Dr. Ted's Blog

FLU VACCINE FOR 3YEARS AND OLDER HAS ARRIVED!!

2010-09-30T07:40:00.000-07:00

We have received our flu vaccines for children 3 years old and older. It is recommended

that all children receive the flu vaccine annually. If you would like your child to receive this

vaccinge please call the office to schedule an appointment. We will also vaccinate parents

and/or grandparents for a self pay cost of $30. Call to get your family scheduled!

FLU VACCINE FOR CHILDREN 6MOS-3YRS OLD HAS ARRIVED

2010-09-09T08:46:00.000-07:00

Flu season is approaching!!

We have received our flu vaccine for children ages 6 months to 3 years old.
If you would like your child to receive this vaccine please call the office
to schedule an appointment.

Flumist has arrived!!

2010-08-02T10:08:00.000-07:00

The 2010-2011 flu season is approaching. We have recieved our Flumist vaccines. This vaccine is a nasal spray for healthy children age 2 and up. To see if this vaccine is appropriate for your child and/or to schedule an appointment please call the office. We have not yet recieved our flushots for this season but anticipate arrival late August or September please check back here for further updates.
Thank you

INSURANCE CARDS

2010-06-24T06:04:00.000-07:00

This is just a friendly reminder to our patients that is very important to bring your most recent insurance card to each visit. Many insurance carriers have very brief timely filing limits which is why we must bill to the correct insurance the first time. Thank you for your cooperation.

Maybe THIS will help people finally get past the fear of vaccines

2010-05-25T11:05:00.000-07:00

A Great Book for Stretching Excercises

2010-03-26T07:28:00.000-07:00

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This is a wonderful and cheap paperback that has muscle group-specific exercises (how do I stretch my hamstrings?) and exercise-specific stretches as well (what do I do for soccer?). If you are tight or having muscle pains from sports (or aging, in my case) this book could help.

Most comprehensive stretching manual

03-26-10

Stretching

I haven’t encountered any source on this subject as broad, accessible, and easily applied as Bob Anderson’s classicStretching, a patient and friendly stand-in for my eight-grade P.E. teacher.

The 30th anniversary edition of this guidebook came out recently, with even more stretches and illustrations, and it’s easily the most comprehensive work on the subject. I love the activity-specific sections: cyclists, for instance, are shown stretches that not only address the muscle groups made tight and tense by our specific sport, but the stretches geared toward bike riders even include a bicycle to be utilized as a support. Activities from weightlifting to computer using get their own sections, too.

Organizationally, Stretching shines. Tight neck? Rigid shoulders? Thumb through to your proscribed routine and get to work. With minimal flexibility but a willingness to make an effort, almost anyone can use this book to become more limber, healthier.

-- Elon Schoenholz

Stretching: 30th Anniversary Revised Edition
By Bob Anderson, illustrations by Jean Anderson
2010, 240 pages
$14

Available from Amazon

Why Stretch?
- Reduce muscle tension and make the body feel more relaxed
- Help coordination by allowing for freer and easier movement
- Make strenuous activities like running, skiing, tennis, swimming, and cycling easier because it prepares you for activity; it's a way of signaling the muscles that they are about to be used.

And Now the Wall Street Journal Weighs In on Autism

2010-02-09T07:21:00.000-08:00

Lancet Retracts Study Tying Vaccine to Autism

By SHIRLEY S. WANG

The study that first suggested a link between vaccines and autism and spurred a long-running, acrimonious debate over the safety of vaccines has been retracted by the British medical journal that published it. The withdrawal supports the scientific evidence that vaccinations don't cause autism, but isn't likely to persuade advocacy groups that believe in a link.

A new autism study shows clusters of high autism rates in parts of California. WSJ's health columnist Melinda Beck joins Simon Constable on the News Hub with more.

The 1998 study of 12 children triggered worry among British parents that the measles-mumps-rubella vaccine caused autism, and many decided not to immunize their children against measles, according to Richard Horton, editor in chief of the Lancet, which issued the retraction Tuesday. He called the study the "starting pistol," though not the only cause, of the controversy.

Concern about the safety of vaccines, particularly regarding the preservative often used, thimerosal, which contains mercury, spread to the U.S. as well. Research has shown that as many as 2.1% of U.S. children weren't immunized with the MMR vaccine in 2000, up from 0.77% of children in 1995, according to a 2008 study published in Pediatrics.

"This retraction by the Lancet came far too late," said Paul Offit, chief of infectious diseases at Children's Hospital of Philadelphia and a coinventor of a vaccination for babies against a gastrointestinal virus, Rotateq, that is marketed by Merck & Co. "It's very easy to scare people; it's very hard to unscare them."

A widely cited 2004 statistical review of existing studies by nonprofit health-information provider the Institute of Medicine, which traced the vaccine theory back to the Lancet study, concluded there was no causal link between the MMR vaccine and autism. Some autism activist groups, however, continue to advocate against vaccinations for children, despite the lack of scientific evidence for such a link.

"Certainly the retraction of this paper doesn't mean that MMR doesn't cause autism and it's all a farce," said Wendy Fournier, president of the National Autism Association. It is "possible" that the MMR vaccine causes autism, she said, but "the science is not there in terms of the mechanism." The concern is that measles virus has been found in children's intestines after vaccination, said Ms. Fournier.

"No one is anti-vaccine," she said. "It's a matter of having vaccines be as safe as they can."

A study published in 2008 by researchers from several universities and the Centers for Disease Control and Prevention examined children with gastrointestinal problems who had autism compared with those who didn't have autism. They concluded there wasn't any evidence that the vaccine was responsible for autism.

Associated Press

Ten of the 13 authors of the original paper, all of whom were researchers at the Royal Free Hospital and School of Medicine in London, partially retracted the paper in 2004. However, the first author, Andrew Wakefield, didn't. Dr. Wakefield, who is now at the Thoughtful House Center for Children in Austin, Texas, didn't immediately return phone calls seeking comment.

"Many consumer groups have spent 10 years waging a campaign against vaccines even in the face of scientific evidence," said Dr. Horton of the Lancet. "We didn't have the evidence back in 2004 to fully retract the paper but we did have enough concern to persuade the authors to partly retract the paper."

The Lancet decided to issue a complete retraction after an independent regulator for doctors in the U.K. concluded last week that the study was flawed. The General Medical Council's report on three of the researchers, including Dr. Wakefield, found evidence that some of their actions were conducted for experimental purposes, not clinical care, and without ethics approval. The report also found that Dr. Wakefield drew blood for research purposes from children at his son's birthday party, paying each child £5 (about $8).

The Lancet's Dr. Horton said the journal was particularly concerned about the ethical treatment of the children in the study, and that the children had been "cherry-picked" by the study's authors rather than just showing up in the hospital, as described in the paper.

The authors "did suggest these children arrived one after another and this syndrome was apparent, which does lead you to think this is something serious," said Dr. Horton.

"I hope this brings closure to this controversy," said Fred Volkmar, an autism researcher and professor of psychiatry at the Yale Child Study Center who wasn't involved in the Lancet study. "My fear, unfortunately, is that this won't totally allay the fear of all parents."

In the 1998 paper, Dr. Wakefield and his colleagues described 12 children with gastrointestinal problems. Eight experienced symptoms that were thought to be related to the MMR vaccine, according to their parents or a doctor, and nine of the 12 children exhibited autistic behaviors.

Dr. Wakefield has been outspoken about his concern about the measles vaccine. He has continually pushed the view that the vaccine caused autism, said Greg Poland, professor of medicine and infectious diseases at the Mayo Clinic and director of the vaccine research group in Rochester, Minn.

"With the retraction, the hypothesis that he put forward has been debunked," said Dr. Poland.

—Peter Loftus contributed to this article.

Write to Shirley S. Wang at shirley.wang@wsj.com

More About Autism and Vaccines

2010-02-05T14:24:00.000-08:00

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This is from the British government and it's equivalent to the American Academy of Pediatrics. They, too, in addition to the AAP, the World Health Organization and the American Committee on Immunization Practices have concluded that vaccines are not only safe but that they CATEGORICALLY DO NOT cause or contribute to autism, which is KNOWN to have genetic causes.

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Study Linking Vaccine to Autism Broke Research Rules, U.K. Regulators Say

Nicky Broyd

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INFORMATION FROM INDUSTRY

Influenza: Improving Outcomes
How can a rapid test for influenza impact medical outcomes?
Learn more about clinical and economic outcomes

February 2, 2010 — The British doctor who led a study suggesting a link between the measles/ mumps/rubella (MMR) vaccine and autism acted "dishonestly and irresponsibly," a U.K. regulatory panel has ruled.

The panel represents the U.K. General Medical Council (GMC), which regulates the medical profession. It ruled only on whether Andrew Wakefield, MD, and two colleagues acted properly in carrying out their research, and not on whether MMR vaccine has anything to do with autism.

In the ruling, the GMC used strong language to condemn the methods used by Wakefield in conducting the study.

In the study, published 12 years ago, Wakefield and colleagues suggested there was a link between the MMR vaccine and autism. Their study included only 12 children, but wide media coverage set off a panic among parents. Vaccinations plummeted; there was a subsequent increase in U.K. measles cases.

In 2004, 10 of the study's 13 authors disavowed the findings. The Lancet, which originally published the paper, retracted it after learning that Wakefield -- prior to designing the study -- had accepted payment from lawyers suing vaccine manufacturers for causing autism.

Fitness to Practice

The GMC's Fitness to Practise panel heard evidence and submissions for 148 days over two and a half years, hearing from 36 witnesses. It then spent 45 days deciding the outcome of the hearing. Besides Wakefield, two former colleagues went before the panel -John Walker-Smith and Simon Murch. They were all found to have broken guidelines.

The disciplinary hearing found Wakefield showed a "callous disregard" for the suffering of children and abused his position of trust. He'd also "failed in his duties as a responsible consultant."

He'd taken blood samples from children attending his son's birthday party in return for money, and was later filmed joking about it at a conference.

He'd also failed to disclose he'd received money for advising lawyers acting for parents who claimed their children had been harmed by the triple vaccine.

Not Over Yet

The GMC will next decide whether Wakefield and his former colleagues committed serious professional misconduct. That could lead to being struck off the medical register. That decision may not be taken for several more months.

Wakefield wasn't in the hearing, but outside the GMC offices he told reporters, "Naturally I am extremely disappointed by the outcome of today's proceedings. The allegations against me and against my colleagues are both unfounded and unjust." He continued, "I invite anyone to examine the contents of these proceedings and come to their own conclusion."

Wakefield was cheered by a group of parents outside the hearing who are still sure he is right, even though his findings have been widely discredited.

"It remains for me to thank the parents whose commitment and loyalty has been extraordinary," he said. "I want to reassure them that science will continue in earnest."

Wakefield now works in the U.S. at an autism center called Thoughtful House, which he helped found. In a statement on its web site the center states that it is "disappointed" by the GMC decision, believing the charges against the three doctors were "unfounded and unfair."

On the web site's "frequently asked questions" the center asks: "Has Dr. Wakefield been accused of any breach of medical ethics while serving as the Executive Director of Thoughtful House?" The answer is "Absolutely not."

Safety of MMR Vaccine

The government and medical experts continue to stress that the MMR vaccine is safe.

The MMR triple vaccine was licensed in the U.S. in 1971 and first used in the U.K. in 1988. Over 100 countries now use it, and it is estimated that more than 500 million doses have been administered.

At the peak of the MMR scare in 2002, there were 1,531 articles about MMR in the U.K. national press; in 1998 there had been just 86.

Between 2001 and 2003, U.K. opinion polls showed that the percent of people believing the MMR vaccine to be safe dropped from over 70% to just over 50%.

U.K. Health Protection Agency figures show measles incidence increased dramatically following the drop in the number of children being vaccinated. The number of confirmed cases between 2007 and 2008 was 2,349, roughly equal to the combined total for the previous eleven years.

SOURCES:

U.K. General Medical Council.

General Medical Counsel, "Fitness to Practise Panel Hearing, 28 January 2010."

Andrew Wakefield, MD.

House of Commons Library Measles and MMR Statistics.

Thoughtful House web site.

BMJ web site.

BBC News online

One More Nail in the Coffin of Autism and Vaccines

2010-02-03T14:23:00.000-08:00

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In what is rapidly becoming a true non-issue, at least among the people that study this for a living, the British journal Lancet has retracted the findings of the ORIGINAL study that they themselves published over 10 years ago that seemed to link autism with vaccines. They now state unequivocally that this study was flawed by the intentional use of falsified numbers and have withdrawn their support for both the study itself and the now disgraced principal author, Dr Andrew Wakefield. Read on.
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From WebMD Health News

Study Linking Autism to Vaccine Retracted

Daniel J. DeNoon

February 2, 2010 — The venerable British medical journal The Lancet has retracted a 1998 study suggesting a link between autism and childhood vaccination with the measles-mumps-rubella MMR vaccine.

The Lancet tells WebMD that it has retracted "10 or 15" studies in its 186-year history. The retraction follows the finding of the U.K. General Medical Council (GMC) that says study leader Andrew Wakefield, MD, and two colleagues acted "dishonestly" and "irresponsibly" in conducing their research.

The Lancet specifically refers to claims made in the paper that the 12 children in the study were consecutive patients that appeared for treatment, when the GMC found that several had been selected especially for the study. The paper also claimed that the study was approved by the appropriate ethics committee, when the GMC found it had not been.

"We fully retract this paper from the published record," The Lancet editors say in a news release.

The retraction means the study will no longer be considered an official part of the scientific literature.

BMJ, formerly known as the British Medical Journal, has competed with The Lancet since 1840. BMJ editor Fiona Godlee says she welcomes the Lancet retraction.

"This will help to restore faith in this globally important vaccine and in the integrity of the scientific literature," Godlee says in a news release.

In 2004, 10 of Wakefield's 13 co-authors disavowed the findings of the 1998 study. Although the study never claimed to have definitively proven a link between the MMR vaccine and autism, sensational media reports ignited a public panic. MMR vaccinations fell dramatically.

More rigorous studies have found no link between autism and the MMR vaccine. Last year, the U.S. "vaccine court" rejected U.S. lawsuits claiming that there was a plausible link between the vaccine and autism.

Wakefield continues to proclaim his innocence and defends his earlier work. He now resides in Texas, where he is executive director of an alternative medicine center for autism treatment and research.

SOURCES:

The Lancet, published online Feb. 2, 2010.

New Year Insurance Changes

2010-01-25T07:57:00.000-08:00

Dear Families and Friends,
I hope everyone enjoyed a safe and joyous holiday season. Now that the holidays are behind and the kids are back to school, it's likely that many of you will be in the office for sick visits and of course your yearly annual well child check ups.

The new year brings for many of our families changes in either insurance carrier or simply changes of your policy withing the same carrier. Many employers have moved from traditional HMO and PPO plans to High deductible , HSA plans where deductible is the part the patient owes the doctor's office. I know from experience these changes can be confusing, and I am happy to help answer any questions you may have regarding insurance billing. With that said, it is ultimately the patient/parents responsibility to know what is a covered service or is not a covered service on your individual plans. Finally, please remember to bring your newest insurance card with you to each visit and to be mindful of changes to your individual policy. Thank you in advance for cooperation.
Sincerely,
Kristin Silver
Office Manager

Developmental Milestones-Possible Red Flags

2010-01-21T05:35:00.000-08:00

Most parents wonder from time to time if their child is developing “normally”. The American Academy of Pediatrics and other national groups have well established guidelines for development, but keep in mind they are just that—guidelines. There can be a wide range of normalcy around these milestones, particularly when you take into consideration prematurity and illness states.
As your healthcare providers, it is important for us to regularly assess your young child for age appropriate skills and behaviors. As long as she/he is continuing to learn and do new things, all should be well!
Listed below are some possible red flags for delayed development. It is important to recognize these possible signs in a timely manner and have the child evaluated by a developmental specialist or early intervention agency. Locally, Early Steps or Face-Autism, Inc. provides free screening for children less than 3 years of age. Children over 3 years can be seen through the school system or privately by Neurology or Psychiatric Services.

Possible Red Flags

The child:
> Does not respond to name by12 months of age or to parent’s smile or other facial expressions
> Doesn’t snuggle when picked up, but arches the back instead
> Does not point to objects to show interest (like the fire truck going by) by 14 months
> Doesn’t play pretend (“feeding dolly” or “driving” the car) by 18 months of age
> Doesn’t bring objects to “show” to parents
> Avoids eye contact and would rather play alone
> Doesn’t say single words by 15 months or 2-word phrases by 24 months
> Repeats exactly what others say without understanding its meaning (parroting or echolalia)
> Doesn’t start or can’t continue a conversation
> Seems to be unaware when others are talking to them but responds to other sounds like a car horn
> Does repetitive behaviors like rocking, spinning, swaying, twirling of fingers or flapping hands (esp. when excited or upset)
> Likes routines, order and rituals
> Doesn’t show concern or empathy for others

If you have any concerns about your child or grandchild, please bring it to our attention so we can assess and make appropriate referrals.

Some Thoughts About Skin

2009-12-18T13:52:00.000-08:00

Seven Steps to Stop Sweaty Feet

There are 250,000 sweat glands in each foot, producing half a pint of moisture per day. People with excess sweating, called hyperhidrosis, can sweat much more than that, leading to scaling, fungus infections, and overall sandal-unworthy feet.

If you have mild to moderate excess sweating:

Wash your feet every day with antibacterial soap, such as an antibacterial hand soap. Then dry them completely, including between the toes (you know you don’t).
Use a hairdryer on the cool setting to get your feet completely dry.
Apply a foot powder (powder is better than corn starch, which tends to absorb the moisture, leaving a wet paste on your skin). Try Lamisil AT defense with tolfnaftate, an antifungal, if you have a tendency to get athlete’s foot, or try Dr. Scholl’s Deodorant Foot Powder with Zinoxol (zinc oxide and baking soda) if you have smelly, sweaty feet.
Wear synthetic socks, instead of cotton (yes, you read it right. NOT cotton). Synthetic socks wick moisture away instead of trapping it like a sponge. Try Adidas’ Clima Cool socks.
Use a spray antiperspirant such as Gold Bond Maximum Strength Foot Spray. Your regular underarm antiperspirant will work as well, but the aluminum chloride concentration is much lower, so it is less effective.

If you have seriously sweaty feet or hyperhidrosis:

Call our office. We can prescribe a prescription-strength antiperspirant (Drysol ®). After one week of applying Drysol nightly, most patients have a significant reduction in foot sweating. It can, however, be irritating and some people cannot tolerate using it every day.
Botox®. Yup, Botox. When injected into your feet, it blocks the signal from the nerves that turn on your sweat glands, stopping sweating. The downside: getting stuck with little needles about a hundred times on the bottom of your feet. The upside: a marked reduction in sweating that lasts many months.

Will Drinking Water Moisturize Your Skin?

This is a popular myth, perpetuated by fitness and fashion magazines.

Only one study ever linked drinking water with skin hydration. That study used expensive mineral water, not plain bottled or tap water, and the study didn’t have any impact on your skin and no controlled study has ever shown that any type of drinking water has an effect on your skin.

From a physiologic perspective, drinking water could only have a negligible impact on your skin’s hydration. In fact, patients who have too much water in their tissues (edema) do not have healthy skin. For example, patients with venus insufficiency who have swollen, fluid filled legs have skin that is often dry, itchy, and scaly.

The amount of water in your skin after a 5 minute shower is magnitudes higher than you could achieve by trying to hydrate it from the inside out. The key is to apply a cream or ointment when your skin is still wet to seal in the moisture.

Then drink as little or as much water as you like.
Lotion or Cream?
When cool, dry air hits it makes many patients’ skin dry. Many tell me that their skin remains scaly and itchy despite moisturizing daily. The best advice I can give is to teach them to moisturize properly.

The first question I ask is: Are you using a lotion or a cream?

The difference between the two comes down to the water content. Creams and lotions are mixtures of oil and water. It is the oil component that is most important for your dry skin.

Lotions are droplets of oil mixed in water. They have a high water and low oil content. As such they are easy to spread on dry skin. However, the water is not well absorbed and quickly evaporates, which actually dries your skin further.

In contrast, creams are droplets of water mixed in oil. They have a high oil and low water content. They are more difficult to smear on dry skin but apply easily to moist skin. Therefore, they are best used immediately after your shower or bath when your skin has soaked up the water like a sponge. Applying cream then creates a layer of oil that locks the moisture in your skin. The water does not evaporate, and your skin stays hydrated.

This is why in the wintertime I advise patients to use only creams. In the warm, humid summer, lotions are actually better.

Lip Licker's Eczema

2009-12-18T13:50:00.000-08:00

With holiday and winter ski trips upon us, this common childhood aliment is likely to arise. When many kids have dry skin, they often also get red irritated skin around their mouths. As the skin gets irritated, many children will begin to lick the area to keep it wet. Unfortunately, the chronic licking establishes a pattern of accelerated evaporation and destruction of the epidermal barrier leading to the classic lip licker's dermatitis. Out of desperation, parents try topical steroid creams and antifungal products with little improvement. Fortunately, this type of rash usually responds well to water barrier moisturizers such as Vaseline, Aquaphor Healing Ointment, and Eucerin Original Moisturizing Cream, etc. The trick is that you have to put moisturizers around your child's lips several times an hour, to help break the cycle of irritation and lip licking.

Sunscreens, UVA and UVB

2009-12-18T12:17:00.000-08:00

I took this from a journal called The Prescriber's Letter. It discusses a few of the things to be considered when buying a sun screen.

A new sunscreen called Mexoryl SX will raise questions about optimal sunscreen protection.
SPF is often misunderstood. SPF applies only to UVB...not UVA. UVB causes the familiar sunburn. Explain that SPF is an estimate of how long a person can stay in the sun without obvious sunburn.
For example, if a person would burn in 10 minutes with NO protection, then an SPF 15 sunscreen will protect 15 times longer or 150 minutes...and an SPF 30 would protect 30 times longer or 300 minutes.
Tell patients there's no proof that an SPF over 50 gives any measurable added benefit.
UVB ratings get the most attention, but are only part of the story.
UVA ratings will appear on some sunscreens. You'll see 1, 2, 3, or 4 stars indicating low, medium, high, or highest protection.
UVA causes skin aging and skin cancer...not visual sunburn.
For now, recommend sunscreens labeled broad-spectrum. These contain UVA blockers such as avobenzone, zinc oxide, and/or titanium.
You'll now see Mexoryl SX (ecamsule) in some Anthelios sunscreens. Mexoryl SX covers some of the shorter UVA rays that are not covered by avobenzone...and it's more stable in sunlight.
But when avobenzone is combined with octocrylene, oxybenzone, or other ingredients it's more stable and has a broader spectrum.
Recommend zinc oxide or titanium dioxide for sensitive skin. They block UVA and UVB by sitting on top of the skin...not binding to it.
Water resistance ratings refer to how long the product is effective during swimming, heavy sweating, etc.
Explain that a product labeled "water-resistant" lasts about 40 mins in water...and a "very water-resistant" product lasts about 80 mins.
Proper application is key. Instruct people to apply sunscreen 20 minutes before sun exposure...and reapply at least every 2 hours.
Emphasize applying enough...about 1/2 to one teaspoon per body part (leg, arm, back, face, etc)...or about 1 ounce for the full body. Applying only half the amount will give only half the protection.
Advise avoiding sunscreen/insect repellent combos. Suggest using separate products because the sunscreen needs to be applied more often than the repellent. Advise patients to apply the sunscreen first, then the repellent.
Drug-induced photosensitivity is primarily due to UVA rays.
Advise patients taking photosensitizing drugs to use a broad-spectrum sunscreen.

H1N1 Flu vaccine recall for ages 6-35 months

2009-12-16T07:49:00.000-08:00

Most of you have heard about the recall of H1N1 flu vaccines for ages 6-35 months. We recieved from the CDC the lot numbers that were affected by this recall and are happy to announce these are not the lots that our office has in stock. So if your child is in this age range and received their vaccine in our office this recall does not pertain to them. Also, if your child is still due for their second dose we still have vaccine available. If you have further questions or concerns please see the link from the CDC which gives you the full report on the recall. http://www.cdc.gov/h1n1flu/vaccination/syringes_qa.htm

Sears Treats Reservists Right

2009-12-14T14:07:00.000-08:00

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This is another post that doesn't have much to do with children's health, but if you or a loved one is or has served in the military's reserves, you will be pleased to find that some large corporations are driven by more than just profit. This is taken from an e-mail that has been circulating through our in-boxes lately, and has been verified by Snopes.com. Read on.

Subject: Sears

I assume you have all seen the reports about how Sears is treating its reservist employees who are called up? By law, they are required to hold their jobs open and available, but nothing more. Usually, people take a big pay cut and lose benefits as a result of being called up...Sears is voluntarily paying the difference in salaries and maintaining all benefits, including medical insurance and bonus programs, for all called up reservist employees for up to two years. I submit that Sears is an exemplary corporate citizen and should be recognized for its contribution.

Suggest we all shop at Sears, and be sure to find a manager to tell them why we are there so the company gets the positive reinforcement it well deserves.

Pass it on.

So I decided to check it out before I sent it forward. I sent the following email to the Sears Customer Service Department:

I received this email and I would like to know if it is true. If it is, the Internet may have just become one very good source of advertisement for your store. I know I would go out of my way to buy products from Sears instead of another store for a like item even if it was cheaper at the other store.

Here is their answer to my email......................

Dear Customer:

Thank you for contacting Sears.

The information is factual. We appreciate your positive feedback. Sears regards service to our country as one of greatest sacrifices our young men and women can make. We are happy to do our part to lessen the burden they bear at this time.

Bill Thorn
Sears Customer Care
webcenter@sears.com
1-800-349-4358

Please pass this on to all your friends, Sears needs to be recognized for this outstanding contribution and we need to show them as Americans, we do appreciate what they are doing for our military!!!!!!!!!!!

