Archive for January, 2011

Online Exercise

Saturday, January 29, 2011 // Uncategorized

In order to be effective, exercise must be convenient.  The more impediments there are to exercise, the less likely it is to happen.  The following is a review of online sites that allow you to download your own exercise class.  This allows more variety that exercise DVD’s which may become boring with repeated use.

Feel the Burn (Not the Shame) of a Workout Class

  • Finding it tough to squeeze your regular exercise class into your busy life? A number of websites offer to bring the group exercise class experience to your living room, but without the scheduling conflicts.

We tested four such sites, which offer everything from live, streaming-video cardio courses to downloadable yoga meditation classes. Users log on to the website, choose an exercise routine and watch them on their computer. Classes vary in length from five to 90 minutes, and some sites let users track their progress. Participants typically pay a monthly fee for unlimited use.

CRANKY

Carl Wiens

CRANKY

CRANKY

Jennifer Salas, founder of Demand Fitness in Austin, Texas, says some customers prefer to work out at home. “There are so many people who don’t like the meat-market feel [of a gym] or the intimidation of not being fit and having to work out in front of others who are very fit,” she says.

We sampled several classes for each site visited, including VirtualGym TV and Demand Fitness. To get started, we disabled our screen-saver so our computer wouldn’t go into sleep mode in the middle of the session. We had to wait for a live class to start on one site, Physiic.com, but the other classes let us exercise right away.

The VirtualGym site offers several hundred courses via download. Several new courses are streamed live each day, but most are available for download. An intermediate cardio kickboxing course we downloaded was challenging, and we enjoyed the level of instruction. Our instructor was lively and even made a few jokes throughout the 45-minute session. At times, it was tough to keep up. “The instructors are encouraged to replicate exactly what they do in real life,” says Richard Davis, founder of U.K.-based VirtualGym TV Ltd.

On a day we didn’t set aside time to work out, we were able to quickly download a 30-minute “Six-Pack Workout” class. The class was upbeat and left our abs sore. VirtualGym had the most diverse offerings, with anything from stability-ball training, to aerobics and strengthening classes. The courses were organized chronologically, so it was difficult to search the archives for specific types of classes.

Yoga Learning Center LLC, an online yoga studio based in Maui, Hawaii, offers audio and video yoga classes. The site offered the fewest classes, but with more than 60 routines, there was still plenty to choose from. The site provided detailed descriptions about each class, and there was no need to wait for classes to download, just hit play.

We tried a 75-minute Kundalini yoga class and several five-minute stretch routines for desk slaves. Instructors were clear, and we liked the flow of each class. But we missed having an instructor in the same room who could help with complicated poses. We had to stop a few complicated yoga poses to look back at our computer screen.

Demand Fitness offers a library of about 300 classes and is constantly adding new ones. Categories include anything from upper-body and fitness dance training to a series targeted at business travelers with short routines that require only a desk chair. When browsing classes, we were able to see what other users had to say about them. The quality of the classes was good, and we enjoyed both a quick arm workout and the lower-body road warrior workout. Each time, we completed a separate warm-up routine.

The courses flowed together well, and it was easy to coordinate. Since many classes are targeted to specific muscle groups, we were encouraged by instructors to mix and match routines to tailor the workout to our needs. The site also made it simple to sneak in a session when we were short on time.

Navigating between the site’s features was a bit difficult, and the interface was cluttered. But we liked a tracking tool, which allows users to see how much time was spent exercising each month.

Physiic LLC offers the closest experience to being in an actual exercise class. It has live courses offered via webcam and allows participants to communicate with instructors in real time.

The site offers about 20 full- and limited-interaction classes per weekday and fewer classes on weekends. Classes are live at exercise studios around the country and equipped with webcams for Physiic users. During a fully interactive 90-minute yoga course, the instructor watched our movement via webcam and called out to us about specific poses (we were encouraged to ask questions via a chat textbox). And we liked the option to work out with friends far away and view them doing the same course, but it was tough to plan.

Our limited-interaction yoga flow Physiic class was taught as a live class, and Physiic users could follow along via webcam but could not get feedback form the instructor. Web quality made it difficult to clearly see others in the class, and the audio disappeared toward the end. (A spokesman says we needed to restart the class.)

Upcoming courses were listed on the site, where we could register for courses. When we overslept and missed an early-morning meditation class, we emailed customer service and received a refund. We saw one course we’d planned to take disappear off the menu before we could register. A spokesman says courses that don’t have any registrants prior to start time may be canceled.

Overall, the online classes were less boring than watching an exercise DVD and are a great option for those days when you can’t get to the gym. Despite some technical glitches, instructor quality was good and classes were easy to follow. One problem: With no one else in the room with you exercising, it was tempting to plop back on the living-room couch.

Living-Room Instructors

Here’s how four sites that offer group exercise classes via the Web compare with each other:

WEBSITE MONTHLY COST CLASS GENRES COMMENT
Physiic.com $5 to $12 per class Live classes in yoga, Pilates, strength training, aerobics Sometimes tough to see poses via webcam; teachers were good. Live broadcast classes, various, conveniently scheduled, few weekend options.
VirtualGym.tv $8 Kickboxing, aerobics, dance, circuit training New courses offered each week. Live broadcast, streaming video and downloadable courses; good quality.
Demandfitness.com $15 Strength training, aerobics, martial arts and many others Good-quality videos, can be paired for more tailored workouts. Additional fitness tools provided, classes could be previewed.
Yogalearningcenter.com $8 Video, audio-only classes, yoga and Pilates Quality instructors, video resolution was good. Easy to use, different yoga offerings, various skill levels.

Write to Alina Dizik at [email protected]

 

Copyright 2011 Dow Jones & Company, Inc. All Rights Reserved

 

 

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Another Good Reason Not to Smoke

Friday, January 28, 2011 // Uncategorized

Smoking is associated with a host of health ills including a risk of cardiovascular disease and an increased risk of cancer of the lung, bladder and mouth.  This is an alert from Journal Watch that adds a cancer risk to the list.  Following it is the abstract from The Archives of Internal Medicine.

