jude of finding cures and saving children. The St. Jude Dream Home Giveaway is one of the largest single-event fundraisers for St. Jude. The program has raised more than $224 million for the hospital and awarded 280 homes over the past 20 years. Ticket holders also have the opportunity to win other great highvalue prizes, including jewelry, electronics and furniture store gift certificates. This year, Shaw Floors, the worlds largest carpet manufacturer and a leading floor-covering provider, has partnered with St. Jude to provide flooring for each home. They join returning national sponsor Brizo, a premium faucet brand, as a national sponsor by donating product to all markets for the St. Jude Dream Home Giveaway. To find out if there is a St. Jude Dream Home Giveaway near you, visit www.dreamhome.org.
About St. Jude Childrens Research Hospital:

Since opening 50 years ago, St. Jude Childrens Research Hospital has changed the way the world treats childhood cancer and other lifethreatening diseases. No family ever pays St. Jude for the care their child receives and, for every child treated here, thousands more have been saved worldwide through St. Jude discoveries. The hospital has played a pivotal role in pushing U.S. pediatric cancer survival rates from 20 to 80 percent overall, and is the first and only National Cancer Institutedesignated Comprehensive Cancer Center devoted solely to children. It is also a leader in the research and treatment of blood disorders and infectious diseases in children. St. Jude was founded by the late entertainer Danny Thomas, who believed that no child should die in the dawn of life. Join that mission by visiting www. stjude.org or following us on facebook. com/stjude and twitter.com/stjude. -This information provided courtesy of St. Jude Children's Research Hospital.
upermodel and home goods style expert Cindy Crawford is partnering with St. Jude to help dozens of lucky people nationwide win a beautiful dream home and support the kids of St. Jude through the St. Jude Dream Home Giveaway. The program is personal for Crawford and combines her love of home design with her passion for St. Jude. Not only is she the mother of two children who has two successful home collections (Cindy Crawford Style and Cindy
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In 2006, Chilis partnered with St. Jude and announced plans to raise $50 million over a 10-year period, the largest single partner donation in the history of St. Jude. However, four years into the pledge, Chilis raised $30 million through its Create-A-Pepper campaign efforts. Chilis and St. Jude celebrated the opening of the Chilis Care Center in 2007. The newest building on the St. Jude campus stands seven stories high and covers 340,000 square feet. It houses the radiological sciences department, bone marrow transplant inpatient unit, and several new research labs.
The Community Believes in St. Jude

More than 50 years ago, Danny Thomas pursued his dream to cure childhood cancer. He spent countless hours driving across the country enlisting friends, business people and anyone else he could convince to join in his dream. He died in 1991, but his dream and his passion have been carried on by so many. Countless celebrities lend their talents, their names and their passion to further his cause. Without all this heart, the Danny Thomas dream would have died with him. But the torch has been passed and his quest continues to this day.
2011 FedEx St. Jude Classic winner Harrison Frazar
The FedEx St. Jude Classic has generated more than $25 million in donations for St. Jude beginning in 1970 with the Danny Thomas Memphis Classic. This years purse is $5.6 million with a $1,008,000 winners share.
Garlic
H
istorically, garlic goes by many names including nectar of the gods, rust treacle, stinking rose and poor mans treacle. It is a member of the lily family, which also includes hyacinths, tulips, onions and chives. According to recent studies published in the National Institutes of Health Library, garlic was thought to be helpful in lowering cholesterolbut a study last year concluded that it wasnt effective. Other proposed benefits of garlic include cancer prevention, circulation enhancement, improved immunity to fight illness, tick repellent and treatment of fungal and respiratory infections. Garlic may slightly alter blood pressure as it contains allicin, which can cause dilation of the blood vessels. Patients on 600 to 900 mg of garlic powder supplement a day (equal to one clove of garlic), may achieve a five-point drop in blood pressure. This would certainly be a modest benefit and garlic alone should not be relied upon for treatment of essential chronic hypertension. Patients taking garlic supplements should also watch for drug interactions and other possible adverse effects. It negatively interacts with warfarin, a common blood thinner, by enhancing the blood-thinning effect. It also affects aspirin and nonsteroidal anti- flammatory medications and should not be taken in capsule or tablet form prior to surgery. It also has the potential to alter the effectiveness of oral contraceptives and interacts with HIV medications. Adverse reactions to garlic may include anaphylaxis (a very severe hypersensitivity allergic reaction), runny nose, rapid swelling, allergic contact dermatitis, diarrhea, eczema, bloating and gas and gastrointestinal irritability. Its also unsafe to take in pill form during pregnancy because it may cause uterine contractions, and its unsafe to take while breastfeeding as well. However, its okay to eat garlic in food while pregnant and breastfeeding. Garlic supplements have a better chance of providing a therapeutic effect than fresh garlic because allicin is heat-sensitive and can be destroyed by high temperatures while cooking. Effective supplements should contain 4 to 5 mg of allicin. And of course, garlic tastes great in food and may have a benefit on your cardiovascular wellbeing. Bon appetit! -Vicki Lyons, MD
Acetaminophen:
Are You Taking Too Much?
hen you have a headache or other pain, the first thing you might do is reach for the pain reliever in your medicine cabinet. This medicine may have an ingredient called acetaminophen. Do you know what it is? Could you be putting yourself at risk by taking too much? Acetaminophen is the generic name of a popular pain killer found in many over-the-counter (OTC) medicines like Tylenol, Theraflu, and NyQuil. Its also in prescription pain medicines; two common ones are Vicodin (acetaminophen and hydrocodone) and Percocet (acetaminophen and oxycodone). Acetaminophen can have harmful side effects in high doses. How aware is the public of these side effects? In a 2007 study published in the Journal of American Pharmacists, researchers found that out of 104 respondents, 80% said that they had used acetaminophen. The majority of these people werent sure if they had received information about the risks of taking high doses. Also, they did not know what would be considered a high dose for regular- or extra-strength products. In June 2009, an advisory committee for the US Food and Drug Administration (FDA) decided to update acetaminophens warning label. This updated label lets the public know that taking more than the maximum dose can cause serious liver damage.
High doses of acetaminophen can be toxic and may cause liver damage, the need for liver transplant, and even death. In a study cited by the FDA, 94 patients were hospitalized in Atlanta for acute liver failure over a five-year period. Sixty-five patients (49 adults, 16 children) agreed to be part of the study. Among the adults, 41% of the cases were due to acetaminophen overdose (either accidental or intentional). When these statistics are applied to the US population, an estimated 1,600 cases of acute liver failure could occur each year640 of these cases related to acetaminophen.