Interesting Facts About Salt

2009-12-14T14:01:00.000-08:00

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This has little or nothing to do with pediatrics and/or children's health. I just thought it is interesting, and you may, too.

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Mining salt in Bavaria
By Morgen Jahnke

Nowadays, we take salt for granted. Sold for a pittance, the most common of spices, we think of it as an everyday thing, when we think of it at all. It wasn’t always so. In fact, great empires and fortunes rose and fell according to its supply. It is hard to imagine a modern war being fought over salt. But consider these historical events, as recounted in Margaret Visser’s Much Depends on Dinner:
Morocco fought Mali in the sixteenth century for the mines of Taoudeni; the Venetians, whose salt interests are an historical study in themselves, destroyed Comacchio in the tenth century and the salt gardens of Cervia in the fourteenth; pirates throughout the centuries ambushed and raided the slow heavy convoys of salt ships.
There are plenty of other examples—all of which seem outlandish to us today, considering that the biggest battles fought over salt have to do with whether it should be spread over icy roads in winter. Salt has lost its nobility, its historical power—but from the salt-starved Vikings to the salt-greedy Romans, salt has played an important role in human history.

The Saltman Cometh

Nowhere does this seem more obvious than in the salt-rich environs of eastern Bavaria and western Austria. The de facto capital of the region, Salzburg (or “salt town”) was built by its first archbishop in the eighth century with profits from salt mining, but the practice of salt mining goes back even further, to the civilization of the early Celts. In his book Salt: A World History, Mark Kurlansky describes the discovery by local salt miners in the 1600s of a “perfectly preserved body, dried and salted ‘like codfish,’” believed now to date to 400 B.C. Dressed in colorful fabrics, this “saltman” and two others like him were found with the tools of their trade near them, proof of an ancient salt mining culture.

Salt of the Earth

This salt mining tradition continues in the modern salt works along the German/Austrian border, and it’s possible to experience some of what those ancient miners might have felt, deep in the mountains of salt. Founded in 1517, the Salzbergwerk Berchtesgaden (“Berchtesgaden salt mine”)—located near Salzburg but on the German side of the border—once entertained only aristocratic visitors, but now welcomes the public to its underground facilities and caves. Berchtesgaden, erroneously linked in the public imagination with Hitler’s southern headquarters (they were actually located at Obersalzberg, a small settlement further up in the mountains) is a town that developed in proximity to the Augustinian monastery that owned the Salzbergwerk. In the early 1800s the monastery was converted into a palace for the Wittelsbachs, rulers of Bavaria at the time, and the entire area became associated with this colorful family.

Mine Games

Still operational, the Salzbergwerk is a joy to visit. Donning the traditional leather vests and helmets of the miners, you start to feel as if you are a miner yourself. This sensation is heightened when, after a short train ride, you are asked to slide down a wooden chute into the mine itself. After overcoming my apprehension, I slid into the dark, feeling even more like a miner heading to work. Our guide, a local man, explained the workings of the mine to us—or so I gathered, since I couldn’t understand his thick “Bayrisch” accent. This only added to the feeling of being in a different world, a world where life goes on underground.
The most striking element of this topsy-turviness was the presence of a large underground lake in the mine. Gliding silently across its depths on a wooden platform boat, it was eerie to see the lights at its edges through the darkness, and to feel the oppressive nearness of the stone “ceiling.” I imagined myself gliding across the river Styx, and shivered in the damp air.

Worth Its Salt

Returning from the depths of the mine, it was hard to think of salt the same way again. It is, after all, the only rock that we eat, and with thousands of tons of it looming above your head, you don’t immediately think, “pass the salt.” Vital to the functioning of our vital organs, we would die without salt, yet we live in a salt-glutted world, so much so that we are told to reduce our intake, for the sake of our health.
In their song “NaCl (Sodium Chloride),” folk singers Kate and Anna McGarrigle make a case for the worthiness of salt. Describing the meeting, mating and melding of a sodium atom and a chlorine atom in the primordial sea, they ask us to “Think of the love that you eat, when you salt your meat.” Silly, meant to be taken with a “grain of salt,” yet it expresses the mystery of salt, the serendipitous compound that protects our cells, and fills the ocean. —Morgen Jahnke

Roller Shoes are Risky Business

2009-12-14T13:55:00.000-08:00

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Protective Gear Recommended When Using Roller Shoes
By Jennifer Warner
WebMD Medical News
Reviewed by Louise Chang, MD
June 4, 2007 --

Gliding down the sidewalk in roller shoes may look like fun, but without protective gear the shoes may wind up sending kids straight to the emergency room.
A new study shows one hospital reported 67 cases of injuries caused by roller shoes last summer vacation. Wrist injuries were the most common. No protective gear was used during the time of these injuries.
"To reduce the rate of such injuries, parents buying roller shoes need to understand both the benefits and risks of this activity," write researcher Mihai Vioreanu, MRCSI, of Temple Street Children's University Hospital in Dublin, Ireland, and colleagues. "Full protective gear needs to be used at all times, including a helmet, wrist guards, knee pads, and elbow pads when using roller shoes."
Roller shoes are a popular type of sneaker that has a detachable or convertible wheel in the heel, which allows the wearer to lean back and glide on the wheel as well as walk. They're often sold under the brand names "Heely" or "Street Gliders."
The shoes were introduced in 2000 in the U.S., but researchers say little is known about their safety.

Roller Shoes Tied to Injury

In the study, published in Pediatrics, researchers tracked the number of roller shoe-related injuries at their Dublin hospital during the 2006 summer school holiday.
They found 67 children suffered orthopedic injuries while using Heelys or Street Gliders, such as broken bones or dislocated joints. Girls were much more likely to be injured than boys, and the average age of injured children was just under 10.
The study showed:
Broken wrists were by far the most common type of injury reported. Other injuries included other broken bones in the arm, elbow dislocation, foot and ankle injuries, and broken bones in the leg.
Injuries were most commonly caused by falling backward or forward as the child tried to transfer their body weight and find balance on the wheels. In a few cases, the injury was caused by jumping or a sudden change of direction.
Most of the injuries happened while gliding outdoors on a road, sidewalk, cycle lane, or playground.
Researchers also found that 20% of the injuries occurred on the first time the child tried to use the roller shoes and 36% occurred while they were learning to use them.
They say the results show that close adult supervision is needed during this learning curve and use of protective gear, including wrist guards, is recommended at all times.

What Are Probiotics and Why Do I Need Them?

2009-12-14T13:27:00.000-08:00

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I am using more and more probiotics in my practice, for problems as wide-ranging as "tummy viruses" to ulcerative colitis and most everything in-between. Here's a little primer on what they are and what they do.

Prepared for the subscribers of
Pharmacist’s Letter / Prescriber’s Letter to give to their patients.
Copyright © 2006 by Therapeutic Research Center

What are probiotics?
Probiotics are live, “friendly” organisms that live in the intestine. They help decrease “unfriendly”
bacteria and viruses that cause diseases such as diarrhea. Examples of probiotics include Lactobacillus,
Bifidobacteria, and Saccharomyces boulardii.

For what conditions are probiotics effective?
Certain probiotics have been shown to be beneficial for preventing and treating some types of diarrhea, including diarrhea caused by antibiotics. Probiotics also seem to help some bowel diseases such as ulcerative colitis and irritable bowel syndrome.
Some yogurts that contain the probiotic Lactobacillus might also help women who get frequent vaginal yeast infections. However, eating yogurt doesn’t seem useful for preventing vaginal yeast infections caused by antibiotics.

What probiotic products are available, and how do I choose one?
Not all probiotic products are the same. Some do not contain what they say on the label. Others do not contain enough live organisms to be effective. And some probiotics work better for certain conditions than others. Clearly, product selection is important. To prevent diarrhea caused by antibiotics, choose Culturelle (Lactobacillus GG) or Florastor (Saccharomyces boulardii). You can also try these products for prevention of traveler’s diarrhea. Start taking them a few days before travel, and continue them for the duration of your trip. Yogurt is a source of probiotics, but not all yogurts contain the right kinds of organisms. Choose a
product with the National Yogurt Association’s “Live and Active Cultures” seal on the label (e.g., Dannon, Yoplait). You will need to eat about 8 oz twice daily to prevent antibiotic-associated diarrhea. To prevent frequent vaginal yeast infections, try 6 oz daily of a yogurt containing Lactobacillus acidophilus.
VSL#3 is a probiotic mixture used for certain bowel conditions such as ulcerative colitis and irritable bowel syndrome. It may help reduce stomach pain and bloating if you have irritable bowel syndrome. Studies published just this year (2009) have documented VSL #3 and Align as very effective for bloating and cramping.

What are the side effects of probiotics?
In some people, probiotics can cause stomach and intestinal upset, including gas and bloating. These usually improve with time.

Are there any drug interactions with probiotics?
Antibiotics are used to reduce harmful bacteria in the body. They can also reduce friendly bacteria like Lactobacillus and Bifidobacteria. If you are using these probiotics or yogurt, you should take them at least two hours before or after the antibiotic. The calcium in yogurt can also decrease the effectiveness of some antibiotics. You may need to allow more than two hours between eating your yogurt and taking your antibiotic. Check with your pharmacist for the best way to avoid this interaction. Saccharomyces boulardii is a fungus. Medications for fungal infections help reduce fungus in and on the body. Taking Saccharomyces boulardii with medications for fungal infections can reduce its effectiveness. Some medications for fungal infections include Diflucan, Lamisil, Sporanox, and others.

Who should not take probiotics?
For healthy people, routine use of probiotics to maintain bowel health is unnecessary. There is a small risk of infection with probiotics. If you have a weakened immune system you should not take probiotics unless you’ve checked with your healthcare professional. If you are pregnant or breastfeeding, you
should get approval from your healthcare professional before taking any probiotic other than yogurt.
Detail-Document #220704
−This Detail-Document accompanies the related article published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
July 2006 ~ Volume 22 ~ Number 220704
More. . .
Copyright © 2006 by Therapeutic Research Center

What Should I Eat to Get My . . .?

2009-12-14T13:14:00.000-08:00

I'm often asked what foods are best for a variety of different nutritional entities. I just found this little list, and while it is not exhaustive, it's a good start.
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Vitamin B6: Beans, nuts, legumes, eggs, meats, fish, whole grains, and fortified breads and cereals

Folate: Beans and legumes, citrus fruits and juices, wheat bran and other whole grains, dark green leafy vegetables, poultry, pork, shellfish, liver

Vitamin D: Fish, fish oils, oysters, fortified foods such as cow milk, soy milk, rice milk, and some cereals

Calcium: Milk, yogurt, buttermilk, cheese, calcium-fortified orange juice, green leafy vegetables (broccoli, collards, kale, mustard greens, turnip greens, and bok choy or Chinese cabbage), canned salmon and sardines canned with their soft bones, shellfish, almonds, Brazil nuts, dried beans

Zinc: Beef, pork, lamb, oysters; dark meat of poultry, peanuts, peanut butter, nuts, and legumes (beans), fortified cereals

Essential fatty acids (omega-3 fatty acids such as linolenic acid)

Fish (tuna, salmon, and mackerel oil) fish oil, flax seeds, flax oil, canola oil, walnut oil, dark green leafy vegetables

Tryptophan: Turkey, chicken, fish, milk, cheese, eggs, soy, tofu, sesame seeds, pumpkin seeds, tree nuts, peanuts, peanut butter

Irritable Bowel Syndrome

2009-12-14T12:45:00.000-08:00

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Irritable bowel syndrome (IBS) affects more than one in ten people. Little is known about the causes of IBS. It can be worsened by stress or emotional upsets. There may be differences in the symptoms of IBS between patients. This means that, of the many different treatment approaches available, you and your healthcare provider will need to select those that are most likely to help your individual symptoms.

What nondrug measures can I use?

Many people say that changing their diet is helpful. Some common culprits thought to make IBS worse are caffeine; alcohol; sorbitol (the artificial sweetener); fried or fatty foods; and gas-forming foods like cabbage, broccoli, or beans. Make sure that, if you do exclude something from your diet, you aren't risking any type of deficiency (calcium, for example, from eliminating dairy products).
Adding fiber might be helpful for reducing the symptoms of IBS. Soluble fiber is best (supplements like Metamucil and dietary sources like applesauce, oatmeal, potatoes, and rice). Insoluble fiber, like wheat bran, doesn't seem to work. The downside of fiber is that it can increase your chances of having gas and bloating. Add fiber gradually to reduce these effects.
You may also benefit from eating smaller, more frequent meals. Large meals can sometimes worsen IBS symptoms.
While stress does not appear to cause IBS, it may make the symptoms worse. Some patients have found that techniques to reduce stress or a good exercise program are helpful. There's no harm in trying, so do what works best for you.

Are there medications I can take?

Over the years a number of different medications have been tried for IBS. You should always consult with your healthcare provider before trying any medication, especially nonprescription ones. Listed below are the most commonly used medications for IBS. Some of these medications require a prescription.
Antidiarrheal agents. Loperamide (Imodium) can be used for diarrhea, but it doesn't help with stomach pain and bloating.
Antispasmodics. Hyoscyamine (Levsin [U.S.]), dicyclomine (Bentyl [U.S.], Bentylol [Canada]), and hyoscine butylbromide (Buscopan [Canada]) can reduce pain and cramping by decreasing muscle spasms in your intestinal tract. They're especially helpful if your IBS symptoms are worsened by meals. However, antispasmodics may have some unpleasant side effects such as dry mouth, sedation, and constipation.
Laxatives. Osmotic laxatives, like polyethylene glycol or PEG (Miralax [U.S.], Lax-A-Day [Canada]) and milk of magnesia (MOM), can be tried for constipation.
Antidepressants. Antidepressants can reduce IBS symptoms as well as relieve depression and anxiety.
Herbal products. Several products have been tried that are available without a prescription. For example, peppermint oil is an antispasmodic that may help. You should consult with your healthcare provider before trying any alternative medications as these are active compounds and may have other physical effects and drug interactions that need to be considered.
Probiotics. Some probiotics might help with the symptoms of IBS, like bloating and gas. Look for products that contain Bifidobacteria, as this probiotic seems to be the most beneficial. Some products that contain Bifidobacteria include Align (U.S.), Activia (U.S.), Bifidox (Canada), or VSL #3.
Other therapies. Lubiprostone (Amitiza [U.S.]) is a prescription drug that's helpful for women with IBS who have constipation. Alosetron (Lotronex [U.S.]) is another prescription drug that's sometimes used in women with severe IBS with diarrhea. These drugs are expensive and have some important side effects, so they are generally used when other treatments have failed.

Where can I go for information?

There are some very good places on the internet where patients with IBS can go to keep up with current information about this disorder. A listing of these sites is given for your reference. Remember to talk with your healthcare provider about any information you find so you can discuss which treatments are best for you.
International Foundation for Functional GI Disorders: www.iamibs.org
The UNC Center for Functional GI and Motility Disorders: www.med.unc.edu/medicine/fgidc
The IBS Page: www.panix.com/~ibs/
IBS Resource Center: www.healingwell.com/ibs/
Canadian Society of Intestinal Research: www.badgut.com/
May 2009

Treatments for Irritable Bowel Syndrome (IBS)
Background
Irritable bowel syndrome (IBS) affects about 7% of individuals in North America. It's defined by abdominal pain and altered bowel habits for a period of at least three months. Patients can experience predominant constipation (IBS-C), predominant diarrhea (IBS-D), or mixed symptoms (IBS-M). Unlike organic bowel diseases (e.g., celiac sprue, colitis, inflammatory bowel disease, etc), there are no structural or biochemical abnormalities associated with IBS.1 A new systematic review of therapies for IBS was recently published. This document discusses the treatments for IBS and their evidence for effectiveness. Recommendations for managing IBS patients are also included.

Fiber and Laxatives

Increasing fiber is one of the most common recommendations made to IBS patients, with the intent of reducing pain and regulating bowel function. However, studies show that insoluble dietary fiber, like wheat bran, is unlikely to improve symptoms.1
Patients may get improvement in overall IBS symptoms with psyllium hydrophilic mucilloid (Metamucil, etc). This is a soluble fiber, which absorbs water and forms a gel that helps food move smoothly through the GI tract. One study also showed some benefit of using calcium polycarbophil (FiberCon [U.S.], Prodiem Bulk Fibre Therapy [Canada], etc) compared to placebo. Like psyllium, calcium polycarbophil is a hydrophilic bulk-forming laxative.1
The downside of adding fiber is the potential for an increase in bloating, abdominal distension, and flatulence. Gradually adding fiber might help avoid this.1
One small study suggests that the osmotic laxative polyethylene glycol (PEG) (Miralax [U.S.], Lax-A-Day [Canada]) can double the frequency of bowel movements in patients with IBS-C. However, pain intensity is not reduced by osmotic laxatives.

Antidepressants

Pooled data from studies of both tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) (n=789) show that these drugs are likely to improve overall symptoms of IBS, regardless of IBS type. About one in four patients treated will have some benefit.
The largest individual trial with a TCA (n=216) looked at desipramine. The dose was started low, and then titrated up to a dose recommended for the treatment of depression. (However, most trials used low doses of TCAs, and using antidepressant doses don't appear to be necessary).2 The presence of depression did not predict a response to treatment for IBS symptoms. A high incidence of side effects resulted in a dropout rate of almost one-third of subjects.1
SSRIs have a better side effect profile than TCAs. Unlike TCAs, good evidence for efficacy in improving IBS symptoms from individual trials of SSRIs is lacking.1
The SSRIs have a prokinetic effect, so they might work better in patients with IBS-C. Since TCAs are more likely to cause anticholinergic side effects like constipation, they might be better for individuals with IBS-D.1 Experts say that TCAs might be best for improving pain.

Antispasmodics

Antispasmodics (e.g., dicyclomine [Bentyl-U.S., Bentylol-Canada], hyoscyamine [Levsin-U.S. only], hyoscine butylbromide [Buscopan-Canada only]) as a class can provide short-term relief of symptoms like abdominal pain and discomfort from IBS. The reason for this might be that pain with IBS is caused by colonic smooth muscle spasms.1
Systematic review (n=1,778) suggests that about one patient will have symptom relief for every five patients treated with an antispasmodic. However, most of the antispasmodics that have been studied for IBS are not available in the U.S. or Canada. In addition, studies typically have not specified the type of IBS treated.1
The most common side effects with antispasmodics are anticholinergic in nature. These include dry mouth, dizziness, and blurred vision. About one in 18 patients treated will experience a side effect, according to available data.
Limited data suggest that peppermint oil, thought to relax smooth muscle in the GI tract, might improve symptoms of IBS in about one out of three patients treated. Side effects reported in studies were rare.1
The usual dose of peppermint oil for adults with IBS is 0.2 to 0.4 mL given three times daily, in enteric-coated liquid-filled capsules.
Antispasmodics should be considered especially when IBS symptoms are exacerbated by meals. In this case, they can be taken about 30 minutes before a meal, on an as-needed basis.

Antidiarrheals

Since patients with IBS-D have a faster colonic transit than healthy patients, drugs that slow colonic transit might be beneficial. There is some data on loperamide. Loperamide (Imodium, etc) doesn't help for IBS symptoms like pain, but it does reduce frequency and improve stool consistency in almost all patients who are treated.1
Alosetron (Lotronex)
There's good evidence that alosetron (Lotronex, available in U.S. only), a serotonin 5HT-3 antagonist, is better than placebo at improving IBS symptoms in patients with IBS-D.1,5
The majority of the body's serotonin is found in the GI tract. Serotonin plays a major role in GI motor and secretory function and visceral sensation. Antagonism at the 5HT-3 receptor specifically delays GI transit, reduces colonic tone, decreases the gastrocolic reflex, and decreases visceral sensation.1
Data from eight placebo-controlled trials (n=5,000) show that about eight patients will need to be treated with alosetron for one patient to experience adequate relief from discomfort and urgency. However, alosetron has serious side effects that include constipation and colon ischemia. The number needed to harm (NNH) for one adverse event with alosetron is ten. About one patient for every 1,000 patient-years of alosetron treatment will have ischemic colitis.1
The benefit vs. risk is most favorable in women who have not responded to other therapies. Several years ago, alosetron was pulled from the market for a period of time. However, it was subsequently returned to the U.S. market, and has since been available through a special prescribing program for women with chronic, severe IBS-D who have failed other therapies.5
A 30-day supply of 1 mg twice daily of Lotronex costs over $1,000.
Tegaserod (Zelnorm)
Tegaserod (Zelnorm) is better than placebo at relieving IBS symptoms in women with IBS-C and IBS-M. However, cardiovascular events like stroke and heart attack are more common with tegaserod compared to placebo. It was withdrawn from the U.S. market in 2007.1
For a period of time, tegaserod was available through FDA under a treatment investigational new drug application (T-IND) protocol. However, it is no longer available under the T-IND, and is only available for emergency use in life-threatening situations.
Tegaserod is no longer available in Canada.
Lubiprostone (Amitiza)
Lubiprostone (Amitiza), available in the U.S. but not Canada, is more effective than placebo at relieving IBS symptoms in women with IBS-C. Its efficacy in men has not been conclusively demonstrated.6
Lubiprostone is derived from prostaglandin. It's a C-2 chloride channel activator. Lubiprostone works topically from the luminal surface of the GI tract to promote chloride secretion into the intestine. Sodium then enters the lumen as a result of the negative charge of the chloride ions, and water follows passively.6
The most common side effects with lubiprostone are nausea, diarrhea, and abdominal pain. Lubiprostone is contraindicated in patients with mechanical bowel obstruction.6
Lubiprostone was first approved for the treatment of chronic constipation. The recommended oral dose for constipation is 24 mcg twice daily. Note that the dose of lubiprostone for IBS is lower, at 8 mcg twice daily.6
A 30-day supply of lubiprostone will cost cash-paying patients around $220.

Antibiotics

Short courses of non-absorbable antibiotics are better than placebo for improving overall symptoms of IBS, and for reducing bloating specifically. There's data for rifaximin (Xifaxan, available in U.S. only), with three RCTs (n=545) supporting its superiority over placebo. Duration of effect is variable. Symptom improvement can last after the antibiotic is stopped, for ten weeks or more in some cases. Most of the patients studied had IBS-D.1
Studies of rifaximin for IBS used higher doses than the FDA-approved dose for treatment of traveler's diarrhea, which is 200 mg three times daily for three days. The dose of rifaximin studied for IBS was 1,100 to 1,200 mg divided two to three times daily for ten to 14 days.1
No severe adverse events were seen with these high doses of rifaximin. Two of the rifaximin studies reported individual side effects, and there was no significant difference between the rifaximin and placebo groups.

Probiotics

Nineteen trials evaluating the use of probiotics in IBS patients (n=1,668) were included in a systematic review. Eleven of these studies (n=936) looked at improvement in IBS symptoms as a dichotomous (benefit vs. no benefit) type of outcome. About one in four patients treated had symptom improvement. All of the different probiotics, including Lactobacillus, Bifidobacteria, Streptococcus, and combinations, showed a trend toward benefit.1
However, when the degree of improvement in IBS symptoms was considered as reported in fourteen trials (n=1,351), Lactobacillus did not have an effect on IBS symptoms. Probiotics with Bifidobacteria (e.g., Align, Activia, VSL #3 [all U.S. only]; Bifidox [Canada]) appear to be more effective.1 For more information about probiotics and their uses see our, "Comparison of Probiotic Products."

Nondrug Therapies

Pooled data (n=1,278) show that psychological therapies (e.g., cognitive behavioral therapy, interpersonal psychotherapy, hypnotherapy) can improve overall symptoms of IBS. However, relaxation therapy alone does not offer any benefit. The mechanism for improvement of IBS symptoms might be stress reduction, empathic attitude of the provider, etc.1
There isn't good evidence to support avoiding specific foods to help improve symptoms of IBS. However, the majority of patients relate symptoms to consumption of certain foods and as a result, avoid those foods. If this is the case, don't discourage the patient unless exclusion of the particular food could lead to dietary deficiencies.

Conclusion

There are a wide variety of treatments for IBS, with varying degrees of effectiveness. Treatment decisions are often based on the severity of disease, and on the predominant IBS symptom of either constipation or diarrhea.3
For all patients with IBS, insoluble fiber like psyllium can be tried for regulating bowel movements and reducing pain.1 Be aware of the potential for gas and bloating. Introduce fiber gradually to minimize these side effects.1
Recommend antispasmodics or peppermint oil to reduce abdominal discomfort.1,2 Consider this especially for patients whose symptoms are worsened by meals.3 Antidepressants might also help with abdominal pain.1
Probiotics containing Bifidobacteria might help improve bloating and flatulence associated with IBS.1 SSRIs or TCAs can be tried for overall symptom improvement as well.1 Consider SSRIs for IBS-C, and TCAs for IBS-D.
Recommend loperamide to reduce the frequency of bowel movements for patients with IBS-D, but don't expect it to help with abdominal cramping.1 Reserve alosetron (Lotronex) for women with severe IBS-D refractory to other therapies. It's available through a restricted prescribing program because of the increased risk for ischemic colitis.1
Try osmotic laxatives like PEG for increasing stool frequency in patients with IBS-C.1 Reserve lubiprostone (Amitiza) for women with IBS-C who haven't responded to other therapies. It's prescription only and quite expensive.1
Psychotherapy can help improve symptoms of IBS, possibly by reducing stress.1 But relaxation therapy alone doesn't offer any advantage over usual care.1
Project Leader in preparation of this Detail-Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor

References

1.Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. An evidence-based systematic review on the management of irritable bowel syndrome. Am J Gastroenterol 2009;104:S1-S35.
2.Jellin JM, Gregory PJ, et al. Pharmacist's Letter/Prescriber's Letter Natural Medicines Comprehensive Database. http://www.naturaldatabase.com (Accessed April 15, 2009).
3.American Gastroenterological Association. American Gastroenterological Association medical position statement: irritable bowel syndrome. Gastroenterology 2002;123:2105-7.
4.Mertz HR. Irritable bowel syndrome. N Engl J Med 2003;349:2136-46.
5.Product information for Lotronex. Prometheus. San Diego, CA 92121. April 2008.
6.Product information for Amitiza. Takeda. Deerfield, IL 60015. April 2008.