Early Cigarette Smoking Associated with Breast Cancer
Young female patients who smoke may benefit from knowing that early smoking is associated with a modest increase in breast cancer risk, according to an Archives of Internal Medicine study.
Researchers analyzing updated data from the Nurses’ Health Study report that they have confirmed their 2002 finding of a slight elevation in breast cancer risk associated with smoking. During some 3 million person-years of follow-up between 1976 and 2006, women who smoked more than 25 cigarettes per day for more than 35 years and began smoking before age 18 had a hazard ratio for invasive breast cancer of 1.25, compared with never-smokers.
The effect was stronger when smoking began before the woman’s first birth and before menopause. Postmenopausal smoking was associated with a slightly decreased risk. There was no apparent increased risk from exposure to secondhand smoke.

Cigarette Smoking and the Incidence of Breast Cancer
Fei Xue, MD, ScD; Walter C. Willett, MD, DrPH; Bernard A. Rosner, PhD; Susan E. Hankinson, ScD; Karin B. Michels, ScD, PhD

Arch Intern Med. 2011;171(2):125-133. doi:10.1001/archinternmed.2010.503

Background Tobacco smoke contains carcinogens, which may increase the risk of breast cancer (BC). Conversely, cigarette smoking also has antiestrogenic effects, which may reduce the risk of BC. The association between smoking and BC remains controversial.

Methods Prospective cohort study of 111 140 participants of the Nurses’ Health Study from 1976 to 2006 for active smoking and 36 017 women from 1982 to 2006 for passive smoking.

Results During 3 005 863 person-years of follow-up, 8772 incident cases of invasive BC were reported. After adjustment for potential confounders, the hazard ratio (HR) of BC was 1.06% (95% confidence interval [CI], 1.01%-1.10%) for ever smokers relative to never smokers. Breast cancer incidence was associated with a higher quantity of current (P for trend = .02) and past (P for trend = .003) smoking, younger age at smoking initiation (P for trend = .01), longer duration of smoking (P for trend = .01), and more pack-years of smoking (P for trend = .005). Premenopausal smoking was associated with a slightly higher incidence of BC (HR, 1.11; 95% CI, 1.07-1.15 for every increase of 20 pack-years), especially smoking before first birth (1.18; 1.10-1.27 for every increase of 20 pack-years). Conversely, the direction of the association between postmenopausal smoking and BC was inverse (0.93; 0.85-1.02 for every increase of 20 pack-years). Passive smoking in childhood or adulthood was not associated with BC risk.

Conclusion Active smoking, especially smoking before the first birth, may be associated with a modest increase in the risk of BC.

Author Affiliations: Obstetrics and Gynecology Epidemiology Center, Department of Obstetrics and Gynecology (Drs Xue and Michels), and the Channing Laboratory, Department of Medicine (Drs Willett, Rosner, Hankinson, and Michels), Brigham and Woman’s Hospital, and Harvard Medical School, Boston, Massachusetts; and Departments of Epidemiology (Drs Xue, Willett, Rosner, Hankinson, and Michels), Nutrition (Dr Willett), and Biostatistics (Dr Rosner), Harvard School of Public Health, Boston.

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Baldness and Other Medical News

Wednesday, January 26, 2011 // Uncategorized

Getting Closer to the Root of What Causes Baldness

By ANN LUKITS

[resreport1] Getty ImagesA decline in a special type of stem cell found in hair follicles may be responsible for pattern baldness.

Male pattern baldness: A decline in activity by a special type of stem cell, known as a progenitor cell, found in human hair follicles appears to be responsible for male pattern baldness, according to a study in the Journal of Clinical Investigation. Male pattern baldness, or androgenetic alopecia (AGA), which affects as many as two-thirds of U.S. men by the age of 50, has previously been linked to testosterone and other factors. Researchers analyzed skin cells from bald and nonbald scalp tissue taken from 54 U.S. men who were undergoing hair transplants. They found both samples had the same number of stem cells but bald scalps had 10 times fewer progenitor cells. Stem cells in hair follicles normally transform into progenitor cells, which in turn produce normal hair strands, the researchers said. But in men with AGA this process is blocked and no hair is produced or is “miniaturized.” In a related experiment, the researchers injected a type of cell similar to a human progenitor cell into mice and were able to create new hair follicles and hair growth. Understanding the signals that turn stem cells into progenitor cells is the next step toward developing new treatments, researchers said.

Caveat: The study was small and included only white men.

Title: Bald scalp in men with androgenetic alopecia retains hair follicle stem cells but lacks CD200-rich and CD34-positive hair follicle progenitor cells

Ectopic pregnancy: Doctors may be able to diagnose a tubal ectopic pregnancy before it becomes a medical emergency by testing cells from the placenta for the presence of a growth factor, according to a study in the Journal of Clinical Endocrinology and Metabolism. Ectopic pregnancy, the leading cause of U.S. maternal death in the first trimester, happens when a fertilized egg implants itself outside the uterus, most often in the fallopian tube, where it can rupture. There is currently no test for tubal pregnancy. Researchers analyzed trophoblast cells from the placenta from 40 pregnant women about to undergo surgery for ectopic pregnancy, miscarriage or abortion. In women with tubal pregnancies, levels of placental growth factor (PIGF), a protein that promotes the formation of new blood vessels, were almost undetectable compared with levels in other patients. Researchers said the differential secretion of PIGF could be an important diagnostic biomarker for the condition and recommended large-scale studies.

Caveat: Technical difficulties plus contamination of some uterine samples prevented collection of trophoblast cells from every patient. The study sample was small.