Changes in the Liver

The FDA also focused on acetaminophens ability to cause changes in liver function tests. In one study, 145 healthy patients were divided into five groups: placebo (sugar pill), acetaminophen, Percocet, Vicodin, and morphine. After two weeks of taking 4 grams of acetaminophen, about 30%-40% of the participants receiving acetaminophen in the treatment groups showed increased levels in their ALT tests (blood test that detects liver disease). These levels returned to normal after the patients stopped taking acetaminophen. The study shows that even taking the maximum dose (not an overdose) can affect liver cells. If acetaminophen can change liver function tests in healthy people, what happens to those who already have liver damage?
People at Higher Risk Alcohol Use

Drinking too much alcohol can damage the liver over time. This damage can affect the way the liver processes acetaminophen. Individuals who have more than three alcoholic drinks a day should talk to their doctor before taking acetaminophen.
On the Label: Getting the Message Across Liver Damage

The liver is vulnerable to harm because it is the organ that processes toxic substances. When the liver is damaged by an overload of toxins, a person may have early signs of acute liver failure, like yellowing of the skin and eyes (called jaundice), nausea, and vomiting. These symptoms can quickly worsen, leading to liver failure and death.
Liver Disease
Liver disease refers to a range of conditions that affect the liver, such as cirrhosis, hepatitis A, hepatitis B, and hepatitis C. Studies show that people with liver disease metabolize acetaminophen differently than healthy people.
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In the case of cirrhosis, the liver becomes scarred, which hinders its ability to detoxify harmful substances. Since people with liver disease are at a higher risk for harmful side effects (even with the recommended dose), they should talk to their doctor before taking acetaminophen.
Warfarin Therapy
Beyond the dangers of liver damage, acetaminophen may also increase the risk of bleeding if mixed with other medicines. Warfarin (eg, Coumadin) is a commonly prescribed drug used to prevent dangerous blood clot formation. Acetaminophen may increase the bloodthinning effect of warfarin, placing people at a higher risk for severe bleeding. In a study published in the journal Pharmacotherapy, 36 people on warfarin were randomly assigned to three groups (placebo, 2 grams of acetaminophen, or 4 grams of acetaminophen). Compared to the placebo group, the people who took acetaminophen had modest increases in their international normalized ratio, or INR (a test the measures how the blood clots). Higher numbers mean that the blood is thin and will take longer to clot, which puts people at an increased risk for bleeding. Because of this, those on warfarin therapy should talk to their doctor before taking acetaminophen.
Follow the dosage directions carefully. Each product may have a different maximum daily dose. Even if you are not getting relief from the medicine, avoid taking more than the recommended dose. Talk to your doctor. Take special care when giving medicine to your child. Closely follow the directions on the label. The dose will be based on your childs age and weight. Be sure to use the measuring tool that comes with the medicine. Dont use a kitchen spoon, because this could cause you to give a higher dose. Also, keep a record of when you gave your child the dose and how much you gave. Note: Cough and cold medicine is not recommended for children aged four years or under.
If you or your child take too much acetaminophen, call 911 or the Poison Control Center (1-800-222-1222) right away. The early signs of acute liver failure (eg, nausea, vomiting) can be mistaken for another illness. Get help if you or your child has these signs. Remember to talk to your doctor before taking acetaminophen if you:
What These Warnings Mean for You

The main goal behind these label changes is to make you more aware of how much acetaminophen you are taking and which conditions put you at a higher risk for liver damage. There are ways that you can safely take acetaminophen:
Have more than three alcoholic drinks a day Have liver disease Take warfarin or other medicines The Right Choice for You
Acetaminophen is safe for most people when taken as directed. For some, its a better option because the medicine doesnt cause stomach upset and isnt associated with Reyes syndrome, a serious condition that can affect children and teens who have or have had a viral infection. If youre unsure which pain reliever is the right choice for you, talk to your doctor or pharmacist. -This information provided courtesy of parklandmedicalcenter.com
Carefully read drug labels to find out what the active ingredients are. Never take more than one product that contains acetaminophen. For example, dont take Tylenol and also take NyQuil both of these products have acetaminophen. If you are taking a prescription medicine, read the leaflet that comes with it to find out what the active ingredients are. Keep in mind that with prescription medicines, acetaminophen may be listed as APAP. If you are unsure about the ingredients, ask your doctor or pharmacist.
Get the Facts on Hands-Only CPR
Know disco? You can help save a life if you do.
f you see a teen or adult collapse, call 9-1-1 and push hard and fast in the center of the chest to the beat of the classic disco song Stayin Alive. The American Heart Associations Hands-Only CPR at this beat can more than double or triple a persons chances of survival. Take 60 seconds and hustle to heart.org/handsonlycprto learn how you can help save a life.
Sadly, 89 percent of people who suffer an out-of-hospital cardiac arrest die because they dont receive immediate CPR from someone on the scene. Most Americans (70 percent) feel helpless to act during a cardiac emergency because they dont know how to administer CPR or theyre afraid of hurting the victim. Dont be afraid. Your actions can only help. BE THE DIFFERENCE FOR SOMEONE YOU LOVE
If you are called on to give CPR in an emergency, you will most likely be trying to save the life of someone you love: a child, a spouse, a parent or a friend.
Unfortunately, only 41 percent of people who experience a cardiac arrest at home, work or in public get the immediate help that they need before emergency help arrives. Hands-Only CPR has been shown to be as effective as conventional CPR for sudden cardiac arrest at home, at work or in public. It can double or even triple a victims chance of survival. DISCO CAN SAVE LIVES
Hands-Only CPR has just two easy steps: If you see a teen or adult suddenly collapse, (1) Call 9-1-1; and (2) Push hard and fast in the center of the chest to the beat of the disco song Stayin Alive.
WHY LEARN HANDS-ONLY CPR?

Sudden cardiac arrest is a leading cause of death.Nearly 400,000 out-of-hospital cardiac arrests occurannually in the United States.
When a teen or adult has a sudden cardiac arrest, survival depends on immediately getting CPR from someone nearby.
80 percent of sudden cardiac arrests happen in private or residential settings.