Holiday Hours/Closing

2009-12-01T07:35:00.000-08:00

Meyer Pediatrics will be closed for Christmas & New Years Holiday as follows:

December 24th - Christmas Eve - Closed at noon.
December 25th - Christmas Day - Closed
December 26th - Saturday - Closed

December 31st - New Years Eve - Open
January 1st - New Years Day - Closed
January 2nd - Saturday - Open

We hope everyone enjoys celebrating the holiday with family and friends!

A "Discussion" With Jim Carrey About Autism

2009-11-25T12:18:00.000-08:00

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The following is a response to actor Jim Carrey following his TV appearance with his wife (and former Playboy bunny) Jenny McCarthy and his very vocal assertions that vaccines cause, or are a causative agent of autism. Mr. Carrey, and especially his wife, have been very outspoken about their belief that vaccines, or a component of vaccines, are associated with autism.

This idea was first proposed by a British doctor who published a "study" allegedly proving that vaccines (specifically the MMR) caused autism. This article has since been proven to be a fake: 10 of the article's co-authors have admitted that they faked their numbers because they were silently being paid by a legal firm that wanted to file a class-action lawsuit. The main author of the study has had his license to practice medicine stripped by Great Britain because of the gross fraudulence involved in the study.

No controlled, double blinded study has EVER linked ANY vaccine with autism and every major health organization in the world (not just the US) has come out in support of vaccinations, and all of them have stated that all evidence is conclusive that vaccines are NOT associated with autism in any way.

Autism, which in reality is a group of different but related problems, is a genetic entity. I can understand that Ms. McCarthy has difficulty accepting that she may have contributed genetically to her child's problems, and that it is FAR more convenient to blame the evil vaccine industry, but facts are facts.

Don't be mislead by emotion, no matter how powerful. Listen to the facts. And now, back to our "discussion" with Jim Carrey.

Jim Carrey And The Autism Argument
By Kevin Leitch , Parent and Autism Activist - April 22, 2009

Today on The Huffngton Post, actor Jim Carrey posted his thoughts about autism and vaccines. With his very first paragraph it became apparent how little Carrey understood the issues involved:

Recently, I was amazed to hear a commentary by CNN’s Campbell Brown on the controversial vaccine issue. After a ruling by the ‘special vaccine court’ saying the Measles, Mumps, Rubella shot wasn’t found to be responsible for the plaintiffs’ autism, she and others in the media began making assertions that the judgment was in, and vaccines had been proven safe. No one would be more relieved than Jenny and I if that were true. But with all due respect to Ms. Brown, a ruling against causation in three cases out of more than 5000 hardly proves that other children won’t be adversely affected by the MMR…

Point one Mr Carrey. The vaccine issue is only controversial to adherents of your belief system. Within scientific, medical, legal, autistic and parental circles its not even slightly controversial.

Point two, the three cases chosen were chosen – by the plaintiffs legal team – to represent their absolute best chance of winning. If they had won, there was an excellent chance all the cases that were suggesting MMR as causation would have just ‘won’ automatically. Thats why its called an Omnibus.

Point three, regarding the MMR, it has been firmly established that:

a) The data supporting the MMR hypothesis was fixed.
b) The science supporting the MMR theory was badly wrong – both badly done and exposed to contaminants.

You might also note that the court was not attempting to see if the children were ‘adversely affected by the MMR’, it was looking to see – using the three cases the legal team representing the families thought were the absolute best – if MMR caused autism. It didn’t. Thats probably why your Campbell Brown found it easy to say the MMR hypothesis was dead and buried.

You go to say Mr Carrey that:

Not everyone gets cancer from smoking, but cigarettes do cause cancer. After 100 years and many rulings in favor of the tobacco companies, we finally figured that out.

Yes, we did – and do you know how? With good science – just like the science that established in the three MMR test cases that the MMR didn’t cause autism. And its fascinating that you bring up this parallel to the smoking issue and then later in your blog post invoke the name of Bernadine Healy. Healy – who’s ‘more sensible voice’ you say you’d rather listen to. Did you know Healy used to be a member of TASSC:

TASSC was created in 1993 by the APCO Worldwide public relations firm, and was funded by tobacco company Philip Morris (now Altria)....

According to Sheldon Rampton and John Stauber in their article How Big Tobacco Helped Create “the Junkman”, one of the forerunners of TASSC at Philip Morris was a 1988 “Proposal for the Whitecoat Project,” named after the white laboratory coats that scientists sometimes wear. The project had four goals: “Resist and roll back smoking restrictions. Restore smoker confidence. Reverse scientific and popular misconception that ETS (passive smoking) is harmful. Restore social acceptability of smoking.”

Is that what you consider a sensible voice Mr Carrey? Someone who supported the tobacco agenda?

Moving on, you say:

If we are to believe that the ruling of the ‘vaccine court’ in these cases mean that all vaccines are safe, then we must also consider the rulings of that same court in the Hannah Polling and Bailey Banks cases, which ruled vaccines were the cause of autism and therefore assume that all vaccines are unsafe. Clearly both are irresponsible assumptions, and neither option is prudent.

First and foremost, the vaccine court did not rule at all in the Hannah Poling case. HHS conceded. And what they conceded was that Hannah Poling was damaged by vaccines resulting in ‘autism like features’. In fact, when we look at the the one piece of medical science carried out on Hannah Poling (co-authored by her own father), we see that only three of the symptoms described as being the result of vaccine injury appear on the DSM (IV) diagnostic criteria for autism.

As for Bailey Banks, this is a perfect illustration of both how the vaccine court in the USA was designed to work and also how terrible the evidence was in the three MMR test cases.

The Banks ruling (subtitled ‘Non-autistic developmental delay’ by the way) drew a line of causation from vaccine to PDD-NOS. It is able to do this as the burden of proof for any science presented to the vaccine court is ‘50% plus a feather’. In other words, it just has to be plausible, no causation needs to be shown.

What doesn’t seem in doubt is that Bailey was injured by a vaccine which resulted in a condition called ADEM. The judge in the case then went on to accept the plaintiffs position that the ADEM in turn caused PDD-NOS. He did this seemingly because there was no evidence to the contrary – e.g. no evidence that ADEM doesn’t cause PDD-NOS.

In any scientific situation – including civil court in the US - this would never have been accepted. The plaintiff would have had to have demonstrated that ADEM did cause PDD-NOS. And a search of PubMed reveals nothing for ‘ADEM autism’ or ‘ADEM PDD’.

So, in the Banks case, because there was no evidence that ADEM does not cause PDD-NOS, they won. In every situation bar the vaccine court, the Banks’ would not have won their case. There is no science to support the idea ADEM causes autism.

Bearing this ‘50% plus a feather’ concept in mind it is clear just how utterly dreadful the evidence was to support the idea MMR caused autism. Not only could plaintiffs not provide any evidence that MMR causes autism, respondents produced reams of evidence to show it clearly doesn’t.

You carry on Mr Carrey to say:

I’ve also heard it said that no evidence of a link between vaccines and autism has ever been found. That statement is only true for the CDC, the AAP and the vaccine makers who’ve been ignoring mountains of scientific information and testimony. There’s no evidence of the Lincoln Memorial if you look the other way and refuse to turn around. But if you care to look, it’s really quite impressive. For a sample of vaccine injury evidence go to www.generationrescue.org/lincolnmemorial.html.

Your analogy is ridiculous. I could go to any library and find evidence for the Lincoln Memorial without ever seeing it. In fact, what your analogy does is demonstrate exactly how blinkered and able to only face one direction at one time you and your colleagues are.

The evidence you present as that being supportive of evidence between a link between vaccines and autism is equally ridiculous and blinkered. I simply don;t have the time to tackle the mountain of misinformation presented on the page you link to suffice to say there’s not a single section that doesn’t have a major error. Most of them have been tackled on this and other blogs over the years.

Next you say:

In all likelihood the truth about vaccines is that they are both good and bad. While ingredients like aluminum, mercury, ether, formaldehyde and anti-freeze may help preserve and enhance vaccines, they can be toxic as well. The assortment of viruses delivered by multiple immunizations may also be a hazard. I agree with the growing number of voices within the medical and scientific community who believe that vaccines, like every other drug, have risks as well as benefits and that for the sake of profit, American children are being given too many, too soon. One thing is certain. We don’t know enough to announce that all vaccines are safe!

Mr Carrey, vaccines do not contain anti-freeze – for goodness sake, even Jay Gordon, Evan’s Paediatrician knows that! Did you also know that (to quote myself):

There’s also Aluminium in breast milk so lets compare the two.

According to this paper (which is from 1990 – any more up to date papers welcomed) the amount of Aluminium in breast milk is 49 ?g/L. The average amount of breast milk expressed per day is 0.85 liters. This means that 41.65?g Aluminium per day is in breast milk. Now, according to this paper, there is between 125 – 850?g of Aluminium per dose in a vaccine.

So, for a 6 year old, total Aluminium is between 2,125 – 14,450?g. In real terms this means that after between 51 and 346 days breast feeding, a 6 year old will have taken onboard the same amount of Aluminium as from the total US vaccine schedule.

Now I couldn’t find out what vaccines contained the lower amount or which contained the higher amount. Even so, this means that if every vaccine a 6 year old has that contains Aluminium contains the highest possible amount, within a year of breast feeding they will have matched that. Or to put it another way, an anti-vax tree-hugger soccer mom who doesn’t vaccinate her baby will have given him the same amount of Aluminium he would’ve had in six years after one year of breast feeding.
And thats of course, not even touched on the fact that:

In the Earth’s crust, aluminium is the most abundant (8.13%) metallic element, and the third most abundant of all elements (after oxygen and silicon)

And is found naturally occurring in sea water, fresh water, the human body etc etc.

[Regarding Formaldehyde]..There’s also Formaldehyde in Apples, Apricots, Banana’s and….ah, I lost interest. Lots of stuff. Including the human body. So – how much is in vaccines? According to this and using it in combination with the US vaccine schedule referenced above, we can see that the total amount of Formaldehyde in vaccines from the vaccine schedule for a 6 year old child is 1.2016mg (again, do your own maths, correct me if I’m wrong).

For comparison to that 1.2mg in all vaccines for a 6 year old, 1 (one) banana contains 16.3mg Formaldehyde. Mr Carrey, you’ve got to stop throwing these scaremongering nonfacts around. Its damned irresponsible for a start.

Lastly Mr Carrey, you say:

If the CDC, the AAP and Ms. Brown insist that our children take twice as many shots as the rest of the western world, we need more independent vaccine research not done by the drug companies selling the vaccines or by organizations under their influence. Studies that cannot be internally suppressed.

In terms of autism, if you want to make a big deal out of the fact that ‘our children take twice as many shots as the rest of the western world’ then please consider this – the UK has less shots than you. We also have a higher prevalence than you. 1 in 100 vs 1 in 150.

And please also don’t invoke silly conspiracy theories. Think about how science works. A study is done, funded by Eli Lily for example. It is peer reviewed and found to be good quality and it is published in, lets say NEJM. Now, every single reader of that study can see exactly what methods and means were used to reach the studies conclusions. I ask you Mr Carrey, how much more independent can you get? How much more transparent? Basically anyone, anywhere can try and replicate that same studies results. If they can and a few others can – the results are good. If nobody can (think Andrew Wakefield) then the results must be bad.

And for goodness sake man, grow up, who is ‘suppressing’ what study exactly? Have you any evidence at all that any study ever has been internally suppressed? Or are you just throwing this stuff out to scare people?

Mr Carrey, I loved the Truman Show but this isn’t it. There’s no god like figure overseeing every aspect of your life and wanting to control it. I ask you – get in contact with an actual scientist and go through your concerns with them. At the very least they’ll be able to stop you saying silly things like there’s anti-freeze in vaccines.

Holiday Hazards

2009-11-25T12:05:00.000-08:00

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Holiday Poisoning Hazards

Preparations for the holidays are happy, hectic times that can double the risk of toxic exposures. Not only are attractive items brought into the home, but the disruption of the household routine means less supervision of curious children. Even safe homes can become hazardous when visitors bring purses with pills in them. Other hazards include:

Poinsettia: This plant is actually not very toxic, but the sap can be irritating. If a piece has been chewed, clear the mouth of plant material and offer something to drink.

Christmas Berry: The leaves and crushed pits are poisonous if a large amount is swallowed.

Holly: Eating a few berries can cause vomiting, cramps and diarrhea.

Mistletoe: Eating berries can cause vomiting, cramps and diarrhea. Large amounts can cause high blood pressure, seizures and confusion.

Christmas trees: The evergreens are non-toxic with the exception of the Yew, which has red cup-like fruits on its branches. The leaves and seed pits are toxic. Be careful what is added to the water in the Christmas tree stand. Pets may drink it and some preservatives are toxic.

Christmas tree ornaments: Antique or imported ornaments may have a lead-based paint which would be a hazard if ingested.

Tinsel: While non-toxic, these shiny icicles can cause airway or intestinal blockage if eaten by children or pets. Veterinarians perform at least one operation each Christmas season to remove tinsel from pets’ intestines.

Angel Hair: This tree decoration is made of spun glass that causes irritation upon contact.

Bubble Lights: These lights contain a poisonous liquid called methylene chloride that can be a danger if the fluid from several lights is swallowed.

Alcohol: Alcohol poisons children by causing a drop in their blood sugar and by making them dangerously drowsy. A combination of these two factors can cause coma. Holiday alcohol is available in many forms: perfume given as a gift, mixed drinks leftover after a party, or even mouthwash by the bathroom sink.

For an emergency or question about poisons, call the Poison Center toll-free 24 hour hotline 1-800-222-1222

For a free poison prevention information package, call our administrative line at (813) 844-7044 or write:
FL Poison Information Center,
Tampa General Hospital, P.O.Box 1289,
Tampa, FL 33601

The Florida Poison Information Center wishes you and your family
a healthy and happy holiday season!

The Gardasil Vaccination for HPV and Cervical Cancer

2009-11-25T11:37:00.000-08:00

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I also took this from Snopes.com. It's not a medical site, per se, but the information about the Gardasil vaccine is accurate. Gardasil prevents infection by the Human Papilloma Virus which is the cause of cervical cancer. Some cancers, such as cervical cancer and liver cancer, are caused by viral infections. So, you don't get the virus, then you don't get the cancer. Gardasil prevents infections from 2 of the HPVs that are responsible for about 70% of all cases of cervical cancer. This virus also causes genital warts, so the vaccine will also help prevent these minor STDs, but in my mind this is not the real reason to get the Gardasil vaccine.

At Meyer Pediatrics, we do recommend this vaccine, although it is NOT required for any school. The vaccine, which is given as a series of 3 shots spread out over 6 months, is available for girls age 9 to 26 and we will probably initiate a conversation with you at your daughter's 9 year old well check. She will never be required to get this vaccine. Boys are not currently eligible for the Gardasil (although it would not harm them to get it, and from a standpoint of social responsibility, it probably should be considered, but insurance companies are unlikely to ever pay for it), and from the look of things, they may never be.

Gardasil Vaccine Side-Effects

The following text is from an e-mail circulating the Internet right now:

32 Girls Have Died

11,916 adverse events already reported to the CDC ... and counting.

Pain and swelling. Life-threatening muscle weakness. Blood clots in the heart and lungs.

And the deaths of 32 innocent girls and young women.

You might think I'm talking about a deadly new disease or a global epidemic ...

I'm not.

Sadly, it's more sinister than that. The health threats listed above have all been linked with Gardasil, the so-called "cervical cancer vaccine." And thanks to Pharma giant Merck, desperate parents and naive young women believe this vaccine saves lives! Tthey couldn't be more wrong.

That's why HSI's Jenny Thompson has released a new video in which she exposes the deception for what it is — and reveals some truly shocking information no one else is talking about.

And you are the very first to see it.

Please, if you have daughters, granddaughters or friends who might be considering this terrible vaccine, you must watch this video. And please forward it to anyone you think would benefit from the vital information it contains.

If you think you know the whole story on Gardasil, I think you'll be shocked by what you're about to see. Just click here to start watching the video. It's just a few minutes long. and those few minutes might just save a young girl's life.

Origins:
Gardasil is a vaccine intended for girls and young women between the ages 9 to 26 to protect against human papillomavirus (HPV), a virus which is currently linked to an estimated 70% of known cervical cancer cases. Because Gardasil prevents only the onset of HPV infections (rather than curing those who have already been infected by HPV), health officials have advocated that girls be vaccinated for HPV prior to adolescence (or as soon as possible thereafter) in order to head off the occurrence of cervical cancer later in life.

The message quoted above warns that the Centers for Disease Control (CDC) has already received nearly 12,000 complaints about adverse medical issues related to Gardasil vaccinations, and that 32 young women died after receiving Gardasil vaccinations. Although this information is accurate in a strictly literal sense, it is raw data that does not in itself establish a causal connection between Gardasil and the posited medical dangers.

The CDC, in conjunction with the Food and Drug Administration (FDA), operates a program known as the Vaccine Adverse Event Reporting System (VAERS). The VAERS program collects and analyzes reports on adverse events following immunizations in order to help track the safety and efficacy of various vaccines. It is important to note that reports collected by VAERS are raw data; they do not in themselves establish causal connections between vaccines and adverse medical issues — such determinations cannot be made until the reports have been investigated, evaluated, and analyzed.

(To illustrate this concept, we offer the following [admittedly far-fetched] scenario: A man who received a flu vaccination and then accidentally hit his hand with a hammer a few hours later might legitimately report that soon after he received the flu vaccine, his hand began to throb painfully. Although such a report would be literally true, it would not establish any causal connection between the flu vaccine and the adverse medical symptom of a throbbing, painful hand.) It WOULD, however, be listed in the package insert as a potential complication of the flu vaccine because that's the way medication side-effect law is written.

As the CDC states in their article on "Reports of Health Concerns Following HPV Vaccination," before the HPV vaccine was licensed, it was studied in five clinical trials involving over 21,000 girls and women ages 9 through 26, and since the licensing the "CDC and FDA have been closely monitoring the safety of the HPV vaccine." The article notes that as of 31 December 2008, more than 23 million doses of Gardasil had been distributed in the United States, and VAERS afterwards collected 11,916 reports of adverse events following Gardasil vaccination. However, the article also notes that 94% of those reports were classified as "non-serious":

This works out to only one adverse event for every 1930 doses given, and only one in 17 of these adverse events was considered serious. So, only one in 32,169 doses of Gardasil resulted in a serious side-effect.

And not all of these could be directly attributed to the vaccine. Since these numbers were taken from the raw VAERS data, there is no way to know how many of these serious side-effects actually occurred because of the vaccine, and how many were unrelated occurrences that simply followed the administration of the Gardasil vaccination.

The vast majority (94%) of the adverse events reports following Gardasil have been non-serious. Reports of non-serious adverse events after Gardasil vaccination have included fainting, pain and swelling at the injection site (the arm), headache, nausea and fever. Fainting is common after injections and vaccinations, especially in adolescents. Falls after fainting may sometimes cause serious injuries, such as head injuries, which can be easily prevented by closely observing the vaccinated person for 15 minutes after vaccination.

Moreover, the article also noted that the relatively small percentage (6%) of reports classified as "serious" (including those involving deaths) could not be definitively linked to the use of the Gardasil vaccine:

All serious reports (6%) for Gardasil have been carefully analyzed by medical experts. Experts have not found a common medical pattern to the reports of serious adverse events reported for Gardasil that would suggest that they were caused by the vaccine.

As of December 31, 2008, there have been 32 U.S. reports of death among females who have received the vaccine. There was no common pattern to the deaths that would suggest that they were caused by the vaccine.

The article concludes by stating that:

Based on all of the information we have today, CDC and FDA continue to recommend Gardasil vaccination for the prevention of 4 types of HPV. As with all approved vaccines, CDC and FDA will continue to closely monitor the safety of Gardasil. Any problems detected with this vaccine will be reported to health officials, healthcare providers, and the public, and needed action will be taken to ensure the public's health and safety.

The video featuring Jenny Thompson of Health Sciences Institute that is linked at the end of the warning reproduced above deals mainly with subjects such as the political and moral issues involved with requiring HPV vaccinations for young girls, the notion that vaccinated girls might mistakenly believe they had been immunized against contracting sexually transmitted diseases (other than HPV), and the claim that cervical cancer deaths can be effectively eliminated through means other than HPV vaccinations. It offers no real evidence that Gardasil vaccinations are dangerous other than to cite the raw VAERS data referenced above (without noting that analysis of those reports failed to establish a causal link between HPV vaccinations and the reported serious adverse events).

Last updated: 22 April 2009
The URL for this page is http://www.snopes.com/medical/drugs/gardasil.asp

Urban Legends Reference Pages © 1995-2009 by Barbara and David P. Mikkelson.
This material may not be reproduced without permission.
snopes and the snopes.com logo are registered service marks of snopes.com.

Sources:
Harris, Gardiner. "Panel Unanimously Recommends Cervical Cancer Vaccine for Girls 11 and Up."
The New York Times. 30 June 2006.
Houppert, Karen. "Who's Afraid of Gardasil?"
The Nation. 8 March 2007.
Litwin, Grania. "Vaccine Can Save Vast Number of Lives, Says Cancer Specialist."
The Victoria Times Colonist. 22 April 2009.
Centers for Disease Control. "Reports of Health Concerns Following HPV Vaccination."
3 March 2009.
Reuters. "Allergic Reactions to Gardasil Uncommon: Study."
canada.com. 22 April 2009.
U.S. Food and Drug Administration. "FDA Approves Expanded Uses for Gardasil."
12 September 2008.

Febrile Seizures (Fever-Induced Convulsions)

2009-11-25T11:07:00.000-08:00

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This is taken from a book written by Dr. Barton Schmidt and deals with febrile seizures. The 2 big take-home points about seizures, or convulsions, that are induced by fever are these: simple febrile seizures that last less than 30 minutes do NOT harm the child's brain (YOU may faint, but your child will be fine) and the 4% of children that have febrile seizures are not just any 4% of the population. They are genetically predisposed to febrile (occurring with a fever) seizures. That means that if your child is not in that 4% of the population that is susceptible to them, he or she will not have a seizure no matter how high the fever goes.

If your child is 2 or 3 years old and is having the 5th or 6th high fever of her life, then there is almost no chance that she's in that 4% and there is no need to worry. One final point: febrile seizures do NOT predispose your child to epilepsy. About 1% of children with febrile seizures will go on and develop epilepsy, which is exactly the same incidence as occurs in the general population, since about 1% of ALL people will one day develop epilepsy.

What are febrile convulsions?
Convulsions are also called seizures. Febrile convulsions are seizures triggered by high fever. They are the most common type of convulsion and are usually harmless. The average body temperature at which they occur is 104°F (40°C). The fever itself can be caused by an infection in any part of the body.
Children who have febrile convulsions are usually 6 months to 5 years old. A child's first febrile convulsion usually occurs by 3 years of age.
During a convulsion, your child may:
• become stiff
• become unconscious or not know where they are
• have jerking or twitching movements
• have the eyes roll backward
• have noisy breathing
• after the seizure, your child may be sleepy and confused for a while.

How long will the effects last?
Each convulsion usually lasts 1 to 10 minutes without any treatment. Febrile convulsions do not cause any brain damage. However, a few children (3%) will have convulsions without fever sometime in the future.
Febrile convulsions occur in 4% of children. Most of these children have just one febrile convulsion in a lifetime. About one-third of children who have had a febrile convulsion have 1 to 3 recurrences over the next few years. Febrile convulsions usually stop happening by the time a child is 5 or 6 years old.

What should I do when my child has a convulsion?
• Reduce the fever. Bringing your child's fever down as quickly as possible may shorten the seizure. Remove your child's clothing and apply cold washcloths to the face and neck. If the seizure persists, sponge the rest of the body with cool water. As the water evaporates, your child's temperature will fall. When the convulsion is over and your child is awake, give the usual dose of acetaminophen or ibuprofen for your child's weight and age, and encourage your child to drink cool fluids.
• Protect your child's airway. If your child has anything visible in the mouth, clear it with a finger to prevent choking. Place your child on the side or stomach (face down) to help drain secretions. If the child vomits, help clear the mouth. Use a suction bulb if available. If your child's breathing becomes noisy, pull the jaw and chin forward. NEVER put your fingers or a spoon into the mouth of a child who is seizing; your fingers will be bitten off, or the child will shatter his teeth on a metallic object such as a spoon.
Call a rescue squad (911) IMMEDIATELY if the febrile convulsion continues more than 10 minutes.
• Driving to a medical facility. If you are told to drive to a medical facility, dress your child lightly (weather permitting). (Warning: Prolonged seizures due to persistent fever have been caused by bundling up sick infants during a long drive.)
• Common mistakes in first aid of convulsions. During the convulsion, don't try to restrain your child or stop the seizure movements. Once started, the seizure will run its course no matter what you do. Don't try to resuscitate your child just because breathing stops momentarily for 5 to 10 seconds. Instead, try to clear the airway. Don't try to force anything into your child's mouth. This is unnecessary and can cut the mouth, injure a tooth, cause vomiting, or result in a serious bite of your finger. Don't try to hold the tongue. Children may rarely bite the tongue during a convulsion, but they can't swallow the tongue.