Title: Placental Growth Factor: A Promising Diagnostic Biomarker for Tubal Ectopic Pregnancy

Shingles: A relatively new vaccine for shingles that isn’t yet widely distributed significantly reduced the risk of the viral disease in older adults, including the more serious form of shingles that attacks the eye, according to a study in the Journal of the American Medical Association. Shingles, or herpes zoster, is caused by the reactivation of the chicken pox virus and characterized by a painful blistery rash that erupts along the nerves. Of the estimated one million cases of shingles in the U.S. every year, about 25% are the ophthalmic form. An analysis of data from a Southern California health system found the risk of shingles was reduced by 55% in 75,761 members age 60 and older who received the vaccine when compared with 227,283 unvaccinated members. The risk of ophthalmic shingles was reduced by 63%. The study, which was carried out by the health system without external funding, confirms the findings of an earlier study led by the Department of Veterans Affairs in collaboration with the National Institute of Allergy and Infectious Diseases and Merck & Co., which was licensed in 2006 to produce the vaccine.

Caveat: The study involved residents of one region of the country so the results may not apply to the general population. The follow-up period was short and not designed to record a decline in the vaccine’s protection.

Title: Herpes Zoster Vaccine in Older Adults and the Risk of Subsequent Herpes Zoster Disease

HDL efflux: The capacity of HDL, or “good cholesterol,” to remove cholesterol from human cells is a better predictor of cardiovascular risk than a static numerical measurement of HDL, according to a study in the New England Journal of Medicine. Studies have consistently shown that a high HDL reading is associated with a reduced risk of coronary artery disease but certain drugs that elevate HDL have raised questions about those findings. Researchers used a special incubator to measure both the quantity and quality of HDL, called efflux capacity, in 442 people with confirmed atherosclerosis and 351 healthy controls. After adjusting for age, sex, smoking status, diabetes and HDL levels, the study found patients with the highest efflux capacity had a 52% reduced risk of coronary disease compared to those with the lowest. In a separate group of 203 participants, efflux capacity had a significant inverse relationship with carotid-artery thickness, a known risk factor for coronary-artery disease. By contrast, carotid-artery thickness had no association with a numerical measurement of HDL. The researchers said the findings could be important in the assessment of new therapies targeting HDL metabolism.

Caveat: Efflux capacity is only one measurement of the complex cellular processes involved in the transport and disposal of cholesterol.

Title: Cholesterol Efflux Capacity, High-Density Lipoprotein Function, and Atherosclerosis

Blood thinners: Use of the widely prescribed anticoagulant warfarin doubles a patient’s risk of dying or suffering complications following an injury, according to a study in Archives of Surgery. Warfarin is a blood thinner commonly used to prevent heart attacks, stroke and blood clots. Its chief side effect is a heightened risk for hemorrhage. A study of 1,230,422 patients admitted to hospitals in the U.S. and Puerto Rico from 2002 to 2006 found that 36,270 were taking warfarin. The rate of death among warfarin users was 9.3% compared with 4.8% for non-warfarin users. Of warfarin users under 65 admitted with severe head injury, 51% died while only 37% of non-warfarin users died. Researchers said the exact role of warfarin in adverse outcomes is not known but its use is a significant independent risk factor for death from injury, especially in younger patients. They recommend trauma centers take an accurate history of warfarin use and develop protocols for reversing warfarin following an injury.

Caveat: Researchers were unable to identify patients admitted to hospital who were previous users of warfarin or to track compliance with outpatient use of the drug.

Title: Prevalence and Implications of Preinjury Warfarin Use

Second-hand smoke: Passive exposure to second-hand smoke caused more than 600,000 premature deaths world-wide, or about 1% of all deaths, in 2004, according to a study in the Lancet. Researchers estimated deaths and disease caused by second-hand smoke in 192 countries using national and international surveys, including a global youth tobacco survey, and comparing risk factors for different diseases with the proportion of a population exposed to second-hand smoke. Modeling was used to assess exposure in countries without survey data. About 40% of children, 33% of male nonsmokers and 35% of female nonsmokers were exposed to second-hand smoke in 2004. More than half the deaths were from heart disease, followed by lower-respiratory infections, asthma and lung cancer. Nearly half the deaths and disease attributed to second-hand smoke occurred in Southeast Asia and the western Pacific. The study notes that 93% of the world’s population lives in countries not covered by smoke-free laws that would rapidly reduce deaths from tobacco.

Caveat: Estimates of exposure to second-hand smoke may be flawed because of gaps in data for specific regions and variations in the definition of exposure in studies used by the researchers.

Title: Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries.

resreport3

Getty ImagesA study suggests sedentary time should be seen as a health risk.

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Sedentary time: Taking short breaks from sitting of even a minute or two throughout the day helps trim waistlines and reduce levels of C-reactive protein, an important inflammatory marker for heart disease, according to a study in the European Heart Journal that examined the health effects of prolonged sitting in sedentary and active people. Smaller studies that used self-reported information have identified sedentary behavior as a unique risk factor for cardiovascular disease and premature death. This study, aiming for a more objective picture, outfitted 4,757 Americans (average age of 46.5 years) with accelerometers, lightweight instruments worn on the hip that measure movement in activity counts. Accelerometers were worn an average 14.5 hours a day for seven days between 2003 and 2006. On average, participants took 15.6 breaks a day, of about four minutes each, and were sedentary about 8.5 hours a day. The least amount of sedentary time was 1.8 hours a day and the most was 21.2 hours a day. People who took the most breaks had a 4.1-centimeter smaller waist circumference and significantly lower C-reactive protein levels than the most sedentary participants. The findings suggest that public-health guidelines identify sedentary time as a health-risk behavior, the researchers said.

Caveat: Accelerometers don’t distinguish between different postures or variations in walking conditions so some standing-still time may be included as sedentary time. Time spent wearing the instrument was estimated rather than measured directly.