According to the American Heart Association, people feel more confident performing Hands-Only CPR and are more likely to remember the correct rhythm when trained to the beat of the disco classic Stayin Alive. "Stayin Alive" has more than 100 beats per minute, which is the rate you should push on the chest during CPR. HUSTLE TO LEARN HOW TO SAVE A LIFE Watch the 60-second demo video. Visit heart.org/handsonlycprto watch the American Heart Associations Hands-Only CPR instructional video and share it with the important people in your life.
The American Heart Associations Hands-Only CPR campaign is supported by an educational grant from the WellPoint Foundation.
NOTE: The AHA still recommends CPR with compressions and breaths for infants and children and victims of drowning, drug overdose, or people who collapse due to breathing problems.
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Is My Child On Target ?
M
y child walked at 6 months. My child didnt talk until he was 4-years-old and then started talking in complete sentences. My child never crawled. My child is so cute, she walks on her toes like a ballerina all the time, and has been doing this since she started walking at 15 months of age; she is 3 years old now. My child didnt roll over until she was 7 months old, but I think it was because she never liked being on her tummy. Parents hear other parents, family members, friends and teachers tell them about children and how they are supposed to develop normally and when they should achieve normal milestones. There is an abundance of information on the Internet and plenty of books to read, but your child will probably have graduated from high school before you get through the myriad of sources available to parents.
Lets look at some practical advice. Making sure your child has the underlying skills to help him progress with gross motor, fine motor and speech activities can be an important key in helping your child be on target for his age. For the child to roll, push up on his arms, rock in hands and knees and get into sitting, he needs to be able to work against gravity and develop good core muscles as well as good stability around the shoulders and hips. The child learns these movements and develops the strength in these areas by spending time on his tummy during waking hours. Reaching while on his tummy and crawling activities help further develop the strength and stability around the shoulder girdle that will help the child have a good base for them to develop manipulative skills in their hands so that they can perform handwriting, buttoning, tying shoes and a variety of ball skills. A good core as well as strength in the upper trunk and neck muscles helps support good breathing, sucking, swallowing and feeding skills.
But its not just about a good core and being on the tummy every waking hour. Its also about spending time with your child playing peek a boo, clapping your hands, reading to him, singing songs and giving him a variety of play activities. These activities help your gurgling, cooing infant learn to identify 1-2 body parts, follow simple one step directions and have an expressive vocabulary of 3 to 20 words by 12-18 months of age. So, you say, What if Im doing all this and my child seems to really struggle to perform similar skills to his peers? Talk to your pediatrician. Simple hearing and vision screens can help rule out some problems. Your pediatrician can also lead you to good resources like pediatric occupational, physical and speech therapists. Being a parent is one of the most important jobs you can have. Be your childs advocate. Your one-on-one time with your child will help him develop on target and help you know early if he is having problems. -This information provided courtesy of Baylor Health Care System
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Unraveling Count
Fast-Food Menu Calorie Counts Legally Compliant But Not as Helpful to Consumers as They Should Be
Calorie Confusion
alorie listings on fast-food chain restaurant menus might meet federal labeling requirements but dont do a good job of helping consumers trying to make healthy meal choices, a new Columbia University School of Nursing (CUSON) study reports.
utility, the authors say. Menu postings for individual servings are easily understood, but complex math skills are needed to interpret meals designed to serve more than one person. In some items, calories doubled depending on flavor, and the calorie posting did not give enough information to make healthier selections. The federal health reform law passed in March 2010 requires restaurants with 20 or more locations to provide calorie data and additional nutritional information for menu items and self-service foods. The Food and Drug Administration is now considering how best to guide chain restaurants in posting calorie counts on menu boards. Easily understood calorie listings could be helpful to consumers trying to make healthy food choices, especially in light of the increasing prevalence of obesity among American adults and children. The trend is a particular problem in low-income and inner-city neighborhoods, where sources of more healthful foods might not be as common as fastfood fare. Studies suggest that consumers are generally unaware of, or inaccurately estimate, the number of calories in restaurant foods. To collect the data, volunteers equipped with digital cameras worked in pairs and canvassed each designated area block by block to identify national restaurant outlets. A total of 70 menus and menu boards from 12 restaurant chains were photographed, and 200 food items rated, using a measure of practical utility that the researchers developed to calculate (1) what constitutes a single serving and (2) the number of calories in a single serving. The researchers then combined this measure with current FDA guidelines to develop a seven-item menu rating tool.
The study, by Elizabeth Gross Cohn, RN, NP, DNSc, assistant professor of nursing at CUSON, and colleagues, was published online on February 16, 2012, in the Journal of Urban Health. The researchers studied the calorie counts for 200 food items on menu boards in fast-food chain restaurants in the New York innercity neighborhood of Harlem. Since 2006, the City has had a standard menu labeling law that includes some, though not all, of the new federal requirements. Although most postings were legally compliant, they did not demonstrate
be more challenging among low socioeconomic groups in urban areas where fast-food chain restaurants tend to be most concentrated. For example, the study reports, a bucket of chicken was listed as 3,240 to 12,360 calories, but the menu board did not contain enough information to determine the number of pieces of chicken in a serving size. Similarly, a hero combo meal ranged from 500 to 2,080 calories, but no information was provided on how a consumer would order within the lower range of this menu item. Specialty pizzas were offered in wide ranges without a clear explanation as to how they differed, since the calorie count was based on a standard size and standard set of toppings. The authors note that their study was limited to one urban community and did not focus on actual food purchasing behavior but rather on the posted menu boards in chain restaurants. Still, they say, their work suggests the need for more understandable and useful calorie information in posted menus. As further legislation is developed, we support the FDA in their commitment to having menu boards that are useful at all levels of literacy, they conclude. Specifically, the authors support a system that uses dashes or slashes to more intuitively associate calorie counts to food combinations instead of the current system of ranges. In such a revised system, a breakfast sandwich, for example, would be listed as egg with ham/bacon/sausage 350/550/750. In low-income communities with a high density of chain restaurants, and where educational attainment of consumers may be low, simplifying calorie postings and minimizing the math required to calculate calories would increase menu board utility, they say. -This article reprinted courtesy of Columbia University Medical Center
The researchers found that, while most restaurants studied have posted calorie counts, in the majority of cases there was insufficient information to make use of them at the point of purchase. One reason for this was that the majority of the items on the menu boards studied were combination meals rather than individual items. Furthermore, it was increasingly difficult to calculate calories per meal when the posting included anything more than an individual unit of measure. Calorie counts became more challenging as the food items became more complex, especially combination and multi-serving items, which represented the largest percentage of items recorded. These required several mathematical and nutritional calculations, which might
Screening Tests
That Can Save a Man's Life
en, on average, die younger than women, and have higher mortality rates from heart disease, cancer, stroke and AIDS.
