health news

Supportive Care for Poisoning and Drug Overdosage

2008-12-18T20:16:00.000-08:00

The goal of supportive therapy is to maintain physiologic homeostasis until detoxification is accomplished and to prevent and treat secondary complications such as aspiration, bedsores, cerebral and pulmonary edema, pneumonia, rhabdomyolysis, renal failure, sepsis, thromboembolic disease, coagulopathy, and generalized organ dysfunction due to hypoxia or shock.

Admission to an intensive care unit is indicated for the following: patients with severe poisoning (coma, respiratory depression, hypotension, cardiac conduction abnormalities, cardiac arrhythmias, hypothermia or hyperthermia, seizures); those needing close monitoring, antidotes, or enhanced elimination therapy; those showing progressive clinical deterioration; and those with significant underlying medical problems. Patients with mild to moderate toxicity can be managed on a general medical service, intermediate care unit, or emergency department observation area, depending on the anticipated duration and level of monitoring needed (intermittent clinical observation versus continuous clinical, cardiac, and respiratory monitoring). Patients who have attempted suicide require continuous observation and measures to prevent self-injury until they are no longer suicidal.

epidemiology for Poisoning and Drug Overdosage

2008-12-18T20:15:00.001-08:00

About 5 million poison exposures occur in the United States each year. Most are acute, accidental (unintentional), involve a single agent, occur in the home, result in minor or no toxicity, and involve children under 6 years of age. Pharmaceuticals are involved in 47% of exposures and 84% of serious or fatal poisonings. Unintentional exposures can result from the improper use of chemicals at work or play; product mislabeling; label misreading; mistaken identification of unlabeled chemicals; uninformed self-medication; and dosing errors by nurses, parents, pharmacists, physicians, and the elderly. Excluding the recreational use of ethanol, attempted suicide (deliberate self-harm) is the most common reason for intentional exposure. Unintended poisonings may result from the recreational use of prescribed and over-the-counter