How can I take care of my child?
• Oral fever-reducing medicines: Febrile convulsions usually occur during the first day of an illness. Although research is lacking, preventing high fevers may prevent some febrile seizures. Begin acetaminophen (Tylenol) or ibuprofen (Advil) at the first sign of any fever (a temperature over 100°F, or 37.8°C) and give it continuously for the first 48 hours of the illness. Because fever is common after DTaP immunizations, begin acetaminophen or ibuprofen in our office when your child is immunized and continue it for at least 24 hours.
• Fever-reducing suppositories: Have some acetaminophen suppositories on hand in case your child ever has another febrile seizure (same dosage as oral medicine). These suppositories may be kept in a refrigerator at the pharmacy, so you may have to ask for them.
• Light covers or clothing: Avoid covering your child with more than one blanket when they are sick. Bundling during sleep can push the temperature up 1 or 2 extra degrees.
• Lots of fluids: Keep your child well hydrated by offering plenty of fluids.

How can I help prevent convulsions?
The only way to prevent future febrile convulsions completely is for your child to take an anticonvulsant medicine on a daily basis until the age of 3 or 4 years. Because anticonvulsants have side effects and febrile seizures are generally harmless, anticonvulsants are rarely prescribed unless your child has other neurologic problems. We will discuss this decision with you.

When should I call Meyer Pediatrics (365-5898)?
Call us IMMEDIATELY after the seizure is over. If your child has had one or more febrile seizures in the past, you may feel comfortable waiting until the following morning to notify us, but feel free to call us whenever you have questions.
________________________________________
Published by McKesson Provider Technologies.
This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.
Written by B.D. Schmitt, M.D., author of "Your Child's Health," Bantam Books.
Copyright © 2005 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved.

Teen Drivers' Greatest Danger: Distractions

2009-11-25T10:27:00.000-08:00

I took this from a series of articles that originally ran in USA Today several years ago. It highlights the dangers posed by cell phones, video games and even other teen passengers when an inexperienced (ie, teen) driver is at the wheel. Sixteen year old drivers kill almost 1,000 people every year including themselves, their passengers, other drivers and even pedestrians. In terms of driving fatalities as a marker for driving ineptitude, 16 year olds are the worst drivers on the road (big surprise, huh?) Seventeen year olds are the third worst, and the group in the middle are 80 years old and up. So, a 78 year old, statistically, is a better driver than a 16 or 17 year old. And it's not even really all that close.

Distractions challenge teen drivers
Posted 1/25/2007 6:01 AM ET
By Larry Copeland, USA TODAY

Teenagers understand the danger of drinking and driving but still don't grasp the risks of driver distractions such as cellphones, loud music and young passengers, says an extensive new study of teen habits behind the wheel.

About 90% of the teens surveyed say they rarely or never drink and drive, although 50% say they have seen other teens do so, according to the study released today by the Children's Hospital of Philadelphia and State Farm Insurance Companies. Much higher percentages say they have seen peers speeding, driving while fatigued or dealing with distractions such as loud music and "passengers acting wild."
The research sought to get inside vehicles with young drivers and their passengers by surveying 5,665 ninth-, 10th- and 11th-graders from 68 randomly selected schools across the nation. The survey is part of a growing effort by child- and auto-safety advocates, insurance companies and others to cut teen driving deaths.

"Probably the most significant finding is that the environment inside the vehicle is very different from what adults might expect," says Laurette Stiles, State Farm's vice president for strategic resources. "Teens have a very challenging (driving) environment, which would challenge even an experienced driver."

Vehicle crashes are the leading cause of death for 15- to 20-year-olds, according to the National Highway Traffic Safety Administration. The nation's 12.5 million young drivers — those ages 15 to 20 — account for 6.3% of 198.9 million licensed drivers in the USA, according to 2005 NHTSA data, the most recent available. But 12.6% of all drivers involved in fatal crashes were in that age group.

Earlier research has shown that teen drivers carrying one teen passenger face double the risk of a fatal crash as teens driving alone. That risk increases to five times as likely for teen drivers with two or more passengers.

Sandy Coble, 47, of Jackson, Tenn., knows all about that risk. His only son, MacKenzie Allen Coble, 15, was one of three teens killed in a 2005 crash. None of the teens was wearing seat belts, he says. "Instead of picking out school clothes, I was picking out a casket."

The CDC Addresses Vaccination Concerns

2009-11-25T08:40:00.000-08:00

In my continuing effort to take information from other sources and make it available to the patients of Meyer Pediatrics, I have copied here the handout from the Centers for Disease Control (CDC) that addresses some of the common concerns that parents might have about the safety of routine childhood vaccines.

The bottom line is that NONE of the required vaccines for children contain mercury (thimerisol), there has NEVER been a single case of mercury toxicity from vaccines EVER reported, and autism is a genetic entity and there are NO well-done studies that suggest a link between vaccines and autism. Read on!

Common Concerns About Childhood Vaccinations

Infants and children get a lot of shots (vaccinations) to prevent against many different diseases. For this reason, parents or caregivers sometimes ask their healthcare provider to space apart, separate, or even not give some vaccines. Parents are worried that their child cannot handle so many shots at the same time. This is one of many concerns that parents may have about vaccinations. This handout provides the facts about vaccines, to help parents make an informed decision about what's best for their child.

CONCERN
"Infants get too many shots at once."
FACTS
Infants do get a lot of shots. But, they could handle even more. Each day, infants come into contact with millions of particles such as pollen, viruses, and bacteria that trigger their immune system. The "immune system triggers" in vaccines are only a very small amount compared to those found in your child's environment. Vaccines will not "overload" your child's immune system.
Some parents think that it would be better if their child didn't get so many shots at the same time. But delaying or not giving some vaccinations is not a good idea. Doing this could leave your child unprotected against certain diseases. Many childhood diseases are dangerous for young children. So it's best to make sure your baby is protected by not delaying their shots. Also, it is much easier to stay up to date with your child's shots, than to try and catch up.

CONCERN
"Vaccines have too many side effects. Besides, vaccine-prevented illnesses are not that serious."
FACTS
Before vaccines were available, many infants and children died from diseases we can now prevent. The diseases that vaccines prevent can be very dangerous. In fact, diseases such as whooping cough, polio, measles, etc. could be much worse and more dangerous for your child than the side effects of any vaccine. Even chickenpox can be serious. One in 200,000 unvaccinated infants who get chickenpox die...one in 100,000 older kids die...and one in 500 are hospitalized.

CONCERN
"Everyone else gets vaccines, so my child doesn't need them."
FACTS
It is true that your child has less of a chance of getting sick when your child plays with other children who have had their shots. But this doesn't mean that your child can't get sick. To be protected, your child must also get their shots. A good example of this is measles and whooping cough. Even though most children get vaccinated, children who do not get their shots have gotten measles or whopping cough, and some have even died.
Also, children who don't get vaccines may get the disease, and then spread it to people who can't be vaccinated or who could become seriously ill (e.g., newborn infants, pregnant women, older people).

CONCERN
"Vaccines are not tested enough."
FACTS
Just like medicines, vaccines are tested in many children for a long time before they are given to all children. Most vaccines are tested in even more children and for an even longer time than most medicines that you give your child.

CONCERN
"Vaccines contain things which are not safe for my child."
FACTS
Shots that are given to infants and children are safe. Shots for infants and children do not have mercury in them anymore. Some shots do have aluminum in them, but the amount of aluminum is much smaller than the amount of aluminum found in baby formula.

CONCERN
"Vaccines cause autism."
FACTS
Some people think that the thimerosal or mercury in vaccines causes autism. But this has never been proven. Actually, common pediatric vaccines, with the exception of some flu shots, no longer contain thimerosal or mercury and haven't since 2001. Those flu shots that do have thimerosal or mercury contain a very small amount, AND it’s a different form than the mercury that is linked with brain and nerve injury. One is methyl mercury, and the other is ethyl mercury. Different entities entirely.

PROTECT YOUR CHILD AND VACCINATE
Infants and children receive more vaccines than ever before. But, these vaccines are safe and protect our children from serious diseases. If you have concerns about any vaccine your child is to get, talk to Dr Ted or Nurse Kay. Remember, vaccines save lives! Do not let the extremists who mistakenly believe that ALL vaccines are bad trick you into making a dangerous mistake. Your child's health literally is at stake.

Autism

2009-11-25T07:28:00.000-08:00

This was taken from Medscape.com. It is an interview with Dr. Eric Hollander and reviews a lot of good information on what is currently known about autism. This interview IS nearly 5 years old, but if anything, the support for autism as a genetic entity and the complete lack of corroboration with vaccines as a cause is even stronger today. Read this and see for yourself, particularly if you are at all worried about vaccines and their refuted link to autism.

Autism: An Interview With Eric Hollander MD

From Medscape Psychiatry & Mental Health

Autism: An Expert Interview With Eric Hollander, MD
Published: 02/03/2005

Editor's Note:
Requests for services related to autism are increasing, although there is controversy over whether this reflects a change in the prevalence of the disorder, better detection, or differences in definition. What is autism? How common is it? What are the best ways to treat it? What makes doing research on autism spectrum disorders exciting today? Elizabeth Saenger, PhD, Medscape Psychiatry & Mental Health, interviewed Eric Hollander, MD, Professor of Psychiatry, Director, Seaver and New York Autism Center of Excellence, Mount Sinai School of Medicine, New York, NY.

Medscape: How would you define autism?
Dr. Hollander: Autism is a developmental disorder that presents before the age of 3 years. It's characterized by impairment in 3 core symptom domains, which include social deficits, communication difficulties, narrow restricted interests, and repetitive behaviors. In addition to that, there are also other associated symptoms that frequently coexist.

Medscape: What are those other symptoms?
Dr. Hollander: The other associated symptom domains can include factors like inattention and motor hyperactivity, impulsivity and aggression, mood instability, EEG abnormalities or seizure related type problems, and cognitive difficulties.

Medscape: How common is this disorder?
Dr. Hollander: It used to be felt to be very rare. The best estimates now are that about 0.6% of the population, a little under 1%, may meet criteria for the broader autism phenotype, or an autism spectrum disorder. Within that spectrum, we include autism, the Asperger syndrome, and pervasive developmental disorder or PDD NOS -- not otherwise specified.

Medscape: How do you treat autism spectrum disorders?
Dr. Hollander: There are a few different treatment approaches. There are behavioral approaches, educational approaches, and medication approaches. We intervene early. There is some evidence that the earlier you pick up the problem and start to intervene with behavioral, educational, speech, and occupational therapy, the better the long-term developmental trajectory. So the idea now is to start to identify people at around 18 months if possible and often to slide people into the educational programs that incorporate a lot of speech and occupational therapy plus behavioral interventions like acute ABA-type treatments -- applied behavioral analysis. And there is evidence that these kinds of treatments actually can be associated with better long-term outcome.
We are also finding that medicines may be very helpful in 2 types of approaches. One is a targeted treatment approach where we select a group of individuals who score high on a particular target symptom like lots of narrow, restricted interests, repetitive behaviors, self-stimulation-type behaviors, and compulsive behaviors, and then treat them, for example, with very low doses of selective serotonin reuptake inhibitors like fluoxetine or fluoxetine in a liquid form. We found that will significantly improve the core symptom domain and improve overall functioning.
Other treatment approaches involve stratifying the population, picking up the subgroup with a lot of disruptive behavior, such as impulsivity and aggression, tantruming, self-injury, and treating them with low doses of atypical antipsychotics, such as risperidone. We also have treatment approaches using the mood-stabilizing, anticonvulsant-type treatments like valproic acid or levetiracetam, finding that these medicines may be helpful in a lot of mood instability, a lot of the disruptive behavior like impulsive, aggressive, or self-injurious behavior. Sometimes for language-related functioning, and particularly those with some abnormal EEGs, patients have a very robust response to the anticonvulsant-type medicines.

Medscape: How successful are these interventions in helping people become what society generally considers normal?
Dr. Hollander: It probably depends on the baseline characteristics of the patient, because it turns out that autism is pretty heterogeneous. You have some individuals who have very high IQs and others with severe mental retardation. You have some individuals who have really outstanding verbal skills and others who have no language at all. You have some people who have accompanying seizure problems or other neurologic problems and others who don't.
So as a group it's fairly heterogeneous. And we know that individuals who start off with a higher IQ and better speech and language tend to have a better long-term outcome than those who have more severe impairment at baseline.
But we know that with early interventions, both behavioral and pharmacologic, people really can do a lot better, that the symptoms that cause distress can be significantly reduced and their overall functional ability can improve.

Medscape: One thing I'm curious about is the paradox in a way of the idiot savant. Can you say something about that?
Dr. Hollander: What's interesting is that within individuals you see a scattering of peaks and valleys in terms of skill levels. And you have some individuals who have extraordinary skills in certain areas. That may go along with their narrow restricted interests, where they become preoccupied with certain things and have all the information in the world about those things. And sometimes people can calculate statistics or memorize calendars or have some extraordinary mathematical or physics ability, or even certain visual/spatial abilities, musical abilities, verbal abilities. We think that there may be some positive attributes that may be coheritable with certain autism symptom domains. The idea is that either there are a number of these core and associated symptom domains that need to come together in order to produce the full syndrome of autism, and that in the first-degree family members, and even in the general population, we frequently see impairment in individual symptom domains. These individuals don't have the full disorder, however, unless they get multiple domains coming together.
Some of the symptom domains that may make up the disorder may also be associated with high abilities in mathematical or visual, spatial, or musical abilities, and it's not unusual to see in first-degree family members a high skill, for example, in physics, math, or computers. It's also not unusual to see many family members who have extraordinary technical skills, for example. Within individuals with autism, you do see individuals with these islands of extraordinary skills also coupled with areas of the real impairment. And it seems that many people with autism have difficulties with the higher order of processing of information. They may be excellent in terms of their raw sensory information or their ability to manipulate the sensory information, but they have more difficulty with the higher-order processing or generating abstract conclusions from the sensory information.

Medscape: In other words, they would be like Raymond in the film, Rain Man, where Raymond could do difficult calculations involving the cards in the casino and win a lot of money or figure out how many toothpicks have been spilled on the floor, but in terms of figuring out how much change he would get if he went to the grocery store to buy something, he was a failure.
Dr. Hollander: Yes. I would say that often there are deficits in certain pragmatic skills -- how to interact with the world in a social fashion to get what you want from the world -- but that they can still have extraordinary specific skills.

Medscape: Can you tell us a little bit about your own research with people who have autism?
Dr. Hollander: Yes. Here at Mount Sinai we have the Seaver and New York Autism Center of Excellence. We have been doing business for over 10 years, initially funded by the Seaver Foundation and now funded by one of the NIH STAART Autism Centers of Excellence. We're very focused on breaking autism down into the different core and associated symptom domains and finding relevant genes, understanding the specific brain circuits, and developing specific treatments for each of the different symptom domains. For example, we found genetic factors that may be associated with speech and language problems or with the repetitive behaviors. We've elucidated the metabolic activity in the limbic system associated with autism. And we have developed new treatments for the symptom domains, particularly the repetitive behaviors and the impulse of aggression. We've also been interested in peptides like oxytocin and the role that those peptides play in social attachment and in the repetitive behaviors; we have done some interesting alterations of that system and found that we can improve social attachment and repetitive behaviors by influencing the oxytocin system. We've also done research on immune abnormalities that may run in families, and related these immune abnormalities to different symptoms.
We've been very interested in the serotonin system and the role that that serotonin system plays in the repetitive behaviors and then how treatments for the serotonin system can improve the repetitive behaviors.

Medscape: This seems to tie into what you once said about the need to look at specific behaviors and then target them with specific medications to improve somebody's behavior and life.
Dr. Hollander: That's right. We think that there are basically 2 approaches with medicines. One is the targeted treatment approach where you stratify the population and you select individuals who have specific types of target behaviors that cause distress and interfere with functioning. You start with low doses of medicines and improve those target symptoms to see how that affects the overall level of functioning. Another approach that we're starting to get into is early interventions to see if we can change the developmental trajectory. In a similar way, early behavioral interventions might improve IQ or social reciprocity with speech and language.

Medscape: The idea of improving IQ seems interesting. Can you tell us more about that?
Dr. Hollander: There are some behavioral treatment studies that suggest that early intervention with behavioral approaches will show an improvement in IQ if you follow individuals over long periods of time.
Some of those studies may be flawed because there wasn't good randomization and people started with different IQ levels at baseline. But generally people feel that early intervention can be associated with improvement. And when you get clinical improvement, you also see a significant improvement in IQ.
Some of the studies that the STAART Centers are looking at now are early interventions with serotonin reuptake inhibitors that follow people over time to see if we can get improvement in IQ. Recently we've also been interested in looking at certain medicines that work on the glutamate system that are used specifically for cognition and memory to see if we can improve cognitive functioning and IQ with those approaches.

Medscape: You mentioned that early intervention in autism means catching a child or a baby at 18 months. How often is autism or potential autism recognized that early?
Dr. Hollander: It used to be very rare, so people usually identified it at around age 3 years when children weren't talking. Nowadays, there's a push to identify earlier problems like eye gaze, not interacting appropriately with other children or peers, or not having good joint attention with parents. And sometimes there can be subtle motor abnormalities that may be present at an earlier stage. There are suggested screening instruments, such as the Checklist For Autism in Toddlers -- CHAT. Cure Autism Now has suggested that pediatricians routinely administer this to all children at 18 months to try to pick up people with developmental delays who should be screened more carefully afterwards.

Medscape: Are pediatricians doing that?
Dr. Hollander: I think that for the most part now, teachers, pediatricians, parents, and other mental health practitioners are doing a better job screening. There is a bit of a controversy in the field as to whether autism is dramatically increasing because the rates were much, much lower before. That may be because everybody is doing a better job screening, so we're picking up the milder cases at an earlier stage. The alternative explanation is that there are environmental factors that interact with strong genetic factors to be associated with an increased risk for people presenting with these problems.

Medscape: I know that's quite controversial. Can you tell us about some of the possible environmental factors that people are thinking about?
Dr. Hollander: Well, there's been a lot of debate about vaccines -- initially the MMR vaccine, and then more recently the thimerosal preservative, which is an ethylmercury preservative that was in certain multidose vials of vaccines. I think that the best available data really suggest that these vaccines are not associated specifically with an increased rate for autism. That's because there have been good studies, for example, in England, shortly after the MMR vaccine was first introduced, that showed that there was no dramatic increase after it was introduced. The Institute of Medicine recently issued a report suggesting that it doesn't look like vaccine played a role. It's clear that mercury can be neurotoxic. It's not good for the developing brain, but probably is not specifically related to the development of autism.
People have hypothesized all kinds of other factors. We were interested in the role that pitocin played in inducing labor and delivery as a possible risk factor. And other people have postulated that things like folate, for example, that are frequently given, may be an epigenetic factor that can turn on and turn off certain genes that could be associated with a greater risk.

Medscape: How did you get interested in this research area?
Dr. Hollander: Originally we were interested in other disorders that present with repetitive behaviors. And then we had the opportunity to partner with the Seaver Foundation and develop a new autism center.
Studying autism is really a great opportunity because if you understand what goes wrong in autism, you understand a little bit more about what makes people human. It gives you insight into issues around being able to see things from other people's perspectives and issues around social attachment, which are really what make us human.

Medscape: What do you see on the horizon in terms of research on autism and social movements about autism?
Dr. Hollander: The media have been talking about autism a lot lately. There are a number of debates, for example, about funding issues in terms of ABA. It's very costly. Does the existing database justify ABA, for example?
There are some controversies about whether autism -- for example, Asperger's disorder -- is just an alternative way of being and whether trying to get rid of target symptoms is not allowing certain patients with Asperger's to fully express who they are.My sense is that it's pretty clear that if we can reduce certain target symptoms, then people will have significantly less distress and their overall level of functioning will improve.

Medscape: Is there anything else you would like to add?
Dr. Hollander: I think this is an exciting time now. The NIH has taken a big interest in autism and launched STAART Autism Centers of Excellence. Many centers are working together to develop important new treatments. And integrated treatments are probably one wave of the future, integrating the behavioral and the medication treatments together.I think there is a lot of exciting work coming out on genetic findings. Mt. Sinai and the Seaver Center have started to actually see specific genes that may play a role in autism. It's clear that there's no single gene, but it may be that if you have a few of these different genes interacting together, you're going to be at high risk for getting the syndrome. Each of the genes may code for the different symptom domains that need to come together to get the full syndrome.
I think that there are new imaging techniques, like functional MRIs, that are allowing us to design specific kinds of experiments to understand the specific neurocircuits that are involved in the different symptom domains of the disorder.
And finally, there's a good partnership between academic medical centers and autism advocacy groups. I think the autism advocacy groups have been extremely effective -- Cure Autism Now (CAN), National Alliance for Autism Research (NAAR), and Autism Society of America (ASA), for example -- in terms of increasing awareness and increasing support for this important area.

Medscape: Thank you very much for sharing your thoughts with Medscape.
Supported by an independent educational grant from Janssen

Myths About Aspartame (NutraSweet)

2009-11-25T07:17:00.000-08:00

I stole this from Snopes.com but I think the information is very good.

http://www.snopes.com/medical/toxins/aspartame.asp

Aspartame

Claim: The artificial sweetener aspartame has been proved responsible for an epidemic of cancer, brain tumors, and multiple sclerosis.

Status: False.

Origins:

To date, FDA has not determined any consistent pattern of symptoms that can be attributed to the use of aspartame, nor is the agency aware of any recent studies that clearly show safety problems.

Aspartame and the Internet (The Lancet):
Our research revealed over 6000 web sites that mention aspartame, with many hundreds alleging aspartame to be the cause of multiple sclerosis, lupus erythematosis, Gulf War Syndrome, chronic fatigue syndrome, brain tumours, and diabetes mellitus, among many others. Virtually all of the information offered is anecdotal, from anonymous sources and is scientifically implausible.

ACSH Debunks Internet Health Hoax (American Council on Science and Health):
Health scare artists have found a whole new medium for terrorizing the public — the Internet. Individuals in search of accurate health information may literally become caught in the Web, where health hoaxes and urban medical myths run rampant. The health scare messages are always the same — whatever it is, it will make you sick.

Beware The E-Mail Hoax: The Evils Of Nutrasweet (Aspartame) (Dr. Dean Edell):
A highly inaccurate "chain letter" is being circulated via e-mail warning the reader of the health dangers of aspartame (Nutrasweet) diet drinks. There is so much scientific untruth in it, it’s scary. Be careful, because others know how to manipulate you by this. Just because something is beyond your comprehension doesn’t mean it is scientific.

FDA Statement on Aspartame (FDA):
Analysis of the National Cancer Institute's public data base on cancer incidence in the United States — the SEER Program — does not support an association between the use of aspartame and increased incidence of brain tumors.

Study Reaffirms Safety of Aspartame (MIT News):
Even daily large doses of the high-intensity sweetener aspartame, also known as NutraSweet, had no adverse effect on study subjects' health and well-being, a visiting scientist at MIT reported in the American Journal of Clinical Nutrition last week. "We conclude that aspartame is safe for the general population," said Paul A. Spiers, visiting scientist in the Clinical Research Center (CRC).

A Web of Deceit (TIME magazine):
A widely disseminated e-mail by a "Nancy Markle" links aspartame to Alzheimer's, birth defects, brain cancer, diabetes, Gulf War syndrome, lupus, multiple sclerosis and seizures. Right away, the long list warrants skepticism. Just as no single chemical cures everything, none causes everything.

Last updated: 25 September 2007
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A Snapshot of ADHD in the US

2009-11-25T06:51:00.000-08:00

Denise Mann
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.

CINCINNATI, Sept.4 -- Almost 9% of U.S. children ages 8 to 15 meet standard diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD), but less than half of them receive treatment.
Only 47.9% of the 2.4 million who met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for ADHD had reportedly had their conditions diagnosed by a health care professional or been treated with medication, according to a report in the September issue of the Archives of Pediatrics & Adolescent Medicine.
A research team led by Tanya E. Froehlich, M.D., of Cincinnati Children's Hospital Medical Center did a cross-sectional phone survey of the parents or caregivers of 3,082 eight- to 15-year old children who were participants in the National Health and Nutrition Examination Survey.
Survey respondents provided information about each child's ADHD symptoms between 2001 and 2004. They also provided sociodemographic information and information about whether the child had ever been diagnosed with ADHD or taken medicine to treat the disorder.
The researchers found that 8.7% (95% CI; 7.3%-10.1%) met the DSM-IV criteria for ADHD in the year before the survey took place. An additional 3.3% of children did not meet the criteria, but had a parent-reported prior diagnosis and had been treated with an ADHD medication at some point during the previous year. The latter group, however, was not included in the main analysis.
More boys than girls met the diagnostic criteria for ADHD, 11.8% versus 5.4%, respectively (P<0.001), but girls were less likely than boys to have had the disorder recognized.
There were also discrepancies in ADHD rates by race and ethnicity. Non-Hispanic white children were more likely to meet criteria for ADHD than were Mexican-American children or children of other races/ethnicities, the study showed. These findings held in both bivariate and multivariate analyses.
The study authors could not explain why Mexican-American children had lower rates of ADHD, but they speculate that this may be related to "differences in the prevalence of causal risk factors, genetic susceptibility, and/or rates of reporting ADHD symptoms across cultures."
Of the children who met the diagnostic criteria for ADHD, 38.8% had received medication to treat inattention, hyperactivity, or overactivity in the prior year and 32.0% had been taking medication for most of that year.
Regular medication use was more likely to be reported for older children than younger ones, the study showed.
Money also mattered in the new study. Children in the poorest quintile were more likely than those in the wealthiest quintile to have been diagnosed with ADHD (adjusted odds ratio [AOR] for PIR, first quintile vs fifth quintile, 2.3; 95% CI, 1.4-3.9)).
"Reasons for the increased likelihood of ADHD in poorer children may include the elevated prevalence of ADHD risk factors (i.e., premature birth and in utero or childhood exposures to toxic substances) in this group," the study authors write.
"In addition, given the high heritability of ADHD and its negative impact on social, academic and career outcomes, it is plausible that families with ADHD may cluster within the lower socioeconomic strata."
Although poor children were more likely to have ADHD, the poorest children were three to five times less likely to consistently receive medication when compared with their counterparts in other income groups, the researchers noted.
This finding "warrants further investigation and possible intervention to ensure that all children with ADHD have equitable access to treatment when appropriate," the authors conclude.
The researchers also analyzed ADHD by subtypes. Specifically, 4.4% of the children met the criteria for ADHD-1A, 2.2% for ADHD-CT and 3.0% for ADHD-HI.
The poorest children were more likely to have ADHD-HI than their wealthier counterparts (AOR for PIR, first vs fifth quintile, 3.1; 95% CI, 1.2-8.3
In addition, African Americans and Mexican Americans were less likely to have ADHD-1A, compared to their non-Hispanic white counterparts, the study showed.