Yet men are much less likely than women to see their doctors. One reason, some men are afraid of what their doctor might find. But ignoring a problem doesn't make it go away. The earlier we diagnose such conditions as diabetes, high blood pressure, high cholesterol and cancer, the more successfully we can treat them. Patients should see their primary care physician at least once a year. While there has been debate over the benefits of an annual physical exam, a yearly visit at a minimum provides an opportunity to conduct appropriate screening tests. There also has been debate over various screening tests. Recommendations vary on such exams as PSA screening for prostate cancer. These recommendations are based on guidelines from the U.S. Preventive Services Task Force and other expert bodies. Among the tests and guidelines men should consider are: Body Mass Index. This is a measure of body fat based on height and weight. A BMI under 18.5 is underweight. Normal is 18.5 to 24.9. Overweight is 25 to 29.9 and obese is 30 and above. BMI should be checked yearly. (You can calculate your own BMI by searching online for "BMI calculator" and plugging in your height and weight.)
Colorectal cancer. Men should be screened beginning at age 50. The gold standard is a colonoscopy. A doctor uses a slender, lighted tube to examine the entire colon. A colonoscopy can find and remove precancerous growths called polyps. If a colonoscopy is normal, it's good for 10 years. Other screening exams include a yearly fecal occult blood test (which can find blood in the stool) or, every five years, a fecal blood test combined with an exam called a sigmoidoscopy, which examines the lower part of the colon. Diabetes. Men with risk factors such as a family history of diabetes, being overweight or experiencing diabetic symptoms should be screened with a fasting blood test. This test measures the amount of a sugar called glucose in your blood. Normal is less than 100 milligrams per deciliter; 101 to 125 is pre diabetes and above 125 suggests diabetes.
Cardiovascular. Men ages 45 to 79 can take a baby aspirin a day to help prevent heart attacks. Cholesterol. Men ages 20 to 35 who have cardiovascular disease risk factors such as diabetes should be screened. After age 35, men should be screened once every five years if normal, or more often if levels are borderline. Prostate cancer. Your doctor will assess your risk of developing prostate cancer, and having sexually transmitted diseases such as HIV and syphilis. Based on your risk factors, your doctor may recommend further testing. Abdominal aortic aneurysm. This is a bulge in the large blood vessel that supplies the abdomen and lower body. If it ruptures, it will cause severe bleeding that often is fatal. An aneurysm can be repaired with surgery. Men aged 65 to 75 who have ever smoked should be screened with an ultrasound. Other conditions. Screening men for depression, smoking and alcohol abuse, as well as talking to them about controlling their weight, getting enough physical activity and avoiding risky sexual behavior, should be part of these annual exams. -Aaron Michelfelder, MD, Loyola University Health System
Dental check-ups. See a dentist at least once a year -- ideally every six months. Bad teeth can affect other parts of the body. For example, dental disease is a risk factor for cardiovascular disease. Hearing. If a patient or his spouse reports a hearing problem, or if the patient works in a job with excessive noise, a hearing test should be ordered. High blood pressure. Every man over age 18 should have his blood pressure checked at least once a year.
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Potential Stroke Victims Aren't Calling

NewYork-Presbyterian/ Weill Cornell Research on Ambulance Use Underscores Need to Urgently Recognize Stroke Symptoms
N
ationwide ambulance use by patients suffering from a stroke has not changed since the mid-1990s, even though effective stroke treatments are now available. In a study published in this week's Journal of the American Medical Association (JAMA), researchers at NewYork-Presbyterian Hospital/Weill Cornell Medical Center found that the number of stroke victims transported via ambulance has remained relatively static over the years, highlighting the need for more education about stroke symptoms and the importance of early intervention. The study, led by Dr. Hoorman Kamel, a neurologist at NewYorkPresbyterian Hospital/Weill Cornell and assistant professor of neurology at Weill Cornell Medical College, analyzed data collected by the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1997 and 2008.
Common Warning Signs of Stroke According to the National Institute of Neurological Disorders and Stroke, you should call 911 if you experience any of these symptoms. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause
"People do not always recognize the seriousness of stroke symptoms, or instead of calling 911, they may call their primary care physician for an appointment and lose valuable time as the damage becomes irreversible," says Dr. Kamel. Based on 1,605 cases, the study found that just 51 percent of adults diagnosed with stroke in emergency departments nationwide arrived via ambulance, with no significant change over the 11-year span. Dr. Kamel says recovery is possible with early treatment. "We have drugs and surgeries that can minimize brain damage from a stroke, but they can be used only within a few short hours. When stroke victims or bystanders quickly recognize the symptoms of a stroke and call 911, patients are more likely to arrive in time to receive these treatments."
The study was co-authored by Dr. Babak Navi, director of the Stroke Center at New YorkPresbyterian Hospital/Weill-Cornell Medical Center and assistant professor at Weill Cornell Medical College, and Dr. Jahan Fahimi, an emergency physician and assistant professor at the University of California, San Francisco. -This information provided courtesy of NewYorkPresbyterian Hospital/Weill Cornell Medical Center.
Intensity Modulated Radiation Therapy and Prostate Cancer

A new study finds that a treatment for localized prostate cancer known as Intensity Modulated Radiation Therapy (IMRT) is better than conventional conformal radiation therapy (CRT) for reducing certain side effects and preventing cancer recurrence.