Title: Sedentary time and cardio-metabolic biomarkers in US adults: NHANES 2003-06

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Bad News for Ocean Spray

Monday, January 24, 2011 // Uncategorized

Cranberry juice has been used for years to alleviate irritation caused by urinary tract infections.  It is also used to prevent them.  There has been conflicting evidence as to it’s effectiveness.  This study exerpted in Journal Watch  suggests that placebo does just as well.

Cranberry Juice Is No Better Than Placebo for Preventing UTIs

Or, alternatively, placebo helped too.  

Cranberry juice for the prevention of urinary tract infections (UTIs) is one of the most durable folk remedies around, but attempts to prove its value have yielded results scattered all over the map. Some researchers have found it is worthless, whereas others have found it to be almost as potent as an antibiotic. 

In a randomized double-blind trial from Michigan, researchers assigned 155 healthy college-age women who sought medical care for UTIs to ingest low-calorie cranberry juice (8 oz twice daily) for 6 months after completion of antibiotic treatment. Another 164 women received placebo liquid carefully formulated to mimic real juice in all ways, except that it contained no proanthocyanidin, the moiety in cranberry juice that is thought to lower Escherichia coliadherence to uroepithelial cells. 

At 6 months, UTI recurrence rates were 19% in the cranberry group and 15% in the placebo group — a nonsignificant difference — with both rates strikingly lower than the expected recurrence rate of 30%. Further, although E. coliaccounted for initial infections in about 80% of both groups, it accounted for far more recurrent infections in the cranberry group than the placebo group (93% vs. 58%) — exactly the opposite of what one might have expected if proanthocyanidin was involved. 

Comment:Here stands another negative study for the cranberry, although this one raises the intriguing possibility that the cranberry’s active ingredient in fact might not be proanthocyanidin but another compound that, in this study, was present in both juice and placebo. And so the strange saga of the little berry that defied science continues. 

Abigail Zuger, MD 

Published in Journal Watch General Medicine January 20, 2011 

Citation(s):

Barbosa-Cesnik C et al. Cranberry juice fails to prevent recurrent urinary tract infection: Results from a randomized placebo-controlled trial. Clin Infect Dis 2011 Jan 1; 52:23. (http://dx.doi.org/10.1093/cid/ciq073)

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Paying For Quality

Friday, January 14, 2011 // Uncategorized

Rewarding doctors for quality of care is something that makes for a good sound bite, but is far more difficult to do.  The problem is, it is hard to define and measure quality.  In addition, adherence to certain guidelines which are often used as markers of quality of care  frequently turn out to be based on poor  data as summarized in the article from Journal Watch.

Study Finds Half of Guideline Recommendations Are Based on Low-Quality Evidence
More than half of recommendations included in guidelines from the Infectious Diseases Society of America rely on low-quality evidence, according to a study in the Archives of Internal Medicine.
Researchers examined 41 guidelines published by IDSA since 1994. Of the 4200 individual recommendations in those guidelines, 55% were supported by level III quality of evidence (e.g., expert opinions), while only 14% were guided by level I evidence (e.g., randomized controlled trials).
Five guidelines were updated during the study interval. In these updates, the number of recommendations increased between 20% and 400%, but only two updates saw an increase in the number of recommendations based on high-quality evidence.
An editorialist said that one of the main take-home messages of this study “is to be wary of falling into the trap of ‘cookbook medicine.’ The existence of guidelines is probably better than no guidelines, but guidelines will never replace critical thinking in patient care.”
Archives of Internal Medicine article (Free abstract)
Archives of Internal Medicine editorial (Subscription required)

4200 individual recommendations! Now we have guidelines for guidelines.  There are so many that no physician could ever adhere to all the recommendations.  Many things that sounded like a good idea at the time, turn out not to be when carfeully scrutinized.  This doesn’t mean that we shouldn’t keep trying, but spotlights how difficult it is.

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Antivaccinationists

Thursday, January 13, 2011 // Uncategorized

Some people don’t want their children vaccinated against disease because of a fear that the vaccines might harm them.  This occurred even before the recent controversial link between MMR (measlesmumpsrubella) and autism.  Some schools allow for children to be admitted without immunizations due to religious objections.  the problem with this is that it puts other children at risk by reducing “herd immunity” and allowing diseases to be spread because fewer people have resistance to the disease.

Herd immunity (or community immunity) describes a form of immunity that occurs when the vaccination of a significant portion of a population (or herd) provides a measure of protection for individuals who have not developed immunity.[1] Herd immunity theory proposes that, in contagious diseases that are transmitted from individual to individual, chains of infection are likely to be disrupted when large numbers of a population are immune to the disease. The greater the proportion of individuals who are immune, the smaller the probability that a susceptible individual will come into contact with an infectious individual.[2]

Estimated Herd Immunity thresholds for vaccine preventable diseases[2]
Disease Transmission R0 Herd immunity threshold
Diphtheria Saliva 6-7 85%
Measles Airborne 12-18 83 – 94%
Mumps Airborne droplet 4-7 75 – 86%
Pertussis Airborne droplet 12-17 92 – 94%
Polio Fecal-oral route 5-7 80 – 86%
Rubella Airborne droplet 5-7 80 – 85%
Smallpox Social contact 6-7 83 – 85%
^ – R0 is the basic reproduction number, or the average number of secondary infectious cases that are produced by a single index case in completely susceptible population.

Vaccination acts as a sort of firebreak or firewall in the spread of the disease, slowing or preventing further transmission of the disease to others.[3] Unvaccinated individuals are indirectly protected by vaccinated individuals, as the latter will not contract and transmit the disease between infected and susceptible individuals.[2] Hence, a public health policy of herd immunity may be used to reduce spread of an illness and provide a level of protection to a vulnerable, unvaccinated subgroup. Since only a small fraction of the population (or herd) can be left unvaccinated for this method to be effective, it is considered best left for those who cannot safely receive vaccines because of a medical condition such as an immune disorder or for organ transplant recipients.