Allergies and "Allergic Shiners"

2009-11-25T05:24:00.000-08:00

Hi Again,

I was also asked by Jennifer, one of our Moms here at Meyer Pediatrics, about allergic shiners, those dark and puffy circles under kid's eyes that are often mistakenly thought to be due to lack of sleep. The're not related to sleep at all. They are a sign of allergies, as are the creases under the eyes called Denny's Lines and the raised pink bumps on the back wall of the throat called cobblestoning. If one parent has allergies, each child has about a 50% chance of having allergies (although what your child is allergic to is NOT inherited; that they have to do for themselves. Just because you are allergic to penicillin does not mean that your child is, or even ever will be). If both parents have allergies, then each child has about a 75% chance of having allergies.

I'm often asked when, or even if, a child should be tested for allergies. My short answer is that I would go through the relative trauma of skin testing (far more accurate than blood testing) only if the child's life is being changed by the allergies. If they can't go to a friends house because the friend has a dog, that may be a good reason to investigate.

There won't be just one or 2 things that your child is allergic to and therefore you could just avoid. It likely will be a dozen or more things. In most cases, you could just treat the allergies and skip the whole testing phase. Obviously, if you think that your child has had a serious reaction to something, or perhaps may even have had a potentially fatal reaction to something such as having had difficulty breathing after eating shellfish, then of course you would want to have this checked by an allergist so that you can know for sure.

It depends on the child, but I often find that for kids with significant allergies it usually takes a combination of Singulair (a prescription medication for airway inflammation) plus an allergy nasal spray such as Omnaris or Nasonex or Nasocort, plus a once-a-day, non-sedating antihistamine (such as Allegra or Clarinex) to control the allergy symptoms well. One or two of those medications just doesn't seem to work as well, in my experience.

I know that most parents don't like the idea of their children taking mutliple medications, and I do prefer just letting the child live with mild symptoms, but if we've made the decision to treat allergies with medication, I think we might as well do it the right way. Go for the win.

As a preventative, Singulair once a day can often be used as a maintenance plan during the time of year when your child is most symptomatic, with antihistamines used on an "as needed" basis. When your child is fully symptomatic, however, you're going to want to do everything, or nothing at all, in my opinion.

I hope that this little overview answered some of your questions about allergies. If not, or if there are other topics that you'd like to see me address, write me here at Dr. Ted's Blog and I'll try to get something written as soon as possible.

Does Your Four Year Old Still Wet the Bed?

2009-11-24T08:01:00.000-08:00

I was asked about this in one of the comments, and I found that it is difficult to find my answer unless you already know where to look. So, I'm repeating myself here as a post to make it easier for everyone to find this information. We just started this blog about a month ago, and I'm still playing around with it to see how it all works. Below is my answer to Jennifer, one of our Moms here at Meyer Pediatrics who asked me about children who are late to get dry at night (and have never been dry before).

OK, at age 4, about 80% of all kids are dry at night. Those that aren't are the "late" group, and they will slowly become dry over the next 10 or so years, at the rate of about 10% per year. SO, at 5 years old, about 90% of them are still wetting, and at 6 about 80% and so on. It's NOT laziness or anything like that. It's because, for reasons unknown to me, these kids are slow to get the night-time rise in a hormone called ADH (Anti-Diuretic Hormone, which is naturally secreted by our brains) that those of us who stay dry get. Ultimately, just about all of them WILL get this night-time surge and they will become dry.

There ARE rare other causes of night-time wetting (and I am ONLY describing kids who have ALWAYS wet the bed here, not kids who WERE dry and then started wetting later). At any rate, these kids should have a good physical exam one time to be sure that there is nothing else causing the enuresis (the medical term for night-time wetting) as there are several treatments available, at least for sporadic use, such as when your child wants to have a spend-the-night party without others finding out. In these cases, there is a prescription medication called DDAVP that is a chewable pill taken before bedtime that in over 80% of cases is successfully able to keep a child dry for that night.

Therefore, to answer your question, I would recommend the pullups until they aren't needed anymore, whatever age that might happen to be. My patient who was the latest to get permanently dry was about 16 or 17. For the routine changeover from pull-ups to underwear, "big kid" underwear should be a reward, NOT an inducement. They should only be allowed to wear "big girl panties" when they can go a whole week without wetting.

Potty Training

2009-11-24T05:33:00.000-08:00

Hi,

I was asked by Jennifer, one of our Moms, about potty training. Since I get asked about that a lot, I thought it made a good topic for a post. I often tell parents who ask that there are basically two ways to potty train a child; the slow and easy way or the fast but difficult way.

The slow but easy way is to wait until your child shows an interest in wearing "big kid underwear." These should be a REWARD for staying dry, NOT an inducement to get dry, which does NOT work. The only downside of this approach is that the motivation for the kids to stop wearing pullups is being teased by their friends ("you're a little baby wearing diapers") which is obviously painful and embarrassing to your child.

The fast but difficult way involves removing yourself from the diaper equation. A child over 3 years of age is perfectly capable of being dry at night. They are choosing to be in diapers or pullups because it's the "hot line" to Mommy. They can commandeer your time and attention simply by saying, "I gotta go NOW." SO, to force the issue, tell the child that you no longer do diapers (as long as they at least 3 years old) and that you will only help them if they go on the potty. This ONLY works, by the way, if you NEVER cave in and help them with pullups. Say to the child, "Here are the pullups, here's the toilet paper, here's where the dirty diapers go. Knock yourself out, but don't call me for ANY help unless you want to go on the potty. I don't do diapers now that you are three. I only will come help if you go on the potty."

This works because the child is not attached to the pullups so much as attached to you and using the pullups to command your time and attention. From a young child's perspective, NO ONE has EVER had enough attention, no matter how much they really get (and believe me, my patients typically get attention by the boat load). When forced to choose between you and diapers, a child will ALWAYS choose you, once they become convinced that you really mean it.

They will, of course, test you to see if you really mean it, but if you don't cave, they likely will voluntarily switch over to "big boy underwear" within a day or so. I promise that this works IF you stick to your guns! Good luck!

Seasonal Flu shot for ages 3 years and older have arrived!

2009-11-23T05:23:00.000-08:00

We have recieved the Seasonal Flu shots for ages 3 years and older. If you want to have your child recieve this vaccine please call the office to schedule an appointment. We also still have H1N1 (Swine Flu) vaccines available for ages 6 months and up. It is recommended that children recieve both the Seasonal and H1N1 vaccines.

Thanksgiving Holiday Hours

2009-11-23T05:19:00.000-08:00

Meyer Pediatrics will be closed on Thursday, November 26th and Friday, November 27th. We will reopen at 8.30a.m. Saturday, November 28th. We are always available 24 hours a day by phone/answering service. I hope everyone enjoys the Thanksgiving Holiday!

Update for Patients with Cigna Insurance

2009-11-13T05:40:00.000-08:00

Please note patients, if you have Cigna insurance you are required to have your laboratory tests sent to Lab Corp, Cigna's preferred vendor. Labs included are Rapid Strep, Rapid Influenza A, Rapid Influenza B. However, you may choose to have the tests in our office with immediate results if you elect to self pay for the services. Rapid Strep is $25.00, Influenza A & B are $20.00 each.

Contact Dermatitis: More Than You Ever Wanted to Know

2009-11-12T15:08:00.000-08:00

Contact dermatitis is simply inflammation that results from the interaction of skin and an external substance (even water) that comes in contact with it. It is an altered state of skin reactivity induced by exposure to an external agent. For the vast majority of people, these substances are harmless. “Eczema” and “dermatitis” are often used synonymously to denote a polymorphic pattern of inflammation of the skin. In all cases the lesions of contact dermatitis are primarily confined to the site of contact. Contact dermatitis can look – and itch – very much like eczema. It usually presents as a rash of tiny blisters, inflamed reddened skin, sometimes dry, or sometimes moist and oozing.

Contact dermatitis is produced through one of two major pathways: irritant or allergic.
Irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD) are two of the most common dermatologic conditions in industrialized societies, with a prevalence of up to 10%. The two conditions are clinically indistinguishable and often both conditions co-exist. Many of the allergens causing ACD are also irritants.
Irritant contact dermatitis predominates, accounting for 80% of all cases of contact dermatitis. ICD is a non-immunologic skin reaction that does not involve immune system sensitization (previous exposure to the allergen). It can occur in all members of the population depending on the "irritancy" of the chemical, the duration of contact and individual susceptibility. Atopics (who invariably have dry skin) are more prone to irritant dermatitis. Water is one of the most common irritants; therefore atopics who do a lot of wet work will often get irritant hand dermatitis. Another reason atopics get irritant dermatitis is that the skin gets injured from chronic scratching, allowing the otherwise harmless chemicals in cosmetics to enter the skin. The most common skin irritants include acids, alkalis, detergents, and solvents that disrupt the barrier function of the skin. Common cosmetics / skin care products causing skin irritation include:

• Bath soaps & shampoos
• Eye shadow & mascara
• Make-up removers,
• Antiperspirants,
• Permanent hair-waving solutions.
• Water present in cosmetics and skin care products is the most common irritant to very dry skin.
Irritant contact dermatitis is a risk factor for allergic contact dermatitis, as the penetration of contact allergens is enhanced when the skin barrier function is disturbed.

Allergic contact dermatitis (ACD), on the other hand, is an immunologic skin reaction that occurs in a genetically predisposed individual. The allergic response occurs only when a person’s immune system is sensitized to the allergen. The more contact the individual has with the allergen the greater the risk of sensitization. In sensitized individuals, allergic contact dermatitis appears or is exacerbated 24 to 96 hours after contact with the causative allergen. ACD is usually accompanied by intense itching. The edges of the lesions are usually well demarcated, but unlike irritant dermatitis it may propagate beyond the site of contact. This reaction is also known as delayed hypersensitivity reaction, since the rash usually develops more than 12 hours after contact with the allergen. The reaction usually peaks about 48 hours after exposure. The number of chemicals known to be capable of causing ACD is said to be near 3000 and constantly increasing.

Site of the skin reaction is usually the face especially around the eyes. In one study allergic contact dermatitis was found to be the cause in 74% of patients with eyelid dermatitis. In Saudi Arabia it is well known that men with dermatitis in the beard have an allergy to permanent hair dyes.
Common allergens in cosmetics and skin care products that cause contact dermatitis
Current reviews demonstrate that the most frequent allergenic groups causing cosmetic allergy are fragrances, preservatives, and paraphenylenediamine (PPD) found in permanent hair dyes.

Fragrance
The commonest allergen causing ACD is fragrance. More than 5000 different fragrances are used in cosmetics and skin care products. Seventy to eighty percent of fragrance allergy can be picked up by patch testing with Balsam of Peru and Fragrance Mix (which contains 8 common fragrances). Fragrance can also cause increased pigmentation of the affected skin, photodermatitis, or contact urticaria.
It is important to know that "unscented" does not mean "fragrance-free". Some unscented products might contain a fragrance to mask other chemical odours. To indicate that no fragrance is added to a product it must be marked "fragrance-free" or "without perfume".
In 1989, less than 10% of the patients patch tested in a multicentre project in Germany reacted to the fragrance mix (a mixture of 8 important fragrances). Between 1990 and 1994, a steady increase in the percentage of sensitizations diagnosed to more than 13% was noted (4).

Screening for Fragrance Allergy:
These are the fragrances tested in a standard patch test battery:
• Balsam of Peru
• Fragrance Mix:
1. Oak Moss
2. Cinnamic aldehyde
3. Cinnamic alcohol
4. Alpha amyl cinnamic alcohol
5. Geraniol
6. Hydroxycitronellal
7. Isoeugenol &
8. Eugenol

• Musk Ambrette and Moskene
In a worldwide multicenter investigation on fragrance contact dermatitis, reaction to fragrance mix occurred in 78% of patients patch tested
Balsam of Peru
Balsam of Peru (BP) is usually included in the standard screening patch-test series as an indicator of fragrance sensitivity. It is positive in 50% of cases of fragrance allergy. BP is a naturally occurring substance, obtained from fir trees. It is composed of many allergens including benzyl acetate, benzoyl alcohol, cinnamic acid, cinnamic alcohol, cinnamic aldehyde, eugenol, and isoeugenol.

Paraphenylenediamine (PPD) Hair dye Allergy
This is the most important dye used for permanent (oxidation) hair colouring and is the third most common ingredient after fragrances & preservatives that cause contact dermatitis from cosmetics. Permanent hair dyes are more sensitizing compared to other types of hair dye.
In most cases the reaction to the dye is itching of the scalp and some redness, but nothing more. These individuals might just think they have a bit of dandruff. In more severe cases the hair dye may trigger scaly skin & pain. The distribution of the affected skin can vary and may not match the exact area to which the dye was applied. In more severe cases there can be swelling around the eyes and scaly skin on the ears, face & neck. Sensitization to hair dye may gradually develop with repeated exposure.
In some European countries, PPD was banned because it was thought to be too hazardous. The regulations of the EEC, however, have allowed up to 6% PPD in hair dyes.
In the consumer, PPD produces acute dermatitis that involves the scalp, eyelids, face, and hairline and may extend to include the neck & upper portion of the trunk, but may spread to involve the whole body. In the hairdresser the most common region affected is the hand, but other exposed areas like the arms & face may be affected. Once the dye becomes fully oxidized it is no longer allergenic; thus dyed hair does not cause dermatitis.
Other damage to the scalp skin can make one more sensitive than normal to hair dye and other chemicals.

Substances related to PPD which should be avoided in PPD-sensitized people
• Benzocaine (found in some haemorrhoid preparations) & procaine – local anaesthetics.
• Azo dyes: used in temporary & semi-permanent hair dyes, pen inks,
• Textiles dyes – especially dark clothing & clothing made of synthetic fiber like polyester or nylon
• Some foods & pharmaceuticals coloured with azo dyes
• Sulfa drugs
• Para-aminobenzoic acid (PABA) – found in sunscreens

Hair dye open skin sensitivity Test (“Dab test”) or Open Patch Test
In many countries there is legislation that requires hair dye products to carry a warning about conducting patch test prior to using the dye. This is a precaution to make sure the individual is not sensitized to the dye.
Allergies to PPD can develop, even though there was no reaction during previous use. For this reason, it is important to take the allergy test 48 hours ahead of every use.
The test area used is either behind the ear or inside the arm at the elbow. A small amount of the “colour base” (or some companies recommend mixing the base with the developer first) is applied to the test area. Do not wash the test area. Wait 48 hours unless there is reddening, burning or other irritation. If there is no reaction on the unwashed patch test site after 48 hours, then one can proceed to the full application.
Three dermatological departments in Italy, Great Britain & Poland, have validated this test. They considered it an effective method to detect delayed hypersensitivity (contact allergy) to hair dyes, and as such are useful in the secondary prevention of hair dye allergy. (5)

Preservatives
Preservatives in cosmetics and skin care products are the second most common cause of skin reactions. Cosmetics that contain water must contain some preservative to prevent bacterial or fungal growth. Examples of cosmetics preservatives that cause allergy include:
• Parabens are the most commonly used preservatives in cosmetics
• Formaldehyde is an important sensitiser & is released by a number of biocides, it is mainly found in shampoos
• Imidazolidinyl urea (Germall 115)
• Quaternium-15 (Dowcill 200) is a formaldehyde releasing preservative found in many cosmetics including, eye makeup, foundations, shampoos, moisturizing lotions, sunscreens, body powders, and skin cleansers.
• Phenoxyethanol
• DMDM hydantoin (Glydant)

Cocamidopropyl Betaine (CAPB) was voted Contact Allergen of the year for 2004 by a committee of international experts. It is a non-ionic surfactant found primarily in rinse off cosmetics (shampoos, soaps, and bath gels). It is less irritating to the skin than older surfactants. For this reason patients may think that a less irritating product such as a baby shampoo is safer for the skin when it is more likely to cause allergic contact dermatitis.
A case was presented in the American Journal of Dermatology (Vol 15, No 1 (March), 2004: pp3-4) of a 37-year-old woman who presented with eyelid dermatitis that had been present for 5 months. She was instructed by her family doctor to apply baby shampoo to the eyelids daily (similar advice given in NZ as well). Patch testing revealed a + reaction to CAPB. CAPB was present in the baby shampoo she applied. Discontinuation of this product resulted in clearing of her allergic contact dermatitis.
CAPB is found in over 600 personal care products (according to FDA). The case of CAPB illustrates an important point regarding allergy to cosmetics. Because CAPB is “less irritating” than other surfactants, it may be preferred by consumers, manufacturers, and doctors. The fact that it is more allergenic came to light only after its widespread use.
The reported prevalence of allergic contact dermatitis (ACD) secondary to CAPB exposure ranges from 3.0 to 7.2% (6).

Lanoline or Wools alcohol
In North America lanoline was the fourth commonest cosmetic allergen (after fragrance, preservatives and PPD) causing contact dermatitis (7). It is felt that the prevalence of ACD to lanoline is decreasing because knowledge of its allergenicity has been known for a very long time.
It is a natural material obtained from the sebum of sheep. It is recovered from raw wool by solvent extraction. It is used in cosmetics because of its emollient, moisturizing, and emulsifying properties.
There are several allergens present in lanoline, and lanoline-sensitive patients can sometimes tolerate one lanoline preparation but not another.

Cosmetics containing lanoline include:

• Moisturizers, Hand creams, Protective creams
• Sunscreens
• Glossy lipsticks
• Makeup remover, Eye makeup
• Foundations, eye makeup
• Baby oils & diaper lotions
• Hair spray

Cosmetics with herbal ingredients
Virtually all-herbal remedies have been reported to cause either allergic sensitization or photosensitization.
In a recent study in Portland, Oregan, USA, 63% of patients with suspected cosmetics dermatitis that had used a skin product containing botanical extracts were patch test positive to a botanical extract. In New Zealand the true prevalence of contact allergy to botanical extracts in patients with cosmetics dermatitis is unknown, as most people who suffer from skin rashes do not seek medical help unless the rash is persistent.
Common herbal products causing contact dermatitis include plants from the Compositae family:
• Artichoke
• Chamomile (found in numerous shampoos & other hair treatment products)
• Daisy (Chrysanthemum)
• Dandelion (Taraxacum)
• Feverfew
• Marigold
• Pyrethrum
• Ragweed (Ambrosia)
• Thistle
Several plants in the Compositae plant family are regularly included in "natural skin care products" in New Zealand, especially shampoos and aromatherapy solutions. In some cases the reactions to Compositae is worsened by sunlight, often giving the appearance of a light-sensitive rash.

Tea Tree (Melaleuca alternifolia) Oil is increasingly being used in NZ in various cosmetics (soaps, deodorants, toothpaste, gargles & aftershave) and allergic contact dermatitis is being found related to this product throughout the world.
The leaves of the tea tree contain an essential oil, which contains turpentines (limonene, alpha-pinene, phellandrene). In one study in Honolulu limonene was the most common allergen causing allergic contact dermatitis from tea tree oil.
The 'tea tree' oil available in the Netherlands is distilled from the Melaleuca alternifolia and mainly contains eucalyptol. Eucalyptol is probably the most important allergen. The Photoaged Melaleuca is a stronger sensitiser than regular tea tree.
There have been recent reports of topical tea tree oil causing anaphylaxis (Allergy Asthma Proc. 2003 Jan-Feb; 24(1): 73-5)
Propolis
There are reports in the literature describing several individual cases of contact dermatitis in patients using propolis as a component of various cosmetic products, listing the most frequently sensitizing constituents of propolis. There are also reports of the existence of a cross-reaction between the components of Peruvian balsam and propolis constituents.

Henna Allergy
With the vigorous back-to-nature trend in Western countries, henna as a natural hair dye has become increasingly popular. This shift away from chemical dyes is enforced by the relatively high risk of sensitization to chemical dyes, in both hairdresser and their clients.
Henna is derived from a shrub Lawsonia inermis, which is native to the Middle East & North Africa.
There have been several reports in the literature of Immediate Allergic (& Anaphylactic) reaction to using Henna hair dyes. Most cases had sneezing, runny nose, cough, & shortness of breath instead of skin reactions. They were all diagnosed with the help of a positive skin prick test to henna extract. Most of these individuals were hairdressers who became sensitized from their work. It is felt that they became sensitized by inhalation of henna powder dispersed in the air.
Henna also causes allergic contact dermatitis.

Photosensitivity is the term used to describe skin disease caused by the interaction of UV radiation and an exogenously (externally) acquired chemical agent, which may be either a drug or food taken orally, or a substance applied to the skin. It can be divided into photodermatitis, also referred to as photoallergic dermatitis, and photoirritant contact dermatitis.

Plants that cause photodermatitis (Phytophotodermatitis)
Phytophotodermatitis produces reddening and blisters on first exposure followed by persistent hyperpigmentation (darkening of the skin). This darkening of the skin can last for months. The rash is produced via a phototoxic reaction, which simply means that the reaction renders the skin susceptible to damage by UV light, and symptoms include burning pain at the affected site. This is in contrast to the reaction produced by plants such as poison ivy, which is classified as allergic contact dermatitis, and involves symptoms such as intense itching.
Compounds related to furocouramins (psoralens) usually cause plant-related photosensitivity. Two requisites for initiation of phytophotodermatitis are contact with a sensitizing plant (e.g. furocouramin) and exposure to ultraviolet light (wavelength greater than 320 nm), usually sunlight. Therefore, this dermatitis is usually seasonal.

Common plants causing photodermatitis:

Common Name
Botanical Name
Family
Angelica
Angelica archangelica
Umbelliferae
Bergamot
Citrus bergamia
Rutaceae
Celery
Apium aurantium
Umbelliferae
Citron
Citrus medica

Dill
Anethum graveolens
Umbelliferae
Fennel
Foeniculum vulgare
Umbelliferae
Fig
Ficus carica
Moraceae
Lemon
Citrus lemon
Rutaceae
Lime
Citrus aurantifolia
Rutaceae
Parsnip
Pastinaca sativa
Umbelliferae
Wild Carrot
Dacus carota
Umbelliferae

In New Zealand many of these plants are also being added to "natural skin care products".
Contact urticaria is a hives-like reaction occurring at the site of contact of the skin product and usually occurring within 15 minutes of the product touching the skin.

Diagnosis of skin rashes caused by cosmetics
Contact Urticaria is diagnosed by applying the product to the skin for 15 – 20 minutes and observing the skin for redness, swelling and itching or doing a skin prick test (applying the suspected allergen/s to the forearm and pricking the skin with a lancet & waiting 15 minutes for a bump like a mosquito bite at the site of the prick)

Contact Dermatitis is diagnosed by doing a patch test. The only way to obtain proof of allergic contact dermatitis is by patch testing. Patch testing is the universally accepted method for the detection of the causative contact allergens. The positive patch test reproduces an experimental contact dermatitis on a limited area of the skin. This is different from skin prick testing (which gives a positive response in 15 minutes) in that it is a delayed hypersensitivity response (it gives a positive response in about 48 hours).
The most frequently encountered contact allergens have been selected by various international contact dermatitis groups and included in standard patch test series. The chemicals are taped to the back in small chambers. The skin is not broken. The patches stay in place for 48 hours. You cannot shower or do any work or exercise that will wet or loosen the patches.
After 2 days, the patches are removed, and a reading is done. The patch sites are marked, and you may be asked to return for a final reading on another day. An experienced doctor can differentiate between allergic contact dermatitis and an irritant reaction on patch testing.

Repeated Open Application Test (ROAT) or Use Test
This is a simple test for new skin care products or products suspected of causing skin reactions. A small amount of the product is applied twice daily to a small area of normal skin, usually on the front of the elbow for 1 week. If no rash appears after 1 week the product is considered safe for that individual. This test simulates the everyday use of cosmetic products and can be used to define the clinical relevance of doubtful or positive diagnostic patch tests.
Photo-patch testing is patch testing with the addition of radiation to induce the formation of photoantigens. All photosensitive patients should be photo-patch tested.

Cosmetic Allergy & The Future
A recent Patch test study done in Austria (published in Paediatrics Dermatology 2003 Mar-Apr; 20(2): 119-23) showed that the overall sensitization rate was highest in children less than 10 years old (62%) and decreased steadily to be lowest among patients more than 70 years old. This coupled with the fact that appearance is so important to adolescents as they are bombarded with numerous cosmetic advertisements; they are significant consumers of toiletry & skin care products. Therefore we would expect the prevalence of cosmetic allergy to continue to increase.