Chen is assistant professor of radiation oncology and a research fellow at the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. He is a member of UNC Lineberger Comprehensive Cancer Center. He explains, In the past 10 years, IMRT has largely replaced conventional CRT as the main radiation technique for prostate cancer, without much data to support it. This study validated our change in practice, showing that IMRT better controls prostate cancer and results in fewer side effects. Our data show that in comparing IMRT to proton therapy, IMRT patients had a lower rate of gastrointestinal side effects, but there were no significant differences in rates of other side effects or additional therapies. Study scientists report that compared to CRT, IMRT was associated with fewer diagnoses of gastrointestinal (GI) symptoms, such as rectal bleeding or diarrhea, hip fractures and additional cancer therapy, but more difficulty with sexual function. Proton therapy was associated with more GI problems than IMRT. The UNC team used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 2000-2009 for approximately 13,000 patients with non-metastatic prostate cancer. SEER is composed of 16 population-based cancer registries representing approximately 26 percent of the US population. This study is an example of comparative effectiveness research, which seeks to inform health care decisions by providing new research-based evidence about the benefits and harms of different health care interventions. Tim Carey, MD, director of the Sheps Center at UNC, said, This type of research is critical, comparing one type of treatment with alternatives, so that patients and their providers can arrive at the best decisions for each individual. CRT, IMRT and Proton therapy represent three types of radiation, each attempting to deliver radiation treatment to a tumor while minimizing radiation dose to surrounding organs. Use of proton therapy use in prostate cancer is controversial because of its high cost and unproven benefit compared to other standard forms of radiation like IMRT. -This information provided courtesy of University of North Carolina Health Care
Other UNC authors are: Nathan Sheets, MD; Greg Golden, MD; Anne-Marie Meyer, PhD; Yang Wu, PhD; Yunkyung Chang, PhD; Til Sturmer, MD, PhD; Jordan Holmes, BS; Bryce Reeve, PhD; and William Carpenter, PhD. With Dr. Chen, Paul Godley, MD, PhD, was co-principal investigator of the grant Comparative Effectiveness of Management Options for Localized Prostate Cancer. The research was conducted through a contract from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. Analytical support was provided by UNC Lineberger Comprehensive Cancer Centers Integrated Cancer Information and Surveillance System (ICISS), which receives support from the State of North Carolinas University Cancer Research Fund.
treatment for localized prostate cancer known as Intensity Modulated Radiation Therapy (IMRT) is better than conventional conformal radiation therapy (CRT) for reducing certain side effects and preventing cancer recurrence, according to a study published in the April 18, 2012 issue of the Journal of the American Medical Association. In 2012, approximately 241,740 American men will be diagnosed with prostate cancer. The study also showed IMRT to be as effective as proton therapy, a newer technique that has grown in popularity in recent years. Ronald Chen, MD, MPH, senior author, says, Patients and doctors are often drawn to new treatments, but there have not been many studies that directly compare new radiation therapy options to older ones.
High-Tech High-Touch
Efficiencies of care bring a healthy bottom line and even healthier patients
ike most men, the last place Arnold -Sulman wanted to be was in a urologists office. Yet there he sat in 2005 in the office of Eric Klein, MD, brought to that place because of an elevated PSA blood test.
He said theyve had good success with the implantation of radioactive seeds, Mr. -Sulman says, and with somebody my age, Id have less problems with undesirable side effects. Patients like Mr. Sulman make the choice to trust their doctors every day. In turn, doctors repay their trust by making the most informed treatment decisions possible. Drs. Klein and Ciezki have an immense information resource to help guide those decisions: the largest single-institution prostate cancer database in the world. By sifting through data from roughly 11,000 patients, they choose the best options for each individual choices about lifesaving treatments and life-altering side effects. Its one example of how data and innovative thinking lead to efficient, effective care. Efficiency. Efficacy. Data. Words like this may lead some people to think of cold calculation and bureaucracy. Efficiency is part of the new policy driven by the Affordable Healthcare Act, an environment in which mandates must be met and outcomes must be measured. With the right goal in mind, though, efficiencies of care are not cold or bureaucratic. They benefit everyone involved. Medical institutions get a better bottom line. Insurance companies and payers such as Medicare not to mention taxpayers get a more reasonable bill. Researchers and clinicians get better data to make decisions now and craft new therapies for the future. Most important of all: Patients get better care.
He had hoped for a kinder diagnosis of prostatitis. But it was prostate cancer, a condition he shares with 2.3 million other American men. Mr. Sulman 68 years old, retired from a career in 3Ms pharmaceutical division and splitting his time between Cleveland and Florida with his wife listened intently as Dr. Klein, Chairman of the -Glickman Urological & Kidney Institute, offered what he considered the best approach: Wait and watch. He said, if you dont let the fact that you have cancer worry you every night, you can take the route of watchful waiting, Mr. Sulman says. Early biopsies showed little disease progression, so treatment was not worth the risk. By 2010, though, a new biopsy showed enough of a change in his Gleason scorethe system that tracks prostate cancers progression that the time for action had arrived. Dr. Klein, who holds the Andrew C. Novick, MD, -Distinguished Chair in Urology, recommended brachytherapy, a process of implanting radioactive seeds into the prostate to treat the cancer locally. He made Mr. Sulman an appointment with Jay Ciezki, MD, a radiation oncologist and brachytherapy expert.
Just ask Mr. Sulman. After having brachytherapy as a one-day outpatient procedure at -Cleveland Clinics -Beachwood Family Health Center in -December 2010 The whole thing was a snap his prognosis is good. The PSA score that was once as high as 9 ng/ml is now down to 2.5 ng/ml and dropping. Ive gone on with my life, Mr. Sulman says. Its a chapter. Its past. I dont think about it.