The proportion of immune individuals in a population above which a disease may no longer persist is the herd immunity threshold. Its value varies with the virulence of the disease, the efficacy of the vaccine, and the contact parameter for the population.[3] No vaccine offers complete protection, but the spread of disease from person to person is much higher in those who remain unvaccinated.[4] It is the general aim of those involved in public health to establish herd immunity in most populations. Complications arise when widespread vaccination is not possible or when vaccines are rejected by a part of the population. As of 2009[update], herd immunity is compromised in some areas for some vaccine-preventable diseases, including pertussis and measles and mumps, in part because of parental refusal of vaccination.[5][6][7]

Herd immunity only applies to diseases that are contagious. It does not apply to diseases such as tetanus (which is infectious, but is not contagious), where the vaccine protects only the vaccinated person from disease.[8] Herd immunity should not be confused with contact immunity, a related concept wherein a vaccinated individual can ‘pass on’ the vaccine to another individual through contact.

Here’s an article from today’s New England of Journal which addresses the issue:

The Age-Old Struggle against the Antivaccinationists

Gregory A. Poland, M.D., and Robert M. Jacobson, M.D.

N Engl J Med 2011; 364:97-99January 13, 2011

Article
References

Since the introduction of the first vaccine, there has been opposition to vaccination. In the 19th century, despite clear evidence of benefit, routine inoculation with cowpox to protect people against smallpox was hindered by a burgeoning antivaccination movement. The result was ongoing smallpox outbreaks and needless deaths. In 1910, Sir William Osler publicly expressed his frustration with the irrationality of the antivaccinationists by offering to take 10 vaccinated and 10 unvaccinated people with him into the next severe smallpox epidemic, to care for the latter when they inevitably succumbed to the disease, and ultimately to arrange for the funerals of those among them who would die (see the Medical Notes section of the Dec. 22, 1910, issue of the Journal). A century later, smallpox has been eradicated through vaccination, but we are still contending with antivaccinationists.

The Cow Pock — or — the Wonderful Effects of the New Inoculation.

Since the 18th century, fear and mistrust have arisen every time a new vaccine has been introduced. Antivaccine thinking receded in importance between the 1940s and the early 1980s because of three trends: a boom in vaccine science, discovery, and manufacture; public awareness of widespread outbreaks of infectious diseases (measles, mumps, rubella, pertussis, polio, and others) and the desire to protect children from these highly prevalent ills; and a baby boom, accompanied by increasing levels of education and wealth. These events led to public acceptance of vaccines and their use, which resulted in significant decreases in disease outbreaks, illnesses, and deaths. This golden age was relatively short-lived, however. With fewer highly visible outbreaks of infectious disease threatening the public, more vaccines being developed and added to the vaccine schedule, and the media permitting widespread dissemination of poor science and anecdotal claims of harm from vaccines, antivaccine thinking began flourishing once again in the 1970s.1

Little has changed since that time, although now the antivaccinationists’ media of choice are typically television and the Internet, including its social media outlets, which are used to sway public opinion and distract attention from scientific evidence. A 1982 television program on diphtheria–pertussis–tetanus (DPT) vaccination entitled “DPT: Vaccine Roulette” led to a national debate on the use of the vaccine, focused on a litany of unproven claims against it. Many countries dropped their programs of universal DPT vaccination in the face of public protests after a period in which pertussis had been well controlled through vaccination2 — the public had become complacent about the risks of the disease and focused on adverse events purportedly associated with vaccination. Countries that dropped routine pertussis vaccination in the 1970s and 1980s then suffered 10 to 100 times the pertussis incidence of countries that maintained high immunization rates; ultimately, the countries that had eliminated their pertussis vaccination programs reinstated them.2 In the United States, vaccine manufacturers faced an onslaught of lawsuits, which led the majority of them to cease vaccine production. These losses prompted the development of new programs, such as the Vaccine Injury Compensation Program (VICP), in an attempt to keep manufacturers in the U.S. market.

The 1998 publication of an article, recently retracted by the Lancet, by Wakefield et al.3 created a worldwide controversy over the measles–mumps–rubella (MMR) vaccine by claiming that it played a causative role in autism. This claim led to decreased use of MMR vaccine in Britain, Ireland, the United States, and other countries. Ireland, in particular, experienced measles outbreaks in which there were more than 300 cases, 100 hospitalizations, and 3 deaths.4

Today, the spectrum of antivaccinationists ranges from people who are simply ignorant about science (or “innumerate” — unable to understand and incorporate concepts of risk and probability into science-grounded decision making) to a radical fringe element who use deliberate mistruths, intimidation, falsified data, and threats of violence in efforts to prevent the use of vaccines and to silence critics. Antivaccinationists tend toward complete mistrust of government and manufacturers, conspiratorial thinking, denialism, low cognitive complexity in thinking patterns, reasoning flaws, and a habit of substituting emotional anecdotes for data.5 Their efforts have had disruptive and costly effects, including damage to individual and community well-being from outbreaks of previously controlled diseases, withdrawal of vaccine manufacturers from the market, compromising of national security (in the case of anthrax and smallpox vaccines), and lost productivity.2

The H1N1 influenza pandemic of 2009 and 2010 revealed a strong public fear of vaccination, stoked by antivaccinationists. In the United States, 70 million doses of vaccine were wasted, although there was no evidence of harm from vaccination. Meanwhile, even though more than a dozen studies have demonstrated an absence of harm from MMR vaccination, Wakefield and his supporters continue to steer the public away from the vaccine. As a result, a generation of parents and their children have grown up afraid of vaccines, and the resulting outbreaks of measles and mumps have damaged and destroyed young lives. The reemergence of other previously controlled diseases has led to hospitalizations, missed days of school and work, medical complications, societal disruptions, and deaths. The worst pertussis outbreaks in the past 50 years are now occurring in California, where 10 deaths have already been reported among infants and young children.