References
(1) Allergic contact dermatitis to topical minoxidil solution: Etiology and treatment. J Am Acad Dermatol 2002; 46:309-12
(2) Dooms-Goossens A et al., Cosmetic products and their allergens. Eur J Dermatol 1992; 2: 465-8
(3) Kohl, et al, Allergic contact dermatitis from cosmetics. Retrospective analysis of 819 patch-tested patients. Dermatology. 2002; 204(4): 334-7
(4) Wolfgang Uter et al. Epidemiology of contact dermatitis. The information network of Departments of Dermatology. European Journal of Dermatology. Vol 8. Number 1. 36-40 Jan – Feb 1998
(5) Maya Krasteva et al. Contact Sensitivity to hair dyes can be detected by consumer open test. European Journal of derm. Vol. 12. Number 4, 322-6
(6) Joseph F. Fowler Jr et al. Allergy to Cocamidopropyl Betaine and Amidoamine in North America. Dermatitis, Vil 15, No 1 March, 2004: pp5-6
(7) Adams et al. A five year study of cosmetic reactions, J Am Acad Dermatol 13: 1062-1069, 1985
Contact & Occupational Dermatology by James G. Marks & Vincent A. DeLeo

Being Mom, by Anna Quindlen

2009-11-12T14:55:00.000-08:00

If not for the photographs, I might have a hard time believing they
ever existed. The pensive infant with the swipe of dark bangs and the black button eyes of a Raggedy Andy doll. The placid baby with the yellow ringlets and the high piping voice. The sturdy toddler with the lower lip that curled into an apostrophe above her chin.

All my babies are gone now. I say this not in sorrow but in disbelief. I take great satisfaction in what I have today: three almost-adults, two taller than I am, one closing in fast. Three people who read the same books I do and have learned not to be afraid of disagreeing with me in their opinion of them, who sometimes tell vulgar jokes that make me laugh until I choke and cry, who need razor blades and shower gel
and privacy, who want to keep their doors closed more than I like.

Who, miraculously, go to the bathroom, zip up their jackets and move food from plate to mouth all by themselves. Like the trick soap I bought for the bathroom with a rubber ducky at its center, the baby is buried deep within each, barely discernible except through the unreliable haze of the past.

Everything in all the books I once pored over is finished for me now. Penelope Leach., T. Berry Brazelton., Dr. Spock. The ones on sibling rivalry and sleeping through the night and early-childhood education, all grown obsolete. Along with Goodnight Moon and Where the Wild Things Are, they are battered, spotted, well used. But I suspect that if you flipped the pages dust would rise like memories.

What those books taught me, finally, and what the women on the playground taught me, and the well-meaning relations --what they taught me, was that they couldn't really teach me very much at all. Raising children is presented at first as a true-false test, then becomes multiple choice, until finally, far along, you realize that it is an endless essay. No one knows anything. One child responds well to positive reinforcement, another can be managed only with a stern voice and a timeout. One child is toilet trained at 3, his sibling at 2.

When my first child was born, parents were told to put baby to bed on his belly so that he would not choke on his own spit-up. By the time my last arrived, babies were put down on their backs because of research on sudden infant death syndrome. To a new parent this ever-shifting certainty is terrifying, and then soothing.

Eventually you must learn to trust yourself. Eventually the research will follow. I remember 15 years ago poring over one of Dr. Brazelton's wonderful books on child development, in which he describes three different sorts of infants: average, quiet, and active. I was looking for a sub-quiet codicil for an 18-month old who did not walk. Was there something wrong with his fat little legs? Was there something wrong with his tiny little mind? Was he developmentally delayed, physically challenged? Was I insane? Last year he went to China. Next year he goes to college. He can talk just fine. He can walk, too.

Every part of raising children is humbling, too. Believe me, mistakes were made. They have all been enshrined in the, "Remember-When-Mom-Did Hall of Fame." The outbursts, the temper tantrums, the bad language, mine, not theirs. The times the baby fell off the bed. The times I arrived late for preschool pickup. The nightmare sleepover. The horrible summer camp. The day when the youngest came barreling out of
the classroom with a 98 on her geography test, and I responded, What did you get wrong? (She insisted I include that.) The time I ordered food at the McDonald's drive-through speaker and then drove away without picking it up from the window. (They all insisted I include that.) I did not allow them to watch the Simpsons for the first two seasons. What was I thinking?

But the biggest mistake I made is the one that most of us make while doing this. I did not live in the moment enough. This is particularly clear now that the moment is gone, captured only in photographs.

There is one picture of the three of them, sitting in the grass on a quilt in the shadow of the swing set on a summer day, ages 6, 4 and 1. And I wish I could remember what we ate, and what we talked about, and how they sounded, and how they looked when they slept that night. I wish I had not been in such a hurry to get on to the next thing: dinner, bath, book, bed. I wish I had treasured the doing a little more and the getting it done a little less.

Even today I'm not sure what worked and what didn't, what was me and what was simply life. When they were very small, I suppose I thought someday they would become who they were because of what I'd done. Now I suspect they simply grew into their true selves because they demanded in a thousand ways that I back off and let them be.

The books said to be relaxed and I was often tense, matter-of-fact and I was sometimes over the top. And look how it all turned out. I wound up with the three people I like best in the world, who have done more than anyone to excavate my essential humanity.

That's what the books never told me. I was bound and determined to learn from the experts. It just took me a while to figure out who the experts were....

Safety of H1N1 Vaccine Confirmed

2009-11-12T14:11:00.000-08:00

FDA Commissioner Addresses H1N1 Vaccine Safety Concerns

Emma Hitt, PhD

Posted: 11/11/2009

November 11, 2009 — In a letter yesterday, the commissioner of the US Food and Drug Administration (FDA), Margaret A. Hamburg, MD, reassured healthcare professionals about vaccine safety and thanked them for their "extraordinary efforts" during the 2009 H1N1 influenza outbreak.

MedWatch, the FDA's safety information and adverse event reporting program, announced the letter in a posting yesterday.

"Delays in vaccine delivery and the persistence of myths about vaccination have not made your job any easier," she stated. "Thank you for rising to this public health challenge."

Reassuring Patients About Vaccine Safety

Dr. Hamburg, who was confirmed on May 18, 2009 as the FDA's new commissioner, described information about H1N1 that can be used to allay patient fears about vaccine safety.

She noted that some patients might think that the safety of the H1N1 vaccine is unconfirmed because the vaccine became available only 6 months after the 2009 H1N1 virus appeared. However, this fear is misguided because the H1N1 vaccine is produced in exactly the same way as the seasonal influenza vaccine.

"Companies began manufacturing the 2009 H1N1 vaccines in the same factories where they are licensed to manufacture seasonal influenza vaccines — using the same equipment and the same testing procedures," she pointed out.

According to Dr. Hamburg, if the H1N1 virus had emerged a few months earlier, "it could have been included as 1 of the 3 strains in the 2009 seasonal vaccine. In this key respect, although the strain of the 2009 H1N1 virus is new, the 2009 H1N1 influenza vaccines are not."

In addition, in National Institutes of Health–sponsored clinical trials of more than 3600 people, no serious adverse events have been attributed to the vaccine.

Dosing of the 2009 H1N1 influenza

Until recently, it was unclear how many doses of the vaccine would be needed. According to the letter, only a single dose of H1N1 vaccine is needed for healthy adults, the elderly, and older children. "For children ages 9 and younger, two doses of the H1N1 vaccine will likely be optimal, also similar to seasonal vaccine," Dr. Hamburg said.

The letter is available on the FDA Web site. More information on H1N1 influenza is available here.

Adverse effects linked to any vaccine, including the 2009 H1N1 influenza vaccine, should be reported to the Vaccine Adverse Event Reporting System (http://vaers.hhs.gov/index).

Adverse events can also be communicated to MedWatch by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, Maryland 20852-9787.
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Authors and Disclosures
Journalist
Emma Hitt, PhD

Emma Hitt is a freelance editor and writer for Medscape.

Newborns Need Pain Relief ,Too

2009-11-12T14:03:00.000-08:00

Pain Control Recommended for Newborns

Laurie Barclay, MD

November 11, 2009 — Feeding and breast-feeding newborns are found to be the most effective methods of pain relief during heel-lancing, according to the results of a prospective study reported in the November issue of Pediatrics.

"Pain experience can alter clinical outcome, brain development, and subsequent behavior in newborns, primarily in preterm infants," write Amir Weissman, MD, from Technion-Israel Institute of Technology in Haifa, Israel, and colleagues. "The aims of this study were (1) to evaluate several simple, commonly used methods for pain control in newborns and (2) to evaluate the concordance between behavioral and autonomic cardiac reactivity to pain in term neonates during heel-lancing."

During heel-lancing for routine neonatal screening of phenylketonuria and hypothyroidism, 180 term newborn infants were randomly selected to 1 of 6 groups: (1) control (no intervention for pain relief); (2) sucking without feeding; (3) holding by mother; (4) ingestion of oral glucose solution; (5) feeding with oral formula; or (6) breast-feeding. Response to pain was assessed with the Neonatal Facial Coding System score; duration of crying; and autonomic variables determined from spectral analysis of heart rate variability before, during, and after heel-lancing.

Compared with newborns in any of the 5 intervention groups, those in the control group with no pain intervention had the greatest levels of pain manifestation. Breast-feeding or feeding with oral formula appeared to be most effective vs all other groups, based on the lowest increase in heart rate (21 and 23 beats per minute, respectively, vs 36 beats per minute; P < .01), neonatal facial score (2.3 and 2.9, respectively, vs 7.1; P < .001), cry duration (5 and 13 seconds, respectively, vs 49 seconds; P < .001), and the lowest decrease in parasympathetic tone (–2 and –2.4, respectively, vs 1.2; P < .02).

"Any method of pain control is better than none," the study authors write. "Feeding and breast-feeding during heel-lancing were found to be the most effective methods of pain relief."

Limitations of this study include low sensitivity of the pain assessment methods, large variability of newborn response to painful stimuli, and the subjective nature of interpreting these data.

"Neonatal pain prevention is the expectation of the parents and should be the goal of the medical staff; therefore, family members or staff may be recruited to help during these procedures, and nursing mothers should be encouraged to breastfeed during the procedure," the study authors conclude. "If family members believe that they cannot withstand the procedure, hear their infant crying, or see the heel-lancing, then bottle-feeding seems to be a good alternative."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:e921-e926.

WHO Urges Rapid Use of Antivirals in H1N1

2009-11-12T13:48:00.000-08:00

New Guidelines on H1N1 Influenza Urge Quicker Use of Antivirals

Robert Lowes

November 12, 2009 — Updated treatment guidelines for H1N1 influenza from the World Health Organization (WHO) urge clinicians to administer antiviral medications as soon as possible to patients in at-risk groups with flu symptoms, patients with pneumonia, and those with uncomplicated influenza-like illness that worsens or fails to improve within 72 hours.

The reason for immediate antiviral therapy is that a mild case of H1N1 influenza can morph into a deadly disease such as pneumonia within 24 hours, according to the revised guidelines released Tuesday.

"The virus can take a life within a week," Nikki Shindo, MD, a medical officer in WHO's Global Influenza Programme, said during a press conference today. "The week of opportunity is very narrow in regard to the progression of the disease. The medicine needs to be administered before the virus destroys the lungs."

Patients in at-risk groups who should receive antivirals once they experience flu symptoms include pregnant women, children younger than 2 years, and individuals with chronic illnesses such as respiratory problems, according to Dr. Shindo.

Dr. Shindo said that earlier WHO guidelines focused on treating severe disease stemming from the H1N1 virus. The updated guidelines, she explained, have more to say about preventing severe disease, especially with the use of antiviral medications. Initial guidance about antivirals had been more conservative because WHO "had almost no experience" in regard to their effectiveness and because supplies were limited, said Dr. Shindo. Now, WHO has more data about the safety and usefulness of the medicine, and supplies are more ample.

The updated guidelines state that clinicians should not delay antiviral treatment for patients with suspected H1N1 influenza for the sake of conducting tests to confirm the diagnosis. In addition, a negative result from some rapid influenza diagnostic tests should not justify withholding antiviral therapy because these tests "miss many infections with pandemic H1N1 virus."

The first-line antiviral for treating the H1N1 virus is oseltamivir (Tamiflu), according to WHO. If oseltamivir is not available, it is not possible to administer it to a particular patient, or if the virus is resistant to oseltamivir, the guidelines recommend that clinicians use zanamivir (Relenza), which is inhaled.

To ensure easier access to treatment, public health authorities should distribute antivirals through general practitioners and not primarily through hospitals, said Dr. Shindo. "Patients should not have to visit the hospital to get antivirals prescribed," she said. "This should help ensure that individuals get the care they need faster. This will leave hospitals freer to treat the more severe cases."

Although Dr. Shindo emphasized the need for the earlier use of antivirals, she said that people not in the at-risk groups who are experiencing only mild flu symptoms do not need to take antiviral therapy. Nor should healthy individuals take it as a preventive measure.

WHO Guidelines Do Not Conflict With CDC Directives

The updated WHO guidelines specify watchful waiting for 72 hours for patients who have uncomplicated influenza-like illness and who do not have an underlying medical condition that puts them at risk. Hallmarks of progressive illness that warrant antiviral therapy include:

* Shortness of breath, hypoxia, and fast or labored breathing in children, which would suggest oxygen impairment or cardiopulmonary insufficiency.
* Altered mental status, unconsciousness, drowsiness, and seizures, which suggest central nervous system complications.
* Evidence of sustained virus replication or invasive secondary bacterial infection.
* Severe dehydration, expressed as decreased activity, dizziness, decreased urine output, and lethargy.

By necessity, this recommendation for follow-up requires patient education, Dr. Shindo said. Clinicians should instruct patients who initially present with uncomplicated influenza-like illness to return for another visit if they develop these or other symptoms of progressive illness — or do not get better — within 72 hours from the onset of symptoms, according to WHO.

The Centers for Disease Control and Prevention (CDC) have not issued any guidance on follow-up care for influenza patients that stipulates a 72-hour time frame, but the agency does advise patients who do not improve within a few days that they might have a complication like a secondary infection, said Anthony Fiore, MD, a medical epidemiologist with the CDC's National Center for Immunization and Respiratory Diseases.

"I do not see the WHO recommendations as being in conflict [with the CDC directives]," Dr. Fiore told Medscape Infectious Diseases. CDC recommendations on administering antiviral medications are revised on average every 4 to 6 weeks, said Dr. Fiore. "We will look at the WHO guidance and the evidence base used to develop the guidance as part of [our] revision."

The updated treatment guidelines are available on the WHO Web site.

CDC Update

At a CDC press briefing today, Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, provided an updated estimate of H1N1 cases using data extrapolated from the CDC’s Emerging Infections Program .

The CDC estimates that during the first 6 months of the pandemic (April through October 17, 2009), a total of 22 million people (range, 14 – 34 million) in the United States became infected with H1N1 influenza. Of these, 98,000 people (range, 63,000 to 153,000) were hospitalized; and 3900 (range, 2500 – 6100) died.

The data are also broken down by age group and highlight that fact that numbers of cases, hospitalizations, and deaths are disproportionately higher in people aged 64 years and younger than in older individuals.

These numbers will be updated every 3 to 4 weeks, she said.

Dr. Schuchat also discussed the effect of H1N1 influenza in patients with diabetes, which afflicts about 19% of adults hospitalized for H1N1. According to Dr. Schuchat, people with diabetes should be vaccinated (with the injectable vaccine not the nasal spray) against H1N1. People with diabetes who also have respiratory illness should receive antiviral therapy, which should be initiated prior to availability of test results. Patients with diabetes should also ensure that they have been vaccinated against pneumococcal infections.

To date, 41.6 million doses of H1N1 vaccine have become available. “This is more than we had before but not as much as we had hoped to have by today,” Dr. Schuchat said. Currently, 94 million doses of seasonal influenza vaccine have been distributed, with 114 million doses total expected by the end of the year.

Emma Hitt, PhD, contributed to this report.

H1N1 (Swine)Flu vaccines are now available to parents and caretakers!

2009-11-12T12:52:00.000-08:00

We are now offering the H1N1(Swine)Flu vaccine to our patients parents and caretakers. There is a $20 admnistration charge for adults. If you are interested in recieving this vaccine please call the office to schedule an appointment.

Preservative free Swine Flu vaccine for ages 6 months - 35 months has arrived!

2009-11-10T08:11:00.000-08:00

Our preservative free H1N1(Swine) Flu vaccines for age 6 months to 35 months has arrived. Please call the office to schedule your childs appointment. Please remember we are trying to accomodate many patients who want their children to have the vaccine and are doing our best to schedule everyone at the earliest time available. We are currently scheduling out 2-3 weeks. Thank you in advance for your understanding.

Cannabinoids Do Not Help Tics in Tourette's Syndrome

2009-10-28T04:13:00.000-07:00

Cannabinoids for Tourette's Syndrome

Curtis A, Clarke CE, Rickards HE
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Summary
Cannabinoids for Tourette syndrome

Cannabinoid medication might be useful in the treatment of the symptoms in patients with Tourette's syndrome. At the present time only two relevant studies have been conducted. Both studies used tetrahydrocannabinol (Δ9THC). In both studies Δ9THC was associated with tic reduction. However the sample size was small and a large number of multiple comparisons were made . There were only 28 participants in total, since eight participants took part in both studies. Possibly the patients who derived the greatest benefit and experienced the least adverse effects would be the most inclined to participate in further studies. There were a high number of drop outs/exclusions in the six week study and it is unclear whether intention to treat analysis (ITT) was performed. The results that are reported are analyses done on the patients who remained in the study on the study medication at the correct dose. In reality, patients do opt not to continue treatment if there is limited efficacy or unpalatable side effects. This introduces attrition bias. Whilst there were some significant results, the authors themselves accept that very few of these results are significant if a Bonferroni correction is performed. It is possible that cannabinoid medication has a beneficial effect which is too weak to be detected using ITT and such a small sample size. There is some weak evidence that cannabinoid medication may have an effect on obsessive compulsive behaviour but the measure used was an addition to the TSSL which has not been validated.There were no data on the effect of Δ9THC on quality of life.There is not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2009 Issue 4, Copyright © 2009 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Curtis A, Clarke CE, Rickards HE. Cannabinoids for Tourette's Syndrome. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006565. DOI: 10.1002/14651858.CD006565.pub2

This version first published online: October 07. 2009
Abstract
Background

Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS.
Objectives

To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS.
Search strategy

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date).

We also searched the reference lists of located trials and review articles for further information.
Selection criteria

We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS.
Data collection and analysis

Two authors abstracted data independently and settled any differences by discussion.
Main results

Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta-9-Tetrahydrocannabinol (Δ9THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Δ9THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures.
Authors' conclusions

Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.

ADHD Represents Delayed, Not Abnormal Brain Maturation

2009-10-22T13:24:00.000-07:00

by
Arline Kaplan MD

Cortical development in children with attention-deficit/hyperactivity disorder (ADHD) generally lags behind that in other children by several years, NIMH researchers reported recently.1 The greatest maturational delay occurs in prefrontal regions important for control of such cognitive processes as attention and working memory, they found.
There has been a long-standing debate as to whether ADHD is caused by a delay in brain development or is partly due to a complete deviation away from typical brain development, said Philip Shaw, MD, PhD, an NIMH staff clinician and leader of the research team.
To help resolve the controversy about the disorder that affects 3% to 5% of school-aged children, Shaw and his colleagues conducted a neuroanatomical MRI study and found evidence suggesting that ADHD is characterized by delay rather than deviance in cortical maturation.
"We looked at the development of the cortex, and we measured its thickness in 446 kids, half... with ADHD and half without the disorder," Shaw told Psychiatric Times.
The researchers scanned the brains of most of the study participants at least twice at about 3-year intervals. While the participants included preschoolers and young adults, most ranged in age from 7 to 16 years. Among the participants with ADHD, 92% had combined-type ADHD at baseline.
Using computational neuroanatomical techniques, the researchers estimated cortical thickness at more than 40,000 cerebral points from 824 MRI scans. They focused on the age of attaining peak cortical thickness—when cortex thickening during childhood gives way to thinning following puberty, as unused neural connections are pruned for optimal efficiency during the teen years.
"While healthy kids reached peak cortical thickness at age 7 or 8, the kids with ADHD reached... peak cortical thickness a few years later, around age 10," Shaw said.
The cortical maturation delay in ADHD was most prominent in the lateral prefrontal cortex, the region, according to the research team, that supports such cognitive functions as the ability to suppress inappropriate responses and thoughts, executive control of attention, evaluation of reward contingencies, and working memory. Delay was also found in the temporal cortex.
The only cortical area in which the ADHD group demonstrated slightly earlier maturation was the primary motor cortex.
"It is possible that the combination of early maturation of the primary motor cortex with late maturation of higher-order motor control regions may reflect or even drive the excessive and poorly controlled motor activity cardinal to the syndrome," the research team wrote.
Although there was a delay in the young people with ADHD, the order in which the different parts of the cortex matured was similar in both groups.
Shaw was asked whether the findings indicate that children will eventually grow out of ADHD. The study findings cannot be interpreted to mean that in ADHD the brain normalizes at age 10 or 12, he said.
"The delay we showed is carried forward into adolescence," he said. "Also we know from a host of other studies that there are very real persisting structural and functional differences between teenagers with ADHD and those who don't have the disorder." Frequently, he said, outcomes reported in previous studies depend on how ADHD is defined. If you use a strict definition, he explained, about one quarter of people who grow up with ADHD will still meet the definition in adulthood. If a broader definition is used, about two thirds of people with childhood ADHD will still have troublesome symptoms in adulthood.
Studies that measure brain volume or function also have detected differences between the brains of young people who have ADHD and those of individuals who do not have the disorder.
"One very striking thing about our findings is that they complement existing imaging studies from other groups that found structural and functional differences, and all of them are pointing to similar parts of the brain," Shaw said.
Why the delay?
Discussing factors that might underpin the delay, the research team mentioned psychostimulants and genetic factors. Most of those with ADHD in the study were receiving standard treatment with psychostimulants, but there were not enough medication-naive children to analyze them as a separate group, according to Shaw. In the published report, the research team wrote "trophic effects of treatment with psychostimulants in the ADHD group are possible, but unlikely, given our previous reports of no effect of psychostimulants on gray matter volume."
"Genetic factors will certainly play a role, with a perturbation in the developmental sequence of the activation and deactivation of genes that sculpt cortical architecture," the team wrote. "In this context, neurotrophins, essential for the proliferation, differentiation, and survival of neuronal and nonneuronal cells, emerge as promising candidates."
"The numbers needed to do genetic studies are enormous," Shaw said. "Of course, there are very good multisite collaborative studies going on, which are helping us identify the key genes."
There are a host of candidates and factors that could control neural growth, Shaw said, acknowledging that dopamine and other neurotransmitters in the brain also are important to the growth of the cortex.
While research continues on possible causes of ADHD, Shaw noted that his team would be using brain-imaging techniques to study what happens to children with ADHD as they grow older.
"There is a large cohort of children who have very persistent ADHD," he explained. "We want to compare them with the kids who get better from ADHD. That involves scanning the kids a little bit later when they are in their mid-teens."
Diagnosis and treatment
Brain imaging is not ready for use as a diagnostic tool in ADHD, Shaw said."It is still too early to use neuroanatomical scans for diagnosis," he said. "We had to scan hundreds of children to identify subtle differences. They [the differences] are very real, but they are subtle. So the scan of any one child will not tell you a great deal about whether [he or she has] ADHD or not. Currently, the diagnosis of ADHD remains clinical."
What's more, the brain imaging study was a "natural history study" and so it did not address treatment, he explained.
"We know the treatments that work for ADHD on the basis of very large clinical studies, including the Multimodal Treatment Study of Children With ADHD and the Treatment of Attention Deficit Hyperactivity Disorder in Preschool-Age Children study," he said.
While the Shaw et al study is not relevant to issues of diagnosis and treatment, it is nevertheless important in providing another facet of our increasing knowledge about the neurobiology of this disorder, said F. Xavier Castellanos, MD, Brooke and Daniel Neidich Professor of Child and Adolescent Psychiatry and director of research for the New York University Child Study Center.
In his own work, Castellanos said, his group is pursuing some novel methods of functional MRI that may well have diagnostic implications.2,3
Also responding to the Shaw et al study was E. Clarke Ross, chief executive officer for Children and Adults With Attention Deficit/Hyperactivity Disorder, a national advocacy and support organization.
"In a time when a vocal minority denies the mountain of evidence showing ADHD to be a real disorder," he said, "it is nice to watch brain scans light up on televisions across the country with images actually showing the structural differences in the brains of those living with ADHD."

Be Aware of Fraudulent "Natural" Flu Treatments

2009-10-22T10:38:00.001-07:00

FDA NEWS RELEASE

For Immediate Release: Oct. 19, 2009

Media Inquiries: Christopher Kelly, 301-796-4676 christopher.kelly@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA

FDA, FTC Issue Joint Warning Letter to Web Site Offering Fraudulent H1N1 Flu Supplements

Agencies continue effort to protect public health from illegal Web activity

On October 15, 2009, the U.S. Food and Drug Administration (FDA) and the Federal Trade Commission (FTC) issued a joint warning letter to a Web site marketing fraudulent supplements that claim to help prevent the spread of the 2009 H1N1 influenza virus.

The warning letter, the first to be issued jointly by the agencies, advises the owners of the site that they must discontinue the fraudulent marketing of their product or face legal action. The letter further advises the owners of the site that they have 48 hours to give the agencies a plan to discontinue their fraudulent marketing.

The FDA and the FTC remind consumers to be cautious of promotions or Internet sites offering products for sale that claim to diagnose, prevent, mitigate, treat or cure the 2009 H1N1 influenza virus. Fraudulent H1N1 influenza products come in many varieties, including dietary supplements, as well as products purporting to be drugs, medical devices or vaccines. Since May 2009, the FDA has warned more than 75 Web sites to stop the sale of more than 135 products with fraudulent H1N1 influenza virus claims.

“Products that are offered for sale with claims to diagnose, prevent, mitigate, treat or cure the 2009 H1N1 influenza virus must be carefully evaluated,” said Commissioner of Food and Drugs Margaret A. Hamburg, M.D. “Unless these products are proven to be safe and effective for the claims that are made, it is not known whether they will prevent the transmission of the virus or offer effective remedies against infection. Furthermore, they can make matters worse by providing consumers with a false sense of protection.”