financial or insurance forms. Were starting to have a source of clinical data thats far more efficient, more useful and, frankly, more credible to clinicians. Credibility and usefulness are major goals of the prostate cancer database, which started in the 1990s as a good, old-fashioned Excel spreadsheet, Dr. Ciezki says. The clinicians who maintain the database gather a wide range of information: the patients background, biopsy and PSA results, other diseases or conditions, types of treatment and dosing, side effects such as sexual problems or incontinence, and much more. In part, the goal is to establish a baseline both for an individual and for the entire patient population. At the most basic level, if youre going to try to be more efficient with your care, the first thing you need to know is: Where are you now? Dr. Ciezki says. A database helps you do that. You input data, analyze it and establish a baseline for whatever metrics you find important. As with Mr. Sulmans case, that data helps inform treatment as well as testing decisions. By analyzing information in the database, Dr. Ciezki and fellow researchers come up with the optimal number of PSA blood tests a prostate cancer patient needs each year: two. Likewise, in a separate study, they found that the frequency of PSA testing was equal in importance to the Gleason score for predicting recurrence of cancer, a finding that bucked conventional wisdom. First and foremost, findings such as these make life easier for patients. The goal is not to do too much testing so you dont get spurious findings that cause unnecessary tests and treatments, but not too few tests so you miss something major that you need to act upon, Dr. Ciezki says. The cost implications of fewer unnecessary tests are undeniable too. Researchers around the world have used the database. In addition to measuring the need for diagnostics, they have used the data to compare treatments, weigh the side effects of these treatments among different populations, and even identify the best follow-up schedule for patients after treatment. Still, the ease of such research has room for improvement. Dr. Levin jokes that current electronic records and databases are in the Model T era, but everyone is working to build a Ferrari. That type of thinking led clinicians and software engineers in Cleveland Clinics Neurological Institute to collaborate on a new system in 2007. This homegrown system, known as the Knowledge Program, attempts to make records and data more extractable and practical, says Irene Katzan, MD, MS, neurologist and -Director of the Knowledge Program and the -Neurological Institute Center for Outcomes Research and -Evaluation. The Knowledge -Program has since spread to other parts of Cleveland Clinic, including the Sydell and Arnold Miller Family Heart & Vascular Institute and the Digestive Disease Institute. It
Better Data=Better Care
David Levin, MD, who joined Cleveland Clinic as Chief Medical Information Officer in September, has a name for what data can do for doctors: embedded decision support. On an individual level, embedded decision support means that doctors can pull up data on command. If they want to know how a patient has been feeling, what treatments have been tried, what test results have revealed, all of that information is close at hand. This approach makes sense when you consider Dr. Levins background. After years working in the information technology field, Dr. Levin went back to school to become a doctor, with the expressed goal of combining what he knows about data and technology with what he wanted to know about medicine. Weve been very limited in healthcare because the data we had was very limited, Dr. Levin says. In the past, a lot of patient information was drawn straight from
Efficiency In Action
Cleveland Clinics efficiency efforts are abundant, including the following: Comparative drug trials help guide treatment decisions, not to mention coverage decisions by Medicare and other payers. Cleveland Clinic doctors have recently led multisite trials comparing statins (the Saturn study), macular degeneration drugs and treatments for kidney cancer, among many others. Minimally invasive surgery techniques can improve outcomes and reduce the time patients spend in the hospital. Robotic assistants improve everything from thyroid surgery to kidney removal, and surgeons are using rare but superior techniques to treat everything from sleep apnea to heart disease. Improved triage systems at emergency rooms and intensive care units are designed to keep patients moving and determine who most needs a hospital bed. Cleveland Clinic has adopted the split flow model that better sorts the most severe emergencies from less serious conditions.
Weve been very limited in healthcare in the past because the data we had was very limited. David Levin, MD
is used to collect information on how patients are feeling during more than 20,000 clinical visits each month. The challenge, Dr. Katzan explains, is that most information in a medical record is entered in free text basically a narrative. In other words, a doctor writes something like, Patient is experiencing the following symptoms This kind of narrative can be valuable to that particular doctor, but it yields very little data for other users. Its very hard to extract information from free text. But if it is entered using drop-down menus and numeric coding, for example, we can extract that in many different ways, says Dr. Katzan, who holds the Wamberg Family Endowed Chair in Stroke Research. Some data in the Knowledge Program comes straight from the patients, who answer questions about their health, their symptoms and their state of mind on tablets and touch-screen computers. Clinicians then use that information to prep for their encounters with patients and to home in on the symptoms that are causing the most problems. They also can use the data collected to screen for conditions such as depression among people with chronic diseases. Increasingly, the Knowledge Program has been integrated with Cleveland Clinics MyChart, a system that allows patients to view summaries of their records, current medications and test results; schedule appointments; set reminders; and refill prescriptions. Such integration is no accident. Drs. Katzan, Levin and others are working to make sure systems talk to each other. They have plenty to say.
Stephen Travarca As Chief Medical Information Officer, David Levin, MD, oversees efforts to make data more effective and efficient.
Dr. Alberts software runs on an iPad. Theres an app for that. When the idea for software to monitor concussions first came up, Dr. Alberts knew he would need a device that measures motion and acceleration. When the iPad came along, complete with a built-in accelerometer and gyroscope, he found his answer. Working with Richard Figler, MD, and Robert Gray, MS, ATC, from Cleveland Clinics Center for Sports Health, he performed a validation study to show that the app worked. The team is now testing it among 100 athletes in Northeast Ohio at John Carroll University, Brecksville--Broadview Heights High School and Solon High School. The accuracy of data that were getting out of the iPad 2, Dr. Alberts says, is pretty much equivalent to what we could get if we were measuring postural stability using the gold standard clinical and research system a system that can cost upwards of $100,000.
Mobile Medicine
Each fall, boys and men suit up in pads and helmets and take to the football field for a game of big hits. Collisions are clearly part of the sports appeal, but in recent years, everyone from youth leagues to the NFL has expressed concern about the long-term repercussions of concussions. Jay L. Alberts, PhD, has created a tool to help measure those repercussions and to guide the sideline decisions of coaches, trainers and medical staff. Dr. Alberts, who holds the Edward F. and Barbara A. Bell Family Endowed Chair in the -Department of -Biomedical -Engineering, developed an idea for software that measures cognitive skills, motor skills, postural stability and other factors related to concussions. Part of the goal is to know when the symptoms of a concussion are lingering so that coaches dont put players back in the game too quickly.