In the face of such a legacy, what can we do to hasten the funeral of antivaccination campaigns? First, we must continue to fund and publish high-quality studies to investigate concerns about vaccine safety. Second, we must maintain, if not improve, monitoring programs, such as the Vaccine Adverse Events Reporting System (VAERS) and the Clinical Immunization Safety Assessment Network, to ensure coverage of real but rare adverse events that may be related to vaccination, and we should expand the VAERS to make compensation available to anyone, regardless of age, who is legitimately injured by a vaccine. Third, we must teach health care professionals, parents, and patients how to counter antivaccinationists’ false and injurious claims. The scientific method must inform evidence-based decision making and a numerate society if good public policy decisions are to be made and the public health held safe. Syncretism between the scientific method and unorthodox medicine can be dangerous.

Fourth, we must enhance public education and public persuasion. Patients and parents are seeking to balance risks and benefits. This process must start with increasing scientific literacy at all levels of education. In addition, public–private partnerships of scientists and physicians could be developed to make accurate vaccine information accessible to the public in multiple languages, on a range of reading levels, and through various media. We must counter misinformation where it is transmitted and consider using legal remedies when appropriate.

The diseases that we now seek to prevent with vaccination pose far less risk to antivaccinationists than smallpox did through the early 1900s. Unfortunately, this means that they can continue to disseminate false science without much personal risk, while putting children, the elderly, and the frail in harm’s way. We can propose no Oslerian challenge to demonstrate our point but have instead a story of science and contrasting worldviews: on the one hand, a long history of stunning triumphs, such as the eradication of smallpox and control of many epidemic diseases that had previously maimed and killed millions of people; on the other hand, the reality that none of the antivaccinationists’ claims of widespread injury from vaccines have withstood the tests of time and science. We believe that antivaccinationists have done significant harm to the public health. Ultimately, society must recognize that science is not a democracy in which the side with the most votes or the loudest voices gets to decide what is right.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From the Mayo Clinic Vaccine Research Group (G.A.P., R.M.J.), the Department of Medicine (G.A.P.), and the Department of Pediatric and Adolescent Medicine (G.A.P., R.M.J.), Mayo Clinic, Rochester, MN

Here is some information from UpToDate on the importance of vaccinations and their necessity.

Patient information: Why does my child need vaccines?
Last literature review version 18.3: September 2010 | This topic last updated: January 7, 2008 (More)

INTRODUCTION — Vaccines are one of the most effective ways to prevent serious illness in children and adults. Vaccine programs in the United States have been quite successful in reducing the number of children affected by many highly contagious diseases, including measles, rubella, mumps, diphtheria, and polio.

The following is a discussion of how immunizations work, common side effects, reasons to avoid a particular vaccine, and common concerns about vaccines. Separate articles discuss individual vaccines for children and adults. (See “Patient information: Vaccines for infants and children age 0 to 6 years” and “Patient information: Vaccines for children age 7 to 18 years” and “Patient information: Adult vaccines”.).

HOW DO VACCINES WORK? — The immune system functions to protect the body against illness and infection. When an organism (bacterium or virus) is foreign to the body, the immune system detects the organism and responds by creating proteins called antibodies. Antibodies fight the infection and help the person to recover.

Antibodies also work to prevent a person from becoming ill in the future. If a person is exposed to the organism again, the immune system recognizes it and rapidly produces more of the antibodies required to destroy the organism. This response protects the individual from developing the disease, ideally for life. For example, a person who had chickenpox as a child is unlikely to develop it again, even if he or she is in close contact with a person who is infected.

Vaccines work by stimulating the immune system to produce antibodies. However, unlike bacteria and viruses, vaccines do not cause the person to become ill in order to develop these antibodies. There are two main types of vaccines: active and passive.

Active vaccines — Active vaccines use a weakened form of the harmful bacteria or virus to stimulate the immune system.

Some bacteria (eg, diphtheria, tetanus) cause illness because they produce harmful substances called toxins. Vaccines that help the immune system protect the body from toxins are called toxoids. Toxoids are made from weakened forms of the bacterial toxins.

Passive vaccines — Passive vaccines provide temporary immunity using antibodies obtained from a large pool of donors; this type of preparation is known as immune serum globulin. Passive vaccines offer short-term protection to children or adults who have been exposed to a specific organism.

One example of a passive vaccine is hepatitis B immune globulin (HBIG). HBIG is given to newborns whose mothers test positive for hepatitis B surface antigen (HBsAg). HBIG provides temporary protection to the newborn against infection with hepatitis B.

Vaccines protect children and adults — Many parents are concerned about the risks of vaccines. However, vaccines have a long record of being a safe and effective way of preventing disease. In most cases, the benefits of vaccinating a child are far greater than the potential risks.

Diseases such as diphtheria and measles were common at one time in the United States, but are no longer a significant threat because of vaccination programs. However, these illnesses are still common in developing countries throughout the world. Because it is easy to travel from one country to another, it is easy for illness to spread from children or adults who are not vaccinated. Vaccination helps to reduce a child’s, family’s, and even an entire community’s chances of becoming ill by decreasing the number of people who get sick and transmit the infection to others. This process is sometimes referred to as “herd immunity.”

An example of a successful vaccination effort is the smallpox program. Before a vaccine was available, smallpox killed millions of people every year. Up until the early 1970s, smallpox disease was a worldwide threat to life. Use of the smallpox vaccine in large populations of people prior to the 1970s led to complete eradication of the disease and the smallpox vaccination is no longer required.

How are vaccines given? — In children, most immunizations are given in the form of a shot. Vaccines are also given in other ways, such as in a liquid taken by mouth (eg, rotavirus) or as a nasal spray (eg, one form of the influenza vaccine).