The FDA and the FTC also warn consumers to take extreme care when buying products over the Internet that claim to diagnose, prevent, treat or cure the H1N1 influenza virus because, in addition to being fraudulent, they could be dangerous.

In collaboration with the FTC, the FDA will continue to work aggressively to identify, investigate and take regulatory action against individuals or businesses that wrongfully promote purported 2009 H1N1 influenza products.

This will include taking joint action, when appropriate, such as the issuance of last Thursday's warning letter. Additional legal action could include an injunction or issuance of an administrative order by the FTC or seizure of products, an injunction or criminal prosecution by the FDA.

“The FDA continues to consider the sale and promotion of fraudulent H1N1 influenza products to be a possible threat to the public health and in violation of the Federal Food Drug and Cosmetic Act,” said Michael Chappell, acting associate commissioner for regulatory affairs. “The FDA has an aggressive surveillance program to detect fraudulent H1N1-related products and will take prompt action to stop the marketing of fraudulent H1N1 influenza products and will hold those who are responsible for doing so accountable.”

To view the warning letters, visit: http://www.fda.gov/ICECI/EnforcementActions/WarningLetters/2009/default.htm.

There are two antiviral drugs approved by the FDA for treatment and prophylaxis of the 2009 H1N1 influenza virus – Tamiflu (oseltamivir phosphate) and Relenza (zanamivir). Tamiflu and Relenza, in addition to their approved labeling, have been issued Emergency Use Authorizations by the FDA that describe specific authorized uses during this public health emergency.

H1N1 Flu Fraud Widget

This week, the FDA enhanced its efforts to warn the public about potentially deceptive H1N1 influenza products and to report suspected criminal activity with the release of an H1N1 flu fraud widget.

The portable application, embedded in a Web page that can be copied onto any other Web site or blog, will allow the public to play an active role in preventing flu fraud, and is available at http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm186340.htm

Consumers are urged to report any suspected fraudulent products or criminal activity relating to FDA-regulated products associated with H1N1 influenza virus, including the names of Web sites that may be offering these products for sale, to the FDA by visiting: http://www.accessdata.fda.gov/scripts/email/oc/oci/flucontact.cfm

Consumers are urged to purchase and consume only FDA-approved or authorized medical products to diagnose, treat, prevent, or cure infections caused by the H1N1 virus. Consumers also are urged to contact their health care provider if they have any questions or concerns about medical products or personal protective equipment.

For more information:

FDA 2009 H1N1 (Swine) Flu Page
http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm150305.htm

Centers for Disease Control and Prevention – 2009 H1N1 Flu (Swine Flu)
http://www.cdc.gov/h1n1flu/

Fraudulent 2009 H1N1 Influenza Products List
http://www.accessdata.fda.gov/scripts/h1n1flu/

Influenza Antiviral Drugs and Related Information
http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm100228.htm

The Federal Government’s Influenza Web site
http://www.flu.gov/

FTC Warns Internet Peddlers that Potentially Bogus H1N1 Influenza Products May Violate Federal Law—Press Release, May 5, 2009
http://www2.ftc.gov/opa/2009/05/swineflu2.shtm

RSS Feed for FDA News Releases [what is RSS?]

Page Last Updated: 10/19/2009

Seasonal Flu shots for children 3 years old and younger now available!

2009-10-22T05:05:00.001-07:00

Our Seasonal flu shots for children 3 years of age or younger are now available. If your child has not yet recieved this vaccine or is due for their second dose please call the office to schedule their appointment. We do not yet have information on when we will recieve the rest of our Seasonal flu vaccine for patients above the age of 3, as soon as we do we will post it on this website.

The H1N1 (Swine) Flu shots for children 3 years and up are in!!

2009-10-16T11:13:00.000-07:00

The shot for children 3 years of age and up for the H1N1 (aka Swine flu) are now available! If you are interested in having your child vaccinated please call the office to schedule an appointment. We are making every effort to get everyone in as quickly as possible, but due to the large number of vaccines we need to administer in a short period of time we have alloted certain times we are scheduling these appointments. Thank you in advance for your understanding and cooperation.
If you have questions regarding the vaccines please follow this link: http://www.cdc.gov/vaccines/pubs/vis/default.htm.for the vaccine information sheets to help you make an informed decision.

Treating Depression or Anxiety without Presciptions?

2009-10-14T04:08:00.000-07:00

CAM for your depressed patient: 6 recommended options

Sy Atezaz Saeed, MD

Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Richard M. Bloch, PhD

Professor and director of research, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Diana J. Antonacci, MD

Associate professor and director of residency training, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Americans with depression turn to complementary and alternative medicine (CAM) more often than conventional psychotherapy or FDA-approved medication. In a nationally representative sample, 54% of respondents with self-reported “severe depression”—including two-thirds of those receiving conventional therapies—reported using CAM during the previous 12 months.¹

Unfortunately, popular acceptance of CAM for depression is disproportionate to the evidence base, which—although growing—remains limited. As a result, your patients may be self-medicating with poorly supported treatments that are unlikely to help them recover from depression.

In reviewing CAM treatments for depression, we found some with enough evidence of positive effect that we feel comfortable recommending them as evidence-based options. These promising, short-term treatments are supported by level 1a or 1b evidence and at least 1 study that demonstrates an ability to induce remission (Table 1).²

For patients seeking “natural” or nonprescription treatments—or when you wish to augment standard treatments that are not working adequately—you might recommend fatty acids, St. John’s wort, or S-adenosyl-L-methionine (SAMe). Similar recommendations can be made for yoga, exercise, and bibliotherapy, as we discuss here.

Table 1
Evidence these authors required to recommend a CAM treatment

Minimum requirements	Level of evidence	Recommendation
Systematic review showing superiority to placebo or standard treatment Plus 1 study showing CAM treatment can induce remission	1a + 1b or 2b	A
At least 2 RCTs showing superiority to placebo or standard treatment Plus 1 study showing CAM treatment can induce remission	1b 1b or 2b	A–
CAM: complementary and alternative medicine; RCT: randomized controlled trial
Source:Reference 2

Reviewing CAM evidence

This article refers to as “alternative” any treatment other than a form of psychotherapy or an FDA-approved medication that substitutes for a standard psychiatric treatment. When used to augment standard psychiatric treatments, these approaches are considered “complementary.”

Our search for evidence on CAM treatments for depressive disorders raised questions about what constitutes acceptable and convincing methodology:

Studies often had problems with blinding and suitable placebos. Many were small, with short duration and no long-term follow-up.
Comparisons with active treatments that showed no differences were assumed to imply comparability, even though the studies were powered to detect only large differences.

Clinical Point

Multiple RCTs have shown consistent superiority of some CAM treatments over comparison conditions

On the other hand, multiple randomized controlled trials (RCTs) have shown consistent superiority of some CAM treatments over comparison conditions.

Applying the evidence. Because CAM use is widespread, be sure to ask psychiatric patients if they are using CAM treatments. If the answer is “yes,” a risk-benefit assessment is needed. Inform patients who are using poorly supported CAM approaches that they could consider better-supported CAM options as well as standard effective antidepressants.

Monitor patients for an adequately prompt positive response to an evidence-based CAM approach that has shown efficacy for their level of depression. As with any treatment, consider other evidence-based options when CAM treatments are inadequate or unsuccessful in achieving remission of depressive symptoms.

Sufficient evidence of efficacy

Yoga. In their systematic review of yoga’s effectiveness for depression, Pilkington et al³ analyzed 5 RCTs that met 3 criteria:

participants had mild to severe depression or depressive disorders
yoga or yoga-based exercises alone were used for treatment
depression rating scales were used as outcome measures.

They found evidence that yoga can reduce depressive symptoms and induce remission (Table 2). The studies were generally small and of short duration, and depression severity and interventions varied widely. Most participants were young and relatively fit, raising questions about yoga’s applicability to older or less fit patients. Reporting of adverse events was limited, but no safety issues or adverse effects were identified.

Conclusion. Yoga has been studied primarily as an alternative treatment, but its physical health and group participation benefits and lack of side effects make it a suitable complementary treatment as well.

Clinical Point

Yoga’s positive effects suggest that exercise does not have to be aerobic to provide an antidepressant benefit

Exercise. Extensive literature has examined the relationship between exercise and depression. We identified 7 reviews published between 1993 and 2008 (Table 3). All supported positive effects of exercise except for patients age <20.>

45% with supervised exercise
40% with home-based exercise
47% with sertraline, 50 to 200 mg/d
31% with placebo.⁴

Table 2
5 RCTs of yoga’s effectiveness in treating depression

RCT	Interventions	Conclusion
Broota and Dhir, 1990	Yoga and PMR vs control	Yoga and PMR were more effective than control, with yoga more effective than PMR
Khumar et al, 1993	Shavasana yoga vs no intervention	College students with severe depression improved during and after yoga treatment
Janakiramaiah et al, 2000	SKY vs ECT vs imipramine	Reductions in BDI scores for all 3 groups; ECT > SKY or imipramine, SKY=imipramine
Rohini et al, 2000	Full SKY vs partial SKY	30 individuals with MDD improved with either therapy, but results were not statistically significant
Woolery, 2004	Iyengar yoga vs wait list	28 mildly depressed individuals benefitted from yoga, as measured by BDI scores at midpoint and throughout treatment
BDI: Beck Depression Inventory; ECT: electroconvulsive therapy; MDD: major depressive disorder; PMR: progressive muscle relaxation; RCT: randomized controlled trial; SKY: Sudarshan Kriya yoga
Source: Broota A, Dhir R. Efficacy of two relaxation techniques in depression. Journal of Personality and Clinical Studies. 1990;6(1):83-90. Khumar SS, Kaur P, Kaur S. Effectiveness of Shavasana on depression among university students. Indian J Clin Psychol. 1993;20(2):82-87. Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, et al. Antidepressant efficacy of Sudarshan Kriya yoga (SKY) in melancholia: a randomized comparison with electroconvulsive therapy (ECT) and imipramine. J Affect Disord. 2000;57(1-3):255-259. Rohini V, Pandey RS, Janakiramaiah N, et al. A comparative study of full and partial Sudarshan Kriya yoga (SKY) in major depressive disorder. NIMHANS Journal. 2000;18(1):53-57. Woolery A, Myers H, Sternlieb B, et al. A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med. 2004;10(2):60-63.

Table 3
Evidence of the antidepressant effect of exercise

Literature review	Methodology	Conclusion
Byrne and Byrne, 1993	13 studies, clinical samples, measured changes in depressed mood	90% of studies reported beneficial effects, especially in clinical populations
Scully et al, 1998	4 literature reviews, 1 monograph, 1 study	Positive relationship of physical activity and depression in healthy and clinical samples, increased over time
Lawlor and Hopker, 2001	14 RCTs from 1966 to 1999 with depression as an outcome	Significant methodologic weaknesses, but exercise effect > no treatment and=cognitive therapy
Dunn et al, 2001	Examined dose effect in 37 studies; subjects diagnosed with depressive disorders, mild-to-moderate symptoms, and no medical comorbidity	Only level B and C evidence; positive effects with exercise from light to heavy intensity; aerobic=nonaerobic; improvement may or may not be related to improved fitness
Brosse et al, 2002	12 RCTs from 1979 to 1999	Significant methodologic limitations, but authors concluded evidence supports a positive effect of exercise in healthy and clinical populations
Larun et al, 2006	4 RCTs in children and youth age <20	Exercise effect same as no intervention, low-intensity relaxation, or psychosocial intervention
Barbour et al, 2007	2 meta-analyses, 1 RCT, 2 studies	Positive effect; high-energy was optimal dose; aerobic=nonaerobic; improvement may or may not be related to improved fitness
RCT: randomized controlled trial
Source: Byrne AE, Byrne DG. The effect of exercise on depression, anxiety and other mood states: A review. J Psychosom Res. 1993;37(6):565-574. Scully D, Kremer J, Meade MM, et al. Physical exercise and psychological well being: a critical review. Br J Sports Med. 1998;32(2):111-120. Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ. 2001;322(7289):763-767. Dunn AL, Trivedi MH, O’Neal HA. Physical activity dose-response effects on outcomes of depression and anxiety. Med Sci Sports Exerc. 2001;33(6):S587. Brosse AL, Sheets ES, Lett HS, et al. Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med. 2002;32(12):741-760. Larun L, Nordheim LV, Ekeland E, et al. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;3:CD004691. Barbour KA, Edenfield TM, Blumenthal JA. Exercise as a treatment for depression and other psychiatric disorders: a review. J Cardiopulm Rehabil Prev. 2007;27(6):359-367.

Conclusion. Evidence supports exercise for short-term treatment of mild or moderate depression in adults. Studies tend to be small and brief, to enroll young physically -sound patients, and to include little follow-up. Studies of subjects age <20>

At least 2 studies suggest that high-energy exercise and aerobic or resistance training provide greater reductions in depressive symptoms than exercises such as walking.^5,6 Yoga’s positive effects suggest, however, that an aerobic effect is not necessary for an antidepressant benefit.

Exercise has not been adequately tested as a complementary treatment but likely is safe for most psychiatric patients. Perspiration and dehydration might alter therapeutic blood levels of lithium or other medications. Advise patients to drink water before, during, and after exercise and to avoid outdoor exercise in extreme temperatures. More vigorous monitoring might be indicated in specific cases.

Tailor exercise programs to individual needs, considering the patient’s age and health status. Refer a patient with a known heart problem or increased cardiovascular risk to his or her physician for selective exercise testing.

Bibliotherapy—reading self-help books, usually about cognitive-behavioral approaches to depressive disorders—has been relatively well studied. A recent meta-analysis examined 29 studies with pre-post designs. Group differences in the 17 controlled studies yielded a large effect size of 0.77. Participants who read the materials benefitted similarly whether they met in groups or applied the information on their own. Older adults tended to be less depressed at baseline and made smaller treatment gains.⁷

Clinical Point

Self-administered CBT learned from reading books has been shown to be an effective treatment for mild-to-moderate depression

A study of 31 patients age >60 with mild-to-moderate depression⁸ compared 16 sessions of professionally administered cognitive-behavioral therapy (CBT) with self-administered cognitive therapy learned from reading a book.⁹ Both groups showed greater improvement in depressive symptoms compared with a control group. Subjects in the CBT group did somewhat better during the trial, but at 3-month follow-up most patients in both treatment groups no longer met diagnostic criteria for MDD.

Conclusion. Evidence supports bibliotherapy as an effective treatment for mild-to-moderate depression. No convincing data support its use as a complementary treatment, but it poses virtually no risk.

St. John’s wort (Hypericum perforatum) has been extensively studied for depressive disorders, with 29 RCTs in a meta-analysis of MDD trials through July 2008.¹⁰ Another meta-analysis compared St. John’s wort with selective serotonin reuptake inhibitors (SSRIs) in 13 studies through June 2008.¹¹ These and most RCTs have found St. John’s wort significantly more effective than placebo in reducing depressive symptoms.

Data selected from double-blind RCTs totaling 217 patients with mild depression [Hamilton Depression Rating Scale (HDRS) scores <20]>12 Studies routinely show that treating MDD with St. John’s wort is comparable to using tricyclic or SSRI antidepressants.

Side effects with St. John’s wort generally are no different than with placebo and significantly less than with comparison treatments. Even so, using St. John’s wort instead of SSRIs for MDD remains controversial.

Studies vs SSRIs. Many of the favorable St. John’s wort trials were conducted in Europe, particularly in Germany. Two large RCTs conducted in the United States reported that the St. John’s wort standardized extract LI-160 was not more effective than placebo, but neither could be clearly interpreted as negative for St. John’s wort:

In an 8-week trial, St. John’s wort and placebo groups improved significantly but at unusually low rates. The remission rate with St. John’s wort was small but significantly higher than with placebo.¹³
A study sponsored by the National Institute of Mental Health compared St. John’s wort, 900 to 1,500 mg/d; sertraline, 50 to 100 mg/d; and placebo in 340 adults with MDD. No positive effects were found for St. John’s wort or sertraline.¹⁴

Side effects. St. John’s wort can affect blood levels of circulating medications metabolized by the cytochrome P450 liver enzyme system, including tricyclic antidepressants. Case studies have reported pregnancy from oral contraceptive failure, skin rashes, headache, and mania with St. John’s wort use. Although these reports are disturbing, St. John’s wort’s side effects when compared with SSRIs have been less frequent (40% vs 49%) and milder (clinical trial dropout rate 2% vs 7%).¹¹

Conclusion. Standardized extracts of St. John’s wort—particularly WS5570, 300 mg tid, and ZE117, 250 mg bid—appear to be effective treatments, especially for mild-to-moderate MDD. Because St. John’s wort is available without prescription and can interact with SSRIs or other antidepressants:

care is required for its complementary use
it is important to ask if patients are using St. John’s wort on their own.

St. John’s wort is used as a first-line depression treatment in Europe, but U.S. physicians may be less familiar with its potential interactions with other medications. We recommend that you consider St. John’s wort:

Clinical Point

Consider St. John’s wort for first-line use only when you can adequately gauge its effects on your patient’s other medications

for first-line use only when you can adequately gauge its effects on your patient’s other medications
especially for depressed patients who cannot tolerate SSRIs.

SAMe is a metabolite involved in bio-synthesis of norepinephrine, serotonin, and dopamine.¹⁵ SAMe salts (such as 1,4-butanedisulfonate) are used as an over-the-counter supplement for depression treatment. Dozens of RCTs show SAMe has greater efficacy than placebo and positive effects comparable to those of standard antidepressants. In a meta-analysis of 28 RCTs by the Agency for Healthcare Quality and Research, SAMe produced significantly greater symptom improvement compared with placebo.¹⁶

SAMe has become a popular alternative treatment for depression since its introduction to the United States in the late 1990s, but it has been studied in only 2 U.S. open trials. One showed SAMe to be very effective in reducing depressive symptoms in patients with HIV/AIDS.¹⁷ The other found a 50% response rate and 43% remission rate with adjunctive SAMe, 800 to 1,600 mg/d for 6 weeks, in 30 adults with MDD who failed to respond adequately to SSRIs or the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. The most common side effects were gastrointestinal (GI) symptoms and headaches.¹⁸ This open trial led to an ongoing National Institutes of Health-sponsored RCT on the safety and efficacy of SAMe for patients with treatment-resistant depression.

Conclusion. SAMe appears to have a faster onset of antidepressant effect than standard SSRIs or SNRIs and a favorable side-effect profile, which make the lack of rigorous trials in the United States striking. We recommend that you consider SAMe:

Clinical Point

SAMe could be useful as a complementary treatment to speed the onset of antidepressant effects

as an adjunct in patients with incomplete response to standard treatments
as a complementary treatment to speed onset of antidepressant effects.

Polyunsaturated fatty acids (PUFAs), usually from fish oils, have long been popular nutritional supplements because of their beneficial effects on cholesterol and cardiovascular health. Omega-3 and omega-6 fatty acids are the most common PUFAs. The omega-3 PUFAs include eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Four meta-analyses independently looked at largely the same dozen RCTs through 2006 and found that 1 to 2 grams daily of omega-3 PUFAs was significantly more effective at reducing depressive symptoms than placebo.^19-22 Other data suggest that omega-3 PUFAs can induce depression remission in depressed Parkinson’s disease patients²³ and depressed pregnant women.²⁴ Since 2006, however, findings have been inconsistent. Several trials have found PUFAs no more effective than placebo.^25-27

An 8-week double-blind study compared EPA, 1 gram daily; fluoxetine, 20 mg/d; or both agents in 60 outpatients with MDD. Response rates—as measured by ≥50% reduction in baseline HDRS scores—were 50% with fluoxetine, 56% with EPA, and 81% with combination therapy.²⁸

Clinical Point

Although PUFAs’ therapeutic effects remain unclear, they appear safe to use as adjuncts if standard treatment is not satisfactory

Conclusion. Questions remain about dosing, ratio of EPA to DHA, patient selection, and baseline blood levels of PUFAs compared with response. PUFAs have a benign side-effect profile, with occasional reports of diarrhea or GI upset. Although their therapeutic effects are being clarified, PUFAs appear safe to recommend as an adjunct treatment if standard care is not satisfactory.

Insufficient evidence

L-tryptophan. It seems reasonable to expect a serotonin precursor to increase serotonin in the CNS and improve depressive symptoms. Of 111 trials on L-tryptophan for depression, however, only 2 met the quality criteria for inclusion in a recent meta-analysis.²⁹ Combining the 2 trials showed L-tryptophan alone and in combination with a tricyclic antidepressant was more effective than placebo for treating depressive disorders in adults.

Conclusion. Very little research continues to test L-tryptophan as a viable CAM for depressive disorder. Its serious side effect of eosinophilia-myalgia syndrome makes clinical use of this agent unlikely.

Acupuncture. Numerous small studies with questionable controls, different needling placements, and poor allocation concealment and blinding limit the ability to draw conclusions about acupuncture for treating depression (Table 4). A recent meta-analysis by Wang et al³⁰ added 2 Chinese trials not included in an earlier review³¹ and found acupuncture significantly reduced depressive symptoms. No consistent differences were detected in response or remission rates, however.

Conclusion. Evidence is methodologically weak, and the use of acupuncture as an alternative or complementary treatment of depression is questionable.

Table 4
Acupuncture: Insufficient evidence of antidepressant effect

Literature review	Methodology	Conclusion
Mukaino et al, 2005	Systematic review of 7 RCTs including 509 patients; compared either manual or electroacupuncture with any control procedure	Inconsistent evidence of manual acupuncture’s effectiveness vs sham; electroacupuncture’s effect may be similar to that of antidepressant medication and merits further study
Leo and Ligot, 2007	Systematic review of 9 RCTs, 5 considered low quality; some focused on very specific populations (ie, hospitalized stroke patients or pregnant depressed patients)	Evidence inconclusive because of study designs and methodologies
Smith and Hay, 2005	Meta-analysis of 7 trials including 517 adults with mild-to-moderate depression; 5 trials (409 participants) compared acupuncture with medication; 2 trials compared acupuncture with wait list or sham acupuncture	No difference between acupuncture and medication; study quality too poor to support acupuncture’s efficacy
Wang et al, 2008	Meta-analysis of 8 small RCTs totalling 477 subjects (256 received active acupuncture, remainder received sham acupuncture); sham acupuncture design, number of acupuncture sessions, and duration varied among studies	Significant reduction in HRSD or BDI scores for acupuncture vs sham, but no significant effect of acupuncture on response or remission rates
BDI: Beck Depression Inventory; HRSD: Hamilton Rating Scale for Depression; RCT: randomized controlled trial
Source: Mukaino Y, Park J, White A, et al. The effectiveness of acupuncture for depression—a systematic review of randomised controlled trials. Acupunct Med. 2005;23(2):70-76. Leo RJ, Ligot JS Jr. A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect Disord. 2007;97(1-3):13-22. Smith CA, Hay PPJ. Acupuncture for depression. Cochrane Database Syst Rev. 2005;(2):CD004046. Wang H, Qi H, Wang BS, et al. Is acupuncture beneficial in depression? A meta-analysis of 8 randomized controlled trials. J Affect Disord. 2008;111(2-3):125-134.

Related resources

National Center for Complementary and Alternative Medicine, National Institutes of Health. http://nccam.nih.gov.
Journal of Alternative and Complementary Medicine. www.liebertpub.com/products/product.aspx?pid=26.
Complementary and alternative medicine. www.nlm.nih.gov/medlineplus/complementaryandalternativemedicine.html.

Drug brand names

Fluoxetine • Prozac

Imipramine • Tofranil

Lithium • Eskalith, Lithobid

Sertraline • Zoloft

Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

Kessler RC, Soukup J, Davis RB, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry. 2001;158(2):289–294.

Phillips B, Ball C, Sackett D, et al. Oxford University Centre for Evidence Based Medicine levels of evidence and grades of recommendation (March 2009). Available at: http://www.cebm.net/index.aspx?o=1025#levels. Accessed August 19, 2009.

Pilkington K, Kirkwood G, Rampes H, et al. Yoga for depression: the research evidence. J Affect Disord. 2005;89(1-3):13–24.

Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69(7):587–596.

Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression: efficacy and dose response. Am J Prev Med. 2005;28(1):1–8.

Legrand F, Heuze JP. Antidepressant effects associated with different exercise conditions in participants with depression: a pilot study. J Sport Exercise Psychol. 2007;29(3):348–364.

Gregory RJ, Schwer Canning S, Lee TW, et al. Cognitive bibliotherapy for depression: a meta-analysis. Professional Psychology: Research and Practice. 2004;35(3):275–280.

Floyd M, Scogin F, McKendree-Smith NL, et al. Cognitive therapy for depression: a comparison of individual psychotherapy and bibliotherapy for depressed older adults. Behav Modif. 2004;28(2):297–318.

Burns DD. Feeling good: the new mood therapy.New York, NY: HarperCollins; 1980.

Linde K, Berner MM, Kriston L. St John’s Wort for major depression. [update of Cochrane Database Syst Rev. 2005;(2):CD000448; PMID: 15846605].Cochrane Database Syst Rev. 2008(4):000448.

Rahimi R, Nikfar S, Abdollahi M. Efficacy and tolerability of Hypericum perforatum in major depressive disorder in comparison with selective serotonin reuptake inhibitors: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2009;33(1):118–127.

Kasper S, Gastpar M, Müller WE, et al. Efficacy of St. John’s wort extract WS 5570 in acute treatment of mild depression: a reanalysis of data from controlled clinical trials. Eur Arch Psychiatry Clin Neurosci. 2008;258(1):59–63.

Shelton RC, Keller MB, Gelenberg A, et al. Effectiveness of St John’s wort in major depression: a randomized controlled trial. JAMA. 2001;285(15):1978–1986.

Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John’s wort) in major depressive disorder: a randomized controlled trial. JAMA. 2002;287(14):1807–1814.