The accuracy of data that were getting out of the iPad 2 is pretty much equivalent to what we could get if we were measuring postural stability using the gold standard clinical and research system a system that can cost upwards of $100,000. Jay L. Alberts, PhD
The cost savings are obvious, but there is another advantage: The results tie directly into the Knowledge Program, so clinicians can access them anywhere. The idea for Dr. AlbertsiPad app came from a project designed for an entirely different group of people who face similar neurological issues, but on a more permanent basis. Dr. Alberts collaborated on computer software that tracks symptoms and progress in people with Parkinsons disease. The system, iCOMET (Internet--Based Cognitive Motor Evaluation and Testing System), allows a neurologist to assess a patients motor and cognitive skills remotely. Doctors can check on their patients and gather crucial data, all without a physical visit to the office. Dr. Levin has a word for that too: pervasiveness. The information itself is pervasive, but in this case, the computer and tablet technology is becoming pervasive as well. Its not just the application software, the electronic medical record or its associated systems, Dr. Levin says. As our society becomes more mobile, its also about devices and connectivity. How can we enable our care team to use this technology? Within a few days of going home, patients receive a visit from a nurse, who provides further coaching and helps set up Bluetooth-compatible telehealth equipment. Patients log in daily for measurements such as weight, blood pressure and oxygen levels. They answer questions about their symptoms. If anything is out of line, a nurse calls them immediately to determine what steps need to be taken. Even if everything is OK, nurses check in regularly. Among participants, only 23 percent were readmitted to the hospital within 30 days. Thats 5 percent lower than the hospitals prior rate. Patients experience less pain and anguish, and the healthcare system saves money. Its not a good experience for anybody to be hospitalized when they dont need to be, Dr. Landers says. When were able to prevent that, I look at it as one of the win-wins, where costs are lower and people have gotten better care. Perhaps even more important, patients dont like to think that once theyre treated, their caregivers no longer care. They want to know that when they leave the hospital, their medical team doesnt leave their side. Thats how Moreno Stuart felt about the Heart Care at Home program. Diagnosed with congestive heart failure 15 years ago, the 38-year-old Cleveland
Right Devices, Right People
It might seem counterintuitive for a hospital to try to keep people away, but thats one of the primary goals of the Heart Care at Home program. The program is designed to reduce readmissions of heart patients after surgery or treatment, to improve their chances of success and a healthy future. Were really trying to improve the whole post-hospital experience for patients, and also the outcomes, says Steven Landers, MD, MPH, Director of Home Health Care. Thats a big area of opportunity for improving value, efficiency and healthcare in general. More than 1,300 patients have gone through the program so far. It provides a smoother transition after heart failure, heart attacks or surgery. Participants receive health coaching before they leave the hospital. They learn how to manage their medications and what red flags to monitor.
Jay L. Alberts, PhD, demonstrates an iPad app he and colleagues developed to monitor symptoms of concussions remotely, with the goal of helping coaches and clinicians make better decisions about head injuries.
resident says he neglected his own health for far too long until this program came along. Before I really understood my diagnosis, I was taking my condition for granted. I would always end up in the hospital. My doctors would put me on different medications and higher doses, which I probably didnt need, all because I wasnt taking care of myself. The neglect came in part from depression. When a young, active man suddenly finds himself unable to support his family or even get out of bed on some days, his pride takes a hit. In the past six months, the care Mr. Stuart received helped him turn his attitude around. In July, on a blazing hot day in Cleveland, he became so dehydrated that he had to go to South Pointe Hospital for treatment. Once he was feeling better, a nurse came in to talk about Heart Care at Home. Suddenly, Mr. Stuart had a new routine. Every day, he woke up and checked his weight, blood pressure and oxygen. A buzzer on his telehealth machine let him know it was time to take medicine. If he gained five pounds in a week, a friendly phone call from a nurse reminded him that he should take an extra water pill, cut out the salt, and get out and walk.
I started to understand my heart failure, Mr. Stuart says, and I started understanding how serious it was for me to take care of myself. When the program ended after 40 days, Mr. Stuart faced a tough decision. Living on a fixed income, he could buy a new scale to keep monitoring himself daily, or he could put that money toward his expensive regimen of pills. Knowing his predicament, a nurse ventured to Mr. Stuarts home and brought him the scale he needed. Now monitoring his health closely remains part of the daily routine for him, his teenage son and daughter, and his wife, Helen. Hospitals can deploy the right devices into the home and other nonclinical settings. Hospitals can watch their data closely and use it to make better decisions. Hospitals can encourage employees to think of novel ways to use technology. But at its core, medicine is still a personal business. At the end of the day, were talking about human beings and their frailties and their needs for human touch and compassion, Dr. Levin says. We dont want technology to get in the way of that. This is an opportunity to combine high-tech and high-touch in new ways. -Chris Blose, courtesy of Cleveland Clinic
Don Gerda
Migraine Pain Relief with Electrical Brain Stimulation

Chronic migraine sufferers saw significant pain relief after four weeks of electrical brain stimulation in the part of the brain responsible for voluntary movement, the motor cortex, according to a new study.
esearchers from the University of Michigan School of Dentistry, Harvard University and the City College of the City University of New York used a noninvasive method called transcranial direct current stimulation (tDCS) as a preventative migraine therapy on 13 patients with chronic migraine, or at least15 attacks a month. After 10 sessions, participants reported an average 37 percent decrease in pain intensity. The effects were cumulative and kicked in after about four weeks of treatment, said Alexandre DaSilva, assistant professor at the U-M School of Dentistry and lead author of the study, which appears in the journal Headache. "This suggests that repetitive sessions are necessary to revert ingrained changes in the brain related to chronic migraine suffering," DaSilva said, adding that study participants had an average history of almost 30 years of migraine attacks. The researchers also tracked the electric current flow through the brain to learn how the therapy affected different regions. "We went beyond, 'OK, this works,'" DaSilva said. "We also showed what possible areas of the brain are affected by the therapy."
They did this by using a high-resolution computational model. They correctly predicted that the electric current would go where directed by the electrodes placed on the subject's head, but the current also flowed through other critical regions of the brain associated with how we perceive and modulate pain. "Previously, it was thought that the electric current would only go into the most superficial areas of the cortex," DaSilva said. "We found that pain-related areas very deep in the brain could be targeted." Other studies have shown that stimulation of the motor cortex reduces chronic pain. However, this study provided the first known mechanistic evidence that tDCS of the motor cortex might work as an ongoing preventive therapy in complex, chronic migraine cases, where attacks are more frequent and resilient to conventional treatments, DaSilva said. While the results are encouraging, any clinical application is a long way off, DaSilva said. "This is a preliminary report," he said. "With further research, noninvasive motor cortex stimulation can be in the future of adjuvant therapy for chronic migraine and other chronic pain disorders by recruiting our own brain analgesic resources." -Content contributed by Laura Bailey, for the University of Michigan Health System
The images above show where on the skull scientists placed the non-invasive electrodes, and where the current flowed through the brain. The areas in blue show low current. The areas in red show high current, and they found that this high current reached key pain processing structures deeper within the brain.
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The esophagus is a muscular tube that conducts food from the pharynx, through the chest, to the stomach. Eosinophilic esophagitis (EoE) is a chronic immunemediated inflammation of the esophagus that can result in disturbing chest, throat, and upper abdominal symptoms, and can cause difficulty swallowing. Recent reports have indicated the EoE is active in approximately 4 of every 10,000 children. In some reports, EoE has been found to be active in as many as 4.8% of adults.