Paying for vaccines — Vaccines are available for every child in the United States, even for those who do not have health insurance. If a child does not have health insurance and the parents are unable to pay for vaccines, a program called Vaccines for Children is available. This program helps to cover the costs of vaccines given at private doctor’s offices, clinics, hospitals, community health clinics, and in some schools (www.cdc.gov/nip/vfc/).

VACCINE SIDE EFFECTS — Most vaccines and toxoids are safe and cause few if any serious side effects. Very rarely, serious side effects do occur. Children who develop unusual reactions such as rashes involving much of the body surface, difficulty breathing, excessively high fevers, seizures or loss of consciousness within a short time after receiving a vaccine should be evaluated by a healthcare provider.

To report an unusual reaction after a vaccine, you can contact the national Vaccine Adverse Events Reporting System (VAERS, vaers.hhs.gov/index, telephone number 1-800-822-7967 begin_of_the_skype_highlighting              1-800-822-7967      end_of_the_skype_highlighting). Parents who are concerned about a particular vaccine should discuss their concerns with their child’s healthcare provider.

Mild side effects — Vaccines and toxoids can occasionally cause mild side effects, including:

 

  • A low-grade fever
  • A red and tender area at the site of an injection
  •  

    Moderate side effects — Occasionally, children can develop a combination of fever, skin rash, swollen lymph nodes, and/or joint pain after vaccination. These reactions, called serum sickness-like reactions, can be uncomfortable, although they are rarely dangerous and resolve without treatment in days to weeks.

    Severe side effects — Severe side effects of vaccines are rare, but may include a severe neurologic reaction (eg, seizures) or severe allergic reactions (eg, anaphylaxis). Allergic reactions usually occur within minutes to hours of receiving the vaccine. If this occurs in the doctor or nurse’s office, emergency care can be given immediately. If a severe reaction occurs later, the parent/guardian should call emergency medical services, available in most areas of the United States by calling 911.

    Reasons to avoid vaccination — A particular vaccine may not be recommended for children with a serious allergic reaction to the following:

     

  • Eggs or egg protein, since some vaccines are prepared with embryonic chicken eggs or cultures (eg, influenza vaccines, yellow fever vaccines). A mild allergic reaction to eggs does not mean that the vaccine should be avoided.
  • The antibiotic medications neomycin or streptomycin (some vaccines contains trace amounts of neomycin)
  • Gelatin
  • A specific vaccine in the past
  •  

    In some cases, parents may not know their child is allergic to one of these components until the vaccine is given and the child develops a reaction.

    In addition, live virus vaccines are generally not recommended for children with a weakened immune system since there is an increased risk of infection as a result of the vaccine. However, there may be exceptions to this recommendation.

    MMR and varicella vaccine should be delayed in children who have recently received a blood transfusion or blood products (eg, immunoglobulin preparations) since these products can make the vaccine less effective.

    Conditions that do not affect vaccination — The following conditions do not require delaying or avoiding vaccines:

     

  • Current or recent mild illness
  • Current or recent antibiotic therapy
  • Previous mild to moderate tenderness, redness, or swelling at the site of injection or fever less than 104.9ºF (40.5ºC) after a previous vaccination
  • A personal history of allergies, except those listed above
  • A family history of adverse reactions to vaccines
  •  

    Are vaccines safe for my child? — There have been concerns about the safety of vaccines for children. These concerns include use of the preservative thimerosal and the relationship between vaccines and autism.

    Thimerosal — Thimerosal is a derivative of mercury that was previously used as a preservative in most vaccines. As the number of vaccinations given to infants increased, there was concern that this preservative could lead to potentially unsafe levels of mercury levels in some infants. As a result, several expert groups recommended in 1999 that all standard childhood vaccines be produced without thimerosal.

    The recommendation was a precautionary change and was not based upon known harm from thimerosal. Thimerosal-free forms of all of the childhood vaccines are available in the United States.

    Vaccines and autism — A second concern was in regards to a possible relationship between certain vaccines and the subsequent development of autism. Despite this concern, there is no scientific evidence that receiving these vaccines causes or increases the risk of developing autism.

    Studies that raised this possibility had significant weaknesses in their design. Several of the studies were based on a small number of children and relied upon the memory of parents or pediatricians to recall when behavioral signs/symptoms related to autism began. Most studies did not include a control group to compare children who were vaccinated with those who were not vaccinated to determine if there was a cause and effect relationship. It was recently reported that some cases of autism are attributable to gene abnormalities.

    For more information about any potential link between vaccines and autism, visit the National Immunization Program Web site at www.cdc.gov/vaccines.

    VACCINE RECOMMENDATIONS — Children should begin receiving vaccines within the first few months of life. This allows the child to be protected from common childhood illnesses as well as illnesses that can develop during adulthood.

    Many diseases prevented by vaccines are more serious in young children. In addition, most infants visit a healthcare provider frequently during the first year, which improves the chances of completing most vaccines that require multiple doses. In most states, specific vaccines are required before the child can attend school. This policy is designed to not only protect the individual child but to prevent the spread of certain contagious diseases to other children attending the school; these requirements vary from one state to another.

    In the United States, certain vaccines are recommended for children between birth and 6 years (figure 1). Using combination vaccines can help to reduce the number of shots needed at each visit. (See “Patient information: Vaccines for infants and children age 0 to 6 years”.)

    The timing of vaccines is important; some vaccines are most effective when given to children at a particular age or in combination with other vaccines. A personal, customized vaccine schedule can be created at the CDC’s web site (http://www2a.cdc.gov/nip/kidstuff/newscheduler_le/). The schedule may be helpful in reminding parents when their child is due for vaccines.

    The CDC has also developed an online tool for parents of children younger than six years to help determine which vaccines have been missed and when the vaccines should be scheduled (www.cdc.gov/vaccines/recs/Scheduler/catchup.htm).

    WHERE TO GET MORE INFORMATION — Your child’s healthcare provider is the best source of information for questions and concerns related to your child’s medical problem.