Mischoulon D, Fava M. Role of S-adenosyl-L-methionine in the treatment of depression: a review of the evidence. Am J Clin Nutr. 2002;76(suppl):1158S–1161S.

Hardy ML, Coulter I, Morton SC, et al. S-adenosyl-L-methionine for treatment of depression, osteoarthritis, and liver disease [comment in ACP J Club. 2003;139(1):20]. Evid Rep Technol Assess (Summ). 2003;Aug(64):1–3.

Shippy RA, Mendez D, Jones K, et al. S-adenosylmethionine (SAM-e) for the treatment of depression in people living with HIV/AIDS. BMC Psychiatry. 2004;4:38.

Alpert JE, Papakostas G, Mischoulon D, et al. S-adenosyl-L-methionine (SAMe) as an adjunct for resistant major depressive disorder: an open trial following partial or nonresponse to selective serotonin reuptake inhibitors or venlafaxine. J Clin Psychopharmacol. 2004;24(6):661–664.

Lin PY, Su KP. A meta-analytic review of double-blind, placebo-controlled trials of antidepressant efficacy of omega-3 fatty acids. J Clin Psychiatry. 2007;68(7):1056–1061.

Freeman MP, Hibbeln JR, Wisner KL, et al. Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry [published correction appears in J Clin Psychiatry. 2007;68(2):338]. J Clin Psychiatry. 2006;67(12):1954–1967.

Ross BM, Seguin J, Sieswerda LE. Omega-3 fatty acids as treatments for mental illness: which disorder and which fatty acid? Lipids Health Dis. 2007;6:21.

Appleton KM, Hayward RC, Gunnell D, et al. Effects of n-3 long-chain polyunsaturated fatty acids on depressed mood: systematic review of published trials [comment in Am J Clin Nutr. 2007;85(6):1665-1666; author reply 1666]. Am J Clin Nutr. 2006;84(6):1308–1316.

da Silva TM, Munhoz RP, Alvarez C, et al. Depression in Parkinson’s disease: a double-blind, randomized, placebo-controlled pilot study of omega-3 fatty-acid supplementation. J Affect Disord. 2008;111(2-3):351–359.

Su KP, Huang SY, Chiu TH, et al. Omega-3 fatty acids for major depressive disorder during pregnancy: results from a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2008;69(4):644–651.

Grenyer BF, Crowe T, Meyer B, et al. Fish oil supplementation in the treatment of major depression: a randomised double-blind placebo-controlled trial. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31(7):1393–1396.

Rees AM, Austin MP, Parker GB. Omega-3 fatty acids as a treatment for perinatal depression: randomized double-blind placebo-controlled trial. Aust N Z J Psychiatry. 2008;42(3):199–205.

Rogers PJ, Appleton KM, Kessler D, et al. No effect of n-3 long-chain polyunsaturated fatty acid (EPA and DHA) supplementation on depressed mood and cognitive function: a randomised controlled trial. Br J Nutr. 2008;99(2):421–431.

Jazayeri S, Tehrani-Doost M, Keshavarz SA, et al. Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J Psychiatry. 2008;42(3):192–198.

Shaw K, Turner J, Del Mar C. Tryptophan and 5-Hydroxytryptophan for depression. Cochrane Database Syst Rev. 2002;(1):CD003198.

Wang H, Qi H, Wang BS, et al. Is acupuncture beneficial in depression: a meta-analysis of 8 randomized controlled trials? J Affect Disord. 2008;111(2-3):125–134.

Smith CA, Hay PPJ. Acupuncture for depression. Cochrane Database Syst Rev. 2005;(2):CD004046.

Current Psy

Swine Flu Mist is now in!

2009-10-09T10:23:00.000-07:00

Hi,

If you are interested in getting the Swine Flu Mist for your child, it is now in. Please remember that the children have to be 2 years old or more and have no chronic illnesses such as asthma or serious egg allergies. Also, if your child has recently had the the Seasonal Flu Mist, you must wait 28 days or more before getting the swine flu mist.

Also, please remember that this is a live virus vaccine, which is what makes it a more effective vaccine than the shot. We do not yet have any confirmation from the Sarasota Health Department about the availability of the Swine Flu shot (killed virus).

Please call the office for an appointment for the nasal mist vaccine. We are making every effort to give as many vaccines as quickly as the demand dictates, including Saturday mornings. We have been allotted 300 doses, so supply is not infinite. Call 365-5898 and ask to be scheduled for the Swine Flu Mist if you would like to get this done. Thanks,

Dr Ted, Nancy, Jen, Kay and all of us at Meyer Pediatrics

Things to Know About MRSA Infections

2009-10-08T06:40:00.001-07:00

Recognize and Prevent MRSA Infections

As kids head back to classrooms and sports venues, parents are encouraged to learn how to recognize and prevent skin infections caused by methicillin-resistant Staphylococcus aureus (MRSA), a type of staph bacteria that is resistant to certain antibiotics.

It is estimated that Americans of all ages visit the doctor more than 12 million times per year for skin infections that are typical of staph, more than half of which are MRSA. The good news is that a few simple steps can help parents protect their families.

Learn about MRSA

Visit www.cdc.gov/MRSA for posters, fact sheets, e-cards, graphics and more.

MRSA is methicillin-resistant Staphylococcus aureus, a potentially dangerous type of staph bacteria that is resistant to certain antibiotics and may cause skin and other infections. As with regular staph infections, recognizing the signs and receiving treatment for MRSA skin infections in the early stages reduces the chances of the infection becoming severe. MRSA is spread by:

Having direct contact with another person’s infection
Sharing personal items, such as towels or razors, that have touched infected skin
Touching surfaces or items, such as used bandages, contaminated with MRSA

Recognize the Signs and Symptoms of Infections

Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that may be:

Red
Swollen
Painful
Warm to the touch
Full of pus or other drainage
Accompanied by a fever

A series of educational posters contain prevention and control messages related to infectious diseases such as MRSA.

Take Action if You Suspect an MRSA Skin Infection

Cover the area with a bandage and contact your healthcare professional. It’s especially important to contact your healthcare professional if signs and symptoms of an MRSA skin infection are accompanied by a fever.

Protect Yourself and Your Family from MRSA Skin Infections

Know the signs of MRSA skin infections and get treated early
Keep cuts and scrapes clean and covered
Encourage good hygiene such as cleaning hands regularly
Discourage sharing of personal items such as towels and razors

National MRSA Education Initiative

The National MRSA Education Initiative is a comprehensive public education campaign to help parents and healthcare providers recognize, treat, and prevent MRSA skin infections in their families and patients. Through the Initiative, parents, healthcare providers and organizations have access to education materials – including printed posters, fact sheets, brochures and flyers, and Web-based e-cards, content and graphics. To access materials, visit www.cdc.gov/MRSA.

More Information

Call 1-800-CDC-INFO
CDC MRSA home page
Methicillin-resistant Staphylococcus aureus (MRSA) (2007) (4:57 minutes)
Dealing with Drug Resistant Bugs (2007) (5:49 minutes)
MRSA in Schools: Fact Sheet
MRSA Among Athletes: Fact Sheet
MRSA and the Environment: Fact Sheet
Healthcare-Associated MRSA Infections

Did You Hear About Tim Tebow's Concussion?

2009-10-07T20:35:00.000-07:00

Learn to Prevent & Recognize Concussions

CDC's youth sports tool kit teaches coaches, athletes, and parents to play it safe when it comes to concussions.

A concussion is a brain injury caused by a bump or blow to the head that can change the way your brain normally works. Even what seems to be a mild bump or blow to the head can be serious.

To help ensure the health and safety of young athletes, CDC developed the Heads Up: Concussion in Youth Sports initiative to offer information about concussions—a type of traumatic brain injury—to coaches, parents, and athletes involved in youth sports. The "Heads Up" initiative provides important information on preventing, recognizing, and responding to a concussion.

CDC wants to equip coaches, parents, and young athletes across the country with the "Heads Up: Concussion in Youth Sports" tool kit, which contains a:

Fact sheet for coaches on concussion
Fact sheet for athletes on concussion
Fact sheet for parents on concussion
Clipboard with concussion facts for coaches
Magnet with concussion facts for coaches and parents
Poster with concussion facts for coaches and sports administrators
Quiz for coaches, athletes, and parents to test their concussion knowledge

You can download the materials or request a free tool kit online.

More Information

Watch a Video
- Keeping Quiet Can Keep You Out of the Game ( 2:00)
  This video tells one young woman's story of sustaining two concussions within a short period of time. Concussion is a serious injury. Athletes, if you think you've had a concussion, don't hide it, report it, and take time to recover.
Listen to a podcast
- Heads Up! Play It Safe When It Comes to Concussions! (6:49 minutes)
- Heads Up! (0:59 minutes); in Spanish (1:27 minutes)
- Heads Up! Concussion Information for Physicians (6:43 mins)
Send a Health-e-Card
Download the Tool Kit on Concussion for High School Coaches
Nonfatal Traumatic Brain Injuries from Sports and Recreation Activities — United States, 2001–2005 (MMWR, July 27, 2007)
Concussion and Sports Fact Sheet ( 216 KB, 2 pages)
Traumatic Brain Injury (TBI) Facts Sheets

When Do I Need Antibiotics, from the CDC

2009-10-07T20:26:00.000-07:00

Get Smart: Know When Antibiotics Work

Antibiotics do not fight infections caused by viruses, like colds, flu, most sore throats and bronchitis, and some ear infections. Rest, fluids, and over-the-counter products may be your or your child's best treatment option.

Dangers of Antibiotic Resistance

If antibiotics are used too often for things they can't treat—like colds, flu, or other viral infections—they can stop working effectively against bacteria when you or your child really needs them. Antibiotic resistance—when antibiotics can no longer cure bacterial infections—has been a concern for years and is considered one of the world's most pressing public health problems. Widespread overuse of antibiotics is fueling an increase in antibiotic-resistant bacteria. So the next time you or your child really needs an antibiotic for a bacterial infection, it may not work.

If You Have a Cold or Flu, Antibiotics Won't Work for You!

Colds and flu are caused by viruses, not bacteria. Taking antibiotics when you or your child has a virus may do more harm than good. Get smart about when antibiotics are appropriate—to fight bacterial infections. Taking them for viral infections, such as a cold, most sore throats, the flu, or acute bronchitis:

Will not cure the infection;
Will not keep other people from getting sick;
Will not help you or your child feel better; and
May cause unnecessary and harmful side effects.

What Not to Do

Do not demand antibiotics when a healthcare provider says they are not needed.
Do not take an antibiotic for a viral infection like a cold or most sore throats.
Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your or your child’s illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.

If your healthcare provider prescribes an antibiotic for you or your child:

Do not skip doses.
Do not save any of the antibiotics for the next time you or your child gets sick.

What to Do

View or download "Snort. Sniffle. Sneeze: No Antibiotics Please!" (video 3:47 mins)

Learn about appropriate antibiotic use and how to feel better when you or your child has a sore throat, ear or sinus pain, fever, cough, or runny nose.

Adults and kids should clean their hands often, especially before meals and after touching pets. And make sure both you and your child are up-to-date on recommended immunizations.

Talk with your healthcare provider about the best treatment for your or your child’s illness. To feel better when you or your child has an upper respiratory infection:

Increase fluid intake;
Get plenty of rest;
Use a cool-mist vaporizer or saline nasal spray to relieve congestion; and
Soothe a throat with ice chips, sore throat spray, or lozenges (do not give lozenges to young children).

Video: Snort. Sniffle. Sneeze. No Antibiotics Please!

CDC created a video to help you learn more about appropriate antibiotic use and how to feel better when you or your child has a sore throat, ear or sinus pain, fever, cough, or runny nose. This video features a doctor, who is also a concerned mom. You can download the video at CDC-TV, download the podcast, or access on your mobile phone.

More Information

Get Smart: Know When Antibiotics Work
Symptom Relief
Antibiotics Information en Español
Tools for Healthcare Providers
Antibiotic Resistance Questions & Answers
Medication Safety
Influenza (flu)
Send a Health-e-Card to
Download a Podcast
- Pharmacists Can Make the Difference (2009) (2:21 minutes)
- Antibiotics: One of the Greatest Discoveries of the 20th Century (2008) (1:38 minutes)
- Get Smart: Know When Antibiotics Work (2008) (5:58 minutes)

Description of Swine Flu from the CDC

2009-10-06T14:29:00.000-07:00

Clinical Features of H1N1 Influenza

Typical Signs and Symptoms

The incubation period for H1N1 influenza is 1-4 days, possibly as long as 7 days. The clinical features of influenza are well known and include:

Sudden onset of fever (usually high);
Headache;
Extreme tiredness;
Dry cough;
Sore throat;
Runny nose; and
Muscle aches and stomach symptoms -- more common in children.

(CDC. Interim guidance for clinicians on identifying and caring for patients with swine-origin influenza A (H1N1) virus infection. June 2009. Available at: http://www.cdc.gov/h1n1flu/identifyingpatients.htm Accessed September 16, 2009.)

The symptoms of pandemic H1N1 influenza of 2009 are essentially the same as the seasonal flu, although some have noted an increased frequency of gastrointestinal symptoms, including vomiting and diarrhea, and others have noted the absence of fever in a significant number with virologically proven cases.

The CDC defines cases as influenza-like illness (ILI) if there is fever of ≥100° F (37.8° C) plus cough and/or sore throat in the absence of a known cause other than influenza. Another category is acute respiratory illness (ARI), defined by the presence of 2 of the following 4 symptoms: fever, cough, sore throat, or rhinorrhea. In the outbreak of pandemic influenza in New York City, 95% of virologically proven cases satisfied the ILI definition. (CDC. Swine-origin influenza A (H1N1) virus infections in a school -- New York City, April 2009. MMWR Morb Mortal Wkly Rep Dispatch. 2009;58:1-3. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0430a1.htm Accessed September 25, 2009.)

Patients with 2009 influenza A H1N1 infections have higher rates of gastrointestinal symptoms and lack of fever compared with those who have seasonal flu. Most patients have mild symptoms, but a small subset of previously healthy young adults have severe pulmonary disease that progresses to acute respiratory distress syndrome (ARDS); this may occur with or without underlying conditions.

Symptoms in virologically confirmed cases. During an outbreak of H1N1 in a New York City high school, a sample of New York City school students (median age, 15 years) with virologically confirmed cases were interviewed about their symptoms by telephone. They reported:

Cough (98%);
Subjective fever (96%);
Fatigue (89%);
Headache (82%);
Sore throat (82%);
Abdominal pain (50%);
Diarrhea (48%);
Dyspnea (48%); and
Joint pain (46%).

The measured mean peak fever in this group was 102.2° F. (CDC. Swine-origin influenza A (H1N1) virus infections in a school -- New York City, April 2009. MMWR Morb Mortal Wkly Rep Dispatch. 2009;58:1-3. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0430a1.htm Accessed September 25, 2009.)

Case Definitions for H1N1 Influenza

Confirmed case: Patient with ILI plus laboratory evidence confirmed by real-time RT-PCR or viral culture;
Probable case: ILI plus laboratory test positive for influenza A and negative for human H1 and H3 by RT-PCR; and
Optional: ILI without negative H1N1 test and (1) previously healthy person > 65 years hospitalized for ILI; (2) epidemiologic link to confirmed or probable case in past 7 days; or (3) ILI plus travel to a state or country with confirmed or probable cases.

Complications of H1N1 Influenza

Exacerbation of underlying chronic disease;
Complications related to the upper airways, including sinusitis or otitis;
Pulmonary complications, including bronchitis, asthma (sometimes with status asthmaticus), and acute exacerbations of chronic bronchitis; and
Miscellaneous conditions, including cardiac (myocarditis and pericarditis), myositis, rhabdomyolysis, central nervous system complications (encephalopathy, encephalitis, seizures), toxic shock syndrome, and secondary bacterial pneumonia.

Severe complications of H1N1 Influenza. In June 2009, the University of Michigan reported severe pulmonary complications of 2009 H1N1 influenza infection in 10 patients with a median age of 49 years. All 10 patients were referred for severe hypoxemia, ARDS, and inability to oxygenate with conventional ventilation methods. All had severe multilobar pneumonia on x-ray, none had evidence of bacterial pneumonia, and 4 had CT scan-confirmed pulmonary embolism. Lab findings included leukocytosis in 5 (median WBC 9500/mm³), elevated AST levels (41-109 IU/L) in all 10, and elevated CPK levels (51-6572 IU/L) in 6; none had evidence of disseminated intravascular coagulation. The major risk factor was obesity in 9 and morbid obesity (BMI > 40) in 7. All 10 required advanced mechanical ventilation with high-frequency oscillatory or bilevel ventilation with mean airway pressures of 32-55 cm H₂O. Two required veno-venous extracorporeal membrane oxygenation (ECMO) support and 6 required dialysis. At the time of the report, 3 had died, 1 was still on ECMO, 1 was still on mechanical ventilation, and 5 had been transferred back to referring institutions. (CDC. Intensive care patients with severe novel influenza A (H1N1) virus infection -- Michigan, June, 2009. MMWR Morb Mortal Wkly Rep. 2009;58:749-752.)

Neurologic complications. Neurologic complications were reported in 4 children ages 7-17 years with 2009 H1N1 influenza A. Findings included seizures in 2 children, encephalitis in 2, and ataxia in 1. All recovered without neurologic sequelae. The editorial comment in this report noted that the neurologic disease in these 4 patients was less severe than what has been described in previous reports of seasonal flu. (CDC. Neurological complications associated with novel influenza A (H1N1) infection in children -- Dallas, Texas, May 2009. MMWR Morb Mortal Wkly Rep. 2009;58:773-778.; Maricich SM, Neuf JL, Lotze TE, et al. Neurologic complications association with influenza A in children during the 2003-2004 influenza season in Houston, Texas. Pediatrics. 2004;114:e626-e633.; Morishima T, Togashi T, Yokota S, et al. Encephalitis and encephalopathy associated with an influenza epidemic in Japan. Clin Infect Dis. 2002;35:512-517.)

Related Risk for Infection, Hospitalization, and Lethal Outcome

Age-related risk. These data are shown in Table 1.

Table 1. Rates for H1N1 for May-July 2009 by Age

Age	Cases/100,000	Hospitalization/100,000	Death %
0-4 yrs	23	4.5	7 (2%)^a
5-24 yrs	27	2.1	48 (16%)
25-49 yrs	7	1.1	124 (41%)
50-64 yrs	4	1.2	71 (24%)
> 65 yrs	1.3	1.7	26 (2%)

^a % of total deaths. Age data not available for 15%.
Rate expressed /100,000 population

US age data

(Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team; Dawood FS, Jain S, Finelli L, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med. 2009;360:2605-2615.)

Median age of confirmed cases: 12 years
Median age of hospitalized cases: 20 years
Median age of lethal cases: 37 years

Additional Influenza Vaccine Information

2009-10-06T13:44:00.000-07:00

Parents/Caregivers: If your child or adolescent has been diagnosed with Mononucleosis (Epstein-Barr Virus), Hepatitis or other serious viral illnesses within the past few months, please make sure our office is aware before obtaining the influenza vaccine (mist or shot). There may be some time constraints or contraindications. Contact us for any questions.

Update on combing H1N1 and seasonal flu vaccines

2009-10-06T12:44:00.000-07:00

A live seasonal and a live H1N1 flu vaccine cannot be given at the same time. They need to be spaced at least 28 days apart. However, one live and one inactivated vaccine can be given at the same time. The H1N1 VIS is now available (at CDC.GOV) and it confirms that children age 9 and younger need two doses.

I am more than happy to answer any questions for you or anyone in the practice. Feel free to call or email me at any time. We are hoping to see the first shipment of H1N1 flu mist vaccine arrive by next week!

Thanks,

Anna Brereton-Hubbard, RN

Sarasota County Health Department
2200 Ringling Blvd.
Sarasota, FL 34237
941-861-2678
941-861-2676 (fax)

H1N1 Vaccine information sheets

2009-10-06T08:30:00.000-07:00

Go to this CDC website for the vaccine information sheets for both types of H1N1 vaccines. We will update the website when we have the vaccines available.
http://www.cdc.gov/vaccines/pubs/vis/default.htm.

Swine Flu (H1N1) General Information

2009-10-02T10:01:00.000-07:00

What is swine flu?

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that

causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and

do happen. Swine flu viruses have been reported to spread from person-to-person, but in the past, this

transmission was limited and not sustained beyond three people.

Are there human infections with swine flu in the U.S.?

In late March and early April 2009, cases of human infection with swine influenza A (H1N1) viruses

were first reported in Southern California and near San Antonio, Texas. Other U.S. states have

reported cases of swine flu infection in humans and cases have been reported internationally as well.

An updated case count of confirmed swine flu infections in the United States is kept at

http://www.cdc.gov/swineflu/investigation.htm. CDC and local and state health agencies are

working together to investigate this situation.

Is this swine flu virus contagious?

CDC has determined that this swine influenza A (H1N1) virus is contagious and is spreading from

human to human. However, at this time, it not known how easily the virus spreads between people.

What are the signs and symptoms of swine flu in people?

The symptoms of swine flu in people are similar to the symptoms of regular human flu and include

fever, cough, sore throat, body aches, headache, chills, and fatigue. Some people have reported

diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and

respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal

flu, swine flu may cause a worsening of underlying chronic medical conditions.

How does swine flu spread?

Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that

seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or

sneezing of people with influenza. Sometimes people may become infected by touching something

with flu viruses on it and then touching their mouth or nose.

How can someone with the flu infect someone else?

Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or

more days after becoming sick. That means that you may be able to pass on the flu to someone else

before you know you are sick, as well as while you are sick.

What should I do to keep from getting the flu?

First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be

physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch

surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.

Are there medicines to treat swine flu?

Yes. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of

infection with these swine influenza viruses. Antiviral drugs are prescription medicines (pills, liquid,

or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you

get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also

prevent serious flu complications. For treatment, antiviral drugs work best if started soon after

getting sick (within 2 days of symptoms).

Page - 2 -

Patient Handout provided to subscribers of Pharmacist’s Letter, Prescriber's Letter, and Pharmacy Technician’s Letter for distribution

to patients. Updates available at www.pharmacistsletter.com, www.prescribersletter.com, www.pharmacytechniciansletter.com.

Content provided by CDC at www.cdc.gov. April 27, 2009.

How long can an infected person spread swine flu to others?

People with swine influenza virus infection should be considered potentially contagious as long as

they are symptomatic and possibly for up to 7 days following illness onset. Children, especially

younger children, might potentially be contagious for longer periods.

What surfaces are most likely to be sources of contamination?

Germs can be spread when a person touches something that is contaminated with germs and then

touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move

through the air. Germs can be spread when a person touches respiratory droplets from another person

on a surface like a desk and then touches their own eyes, mouth, or nose before washing their hands.

How long can viruses live outside the body?

We know that some viruses and bacteria can live 2 hours or longer on surfaces like cafeteria tables,

doorknobs, and desks. Frequent handwashing will help you reduce the chance of getting

contamination from these common surfaces.

What can I do to protect myself from getting sick?

There is no vaccine available right now to protect against swine flu. There are everyday actions that

can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these

everyday steps to protect your health:

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the

trash after you use it.

• Wash your hands often with soap and water, especially after you cough or sneeze. Alcoholbased

hand cleaners are also effective.

• Avoid touching your eyes, nose, or mouth. Germs spread this way.

• Try to avoid close contact with sick people.

• If you get sick with influenza, CDC recommends that you stay home from work or school

and limit contact with others to keep from infecting them.

What is the best way to keep from spreading the virus through coughing or sneezing?

If you are sick, limit your contact with other people as much as possible. Do not go to work or school

if ill. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those

around you from getting sick. Put your used tissue in the waste basket. Cover your cough or sneeze if

you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze.

What is the best technique for washing my hands to avoid getting the flu?

Washing your hands often will help protect you from germs. Wash with soap and water or clean with

alcohol-based hand cleaner. We recommend that when you wash your hands -- with soap and warm

water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based

disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and

drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the

alcohol in it kills the germs on your hands.

What should I do if I get sick?

If you live in areas where swine influenza cases have been identified and become ill with influenzalike

symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea,

you may want to contact your health care provider, particularly if you are worried about your

symptoms. Your health care provider will determine whether influenza testing or treatment is needed.

Page - 3 -

Patient Handout provided to subscribers of Pharmacist’s Letter, Prescriber's Letter, and Pharmacy Technician’s Letter for distribution

to patients. Updates available at www.pharmacistsletter.com, www.prescribersletter.com, www.pharmacytechniciansletter.com.

Content provided by CDC at www.cdc.gov. April 27, 2009.

If you are sick, you should stay home and avoid contact with other people as much as possible to

keep from spreading your illness to others.

If you become ill and experience any of the following warning signs, seek emergency medical care.

In children, emergency warning signs that need urgent medical attention include:

• Fast breathing or trouble breathing

• Bluish skin color

• Not drinking enough fluids

• Not waking up or not interacting

• Being so irritable that the child does not want to be held

• Flu-like symptoms improve but then return with fever and worse cough

• Fever with a rash

In adults, emergency warning signs that need urgent medical attention include:

• Difficulty breathing or shortness of breath

• Pain or pressure in the chest or abdomen

• Sudden dizziness

• Confusion

• Severe or persistent vomiting

How serious is swine flu infection?

Like seasonal flu, swine flu in humans can vary in severity from mild to severe. Between 2005 until

January 2009, 12 human cases of swine flu were detected in the U.S. with no deaths occurring.

However, swine flu infection can be serious. In September 1988, a previously healthy 32-year-old

pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu

and died 8 days later. A swine flu outbreak in Fort Dix, New Jersey, occurred in 1976 that caused

more than 200 cases with serious illness in several people and one death.

Can I get swine influenza from eating or preparing pork?

No. Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork

or pork products. Eating properly handled and cooked pork products is safe.