Esophagus
It Could Be Allergy Season in Your
Eosinophilic Esophagitis
Eosinophil: An eosinophil is a kind of white blood cell that normally circulates freely in the blood until attracted to a site of inflammation. The term eosinophil refers to the property of these cells to stain intensely red in normal blood smears because they take up large amounts of the dye eosin. Eosinophils main known normal function in the human body is to kill invading parasites. Eosinophils also may play roles in tissue healing from diverse kinds of injury. may look normal, but be very inflamed beneath the surface. Susceptibility genes have been discovered, but this research has not yet become useful for clinical diagnosis. Several laboratory measurements do hold promise for future use in diagnosis, but at the present time we do not know how or if they will contribute to accurate diagnosis of EoE. Symptoms of EoE: The symptoms of EoE often vary according to the age of the individual. Infants and toddlers: Feeding difficulties School age: Vomiting and pain Adolescents: Dysphagia (difficulty swallowing) Adults: Dysphagia (difficulty swallowing, especially with solid food), chests pain, food impaction (food becoming lodged in the esophagus), upper abdominal pain. Mechanisms of tissue injury: Eosinophils normally are harmless, but when attracted into sites of immune inflammation and activated by local inflammatory molecules, eosinophils can be very destructive to nearby tissues. Current research supports the concept that allergic reactions in the wall of the esophagus attract and activate eosinophils. The eosinophils then cause damage to the esophageal tissues resulting in the clinical problems. Sophisticated ultrasound studies in EoE have shown that the inflammation involves the full thickness of the esophagus, not just the surface. Diagnosis of EoE: Eosinophilic esophagitis is detected when there are esophageal symptoms, large numbers of eosinophils are present in samples of tissues taken from the esophagus, and other diseases known to cause esophageal problems and the accumulation of eosinophils are not present. Upper gastrointestinal endoscopy is an essential part of the evaluation because there are no distinctive symptoms or other reliable diagnostic tests for this disorder. Several biopsy samples are taken because the EoE inflammation is patchy and the surface of the esophagus 15% of food impaction in adults is caused by EoE 33% to 54% of adults with EoE develop food impaction. Nonspecific throat symptoms and acid reflux symptoms may be present. Allergic diseases in patients with EoE: Multiple studies have shown that food allergy, allergic rhinitis, asthma, or eczema (atopic dermatitis) are present in 42% to 93% of children and 28% to 86% of adults with EoE. Food allergy is present in 15-43%, allergic rhinitis in 40-75%, asthma in 14-70%, and eczema in 4-60%. Recent research indicates that foods, and sometimes airborne substances, can be the cause of EoE in some patients. Laboratory abnormalities in EoE: The numbers of circulating blood eosinophils are increased in only 40-50% of EoE patients. Total serum IgE (the allergy causing antibody) is increased in the blood in 50-60% of patients. IgE antibodies to foods and inhaled substances often are present, but their presence is not reliable for detecting or monitoring EoE.
Eosinophilic esophagitis (EoE) should be suspected when persistent feeding difficulties, vomiting, chest and upper abdominal pain, or swallowing problems are present and more common causes are found not to be present. The diagnosis can be suspected from the clinical problems, but upper gastrointestinal endoscopy with multiple biopsies is essential. Large numbers of eosinophils in the inflamed esophagus are a defining characteristic of EoE. The only known cure for EoE is detection and elimination of the cause. Allergic reactions to foods are the cause in as many as 97% of patients. Topical and systemic anti-inflammatory steroid therapy can be very helpful for controlling symptoms. Steroid therapy does not cure EoE.
to those that infrequently cause food allergy or EoE. These diets can be effective, but may inadvertently retain a food that plays an important role in EoE. Specific food exclusion diets: An Allergy and Immunology specialist can perform and interpret tests for immune reactivity to foods. A diet that avoids specific foods to which the patient reacts can then be devised. This approach can lead to elimination of EoE in as many as 80% of EoE patients.
Medications to treat EoE:

If acid reflux is present in patients with EoE, treatment with acid suppressing medications may provide significant improvement in EoE symptoms. The suspicion is that acid in the esophagus can aggravate EoE. Steroid medications that have been developed to treat asthma and other allergic conditions can be very effective for treatment of EoE. Fluticasone can be delivered using the metered dose inhaler available to treat asthma. The drug is puffed into the mouth and then swallowed twice a day. A viscous suspension of budesonide, another anti-inflammatory steroid, can be given once a day. The doses vary according to disease severity and the age of the patient. Oral or injected steroids usually are very effective, but their use is reserved for severe or complicated cases. When feasible, whole body treatment with antiinflammatory steroids is avoided because of diverse undesirable side effects associated with long-term use. Esophageal dilation and other endoscopic interventions: Avoidance of causes and topical steroid therapy may lead to resolution of the inflammation and symptoms, and may allow healing of complications such as fissures in the esophagus and even strictures (fixed narrowing of the esophagus). In some cases widening (dilation) of the esophagus is necessary. Dilation procedures may be needed more than once over the course of the illness. Because dilation, even endoscopy, can cause complications in EoE patients, careful gastroenterology assessment is needed to determine when and how these physical interventions should be undertaken. -Timothy J. Sullivan, MD and Vicki Lyons, MD
Identification of the causes of EoE: The only known cure for EoE is identification and elimination of the cause. The identification of cause involves some form of an elimination diet. Elemental diets: All foods that might be a cause of EoE can be avoided by using specialized commercially prepared nutrition materials that supply pure amino acids, sugars, fatty acids, minerals, vitamins, and other nutrients needed for children to grow and for adults to maintain good health. No proteins, starches, complex fats, or additives are present, thereby eliminating all possible food allergies. Small children tolerate this approach well. Adults find this approach very difficult to tolerate for the 4 to 8 weeks needed to see if the cause has been eliminated. As many as 97% of EoE patients on an elemental diet have clinical and laboratory (biopsy) improvement. Of these patients, up to 84% can then identify specific foods to avoid and continue to do well. Limited food exclusion diets: The most common foods that cause of EoE are milk, corn, peanut, wheat, beef, soy, and eggs. Many other foods have been identified as causes in specific patients. Several diets have been devised that restrict the foods eaten
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THE MONSTER ISNT UNDER THE BED. ITS IN THE fRIDgE.
People with eating disorders often distort the size of their food, so theyll eat less. They distort the size of their body, so thin looks fat. Which yields a fact that isnt distorted at allwithout treatment, many wont survive. But to read about those who have, go to myneda.org
National Eating Disorders Association

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