    This article will be updated as needed every four months on our Web site (www.uptodate.com/patients).

    Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

    Patient level information

    Patient information: Vaccines for infants and children age 0 to 6 years
    Patient information: Vaccines for children age 7 to 18 years
    Patient information: Adult vaccines

    Professional level information

    Allergic reactions to vaccines
    Clinical trials of human papillomavirus vaccines
    Epidemiology, clinical manifestations, diagnosis and management of mumps
    Hepatitis A virus vaccination and postexposure prophylaxis
    Hepatitis B virus vaccination
    Meningococcal vaccines
    Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children
    Poliovirus vaccination
    Prevention of varicella-zoster virus infection: Chickenpox
    Recommendations for the use of human papillomavirus vaccines
    Rubella
    Seasonal influenza vaccination in children
    Standard childhood immunizations
    Treatment of varicella-zoster virus infection: Chickenpox
    Vaccinia virus as the smallpox vaccine

    The following organizations also provide reliable health information.

  • National Library of Medicine
  •  

          (www.nlm.nih.gov/medlineplus/healthtopics.html)

  • National Institute of Allergy and Infectious Diseases
  •  

          (www.niaid.nih.gov/)

  • Centers for Disease Control and Prevention (CDC) National Immunization Program
  •  

          Toll-free: (800) 311-3435 begin_of_the_skype_highlighting              (800) 311-3435      end_of_the_skype_highlighting

          (www.cdc.gov/vaccines/)

  • National Foundation for Infectious Diseases
  •  

          Tel: (301) 656-0003 begin_of_the_skype_highlighting              (301) 656-0003      end_of_the_skype_highlighting
          (www.nfid.org)

  • The Children’s Hospital of Philadelphia Vaccine Education Center
  •  

          (http://www.chop.edu/service/vaccine-education-center/home.html)

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    REFERENCES

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    Sensible Choices for the New Year

    Wednesday, January 5, 2011 // Uncategorized

    I like practical advice.  Weight is usually gained over a long period of time.  Rapid weight loss is usually followed by rapid weight gain.  We need to make healthy lifestyle changes that make the difference over the long run.  The following article is from the Baptist Medical System’s E newsletter.  My only objection is the egg white breakfast tacos.  Why ditch the yolk?  It’s a great source of protein.  They’ve gotten a bum rap for the amount of cholesterol in the yolk, but egg intake hasn’t been shown to affect blood cholesterol levels.

    Simple and Sensible Swaps to achieve Health for Life
    By Jennifer Meachum RD, LD, CNSD, Baptist Health System Dietitian

    Happy New Year! I know many of you have already started 2011 with a BANG, working tirelessly and diligently on your resolutions to lose weight, eat healthier, or be fit. Although I am pleased to see so many people excited about diet and exercise, this enthusiasm can be short lived if you have set poorly defined and unrealistic New Year’s Resolutions. Long-term, unrealistic goals can lead to disappointment, a decrease in self confidence, or a loss of interest when immediate results are not seen. You then begin to seek refuge in your old unhealthy habits reverting back to what is comfortable and safe.

    This year I challenge you to adopt a new way of taking charge of your overall health and wellness. Lose the New Year’s Resolutions and “quick fix” mentality; instead choose Health for Life. Choosing Health for Life is not about instant results rather it is about making permanent healthy lifestyle changes and taking a proactive instead of a reactive approach to your healthcare. Health for Life means constantly setting small, realistic goals that are measureable and achievable to ensure success, build self confidence, and keep you motivated.

    Your Health for Life is largely dependent on the food choices you make and your eating habits. What we eat or don’t eat can have an impact on our weight, physical capabilities, disease risk, brain function, energy, and mood. When it comes to making changes in your diet, once again small changes and substitutions can make a big difference in your health and wellness. Below I will share sensible and simple swaps you can make in your diet that will help you gain confidence in making nutritious choices, develop permanent healthy eating habits, and have a positive impact on your health.

    Breakfast

    Swap instant oatmeal prepared with water with instant oatmeal prepared with skim milk for an additional 8 grams of satisfying protein and bone building calcium.
    Swap a plain white bagel with cream cheese with a whole wheat English muffin with 1 Tbsp. natural peanut butter for filling fiber and a spread packed with heart healthy monounsaturated fat and protein.
    Swap 2 bean and cheese tacos on flour tortilla with 2 egg white tacos (scrambled egg whites with onions and green peppers and low fat cheese on corn tortilla) for an impressive slash in saturated fat and cholesterol.

    Snacks

    Swap a handful of salted peanuts with a handful (about 12) of walnuts to boost your intake of heart healthy Omega 3 fats.
    Swap ½ cup canned fruit for ¾ cup of blueberries for an antioxidant punch.
    Swap cheese flavored crackers with 10 whole grain crackers and one ounce low fat cheese for a powerful combination of lean protein and nutrient dense carbs.

    Lunch & Dinner

    Swap that second or third slice of pizza with a Spinach salad (2 cups of fresh spinach and cherry tomatoes with 1 Tbsp Olive oil based dressing) to help achieve your daily recommended intake of green leafy vegetables and heart healthy fat.
    Swap a baked potato with a sweet potato, packed with disease fighting and age defying antioxidants such as beta carotene and Vitamin C.
    Swap a cheese burger with a veggie burger for a meatless alternative that can aid in weight loss and help decrease your total cholesterol.

    Beverages

    Swap a 12 ounce diet soda with a 12 ounce glass of iced green tea to help rev up your metabolism while warding off heart disease and cancers.
    Swap an 8 ounce frozen strawberry margarita with an 8 ounce glass of white or red wine for a savings of over 300 calories and a bonus of cancer fighting flavanoids.
    Swap a 12 ounce orange flavored fruit drink with an 8 ounce glass of 100% orange juice for immunity boosting Vitamin C and a serving of fruit.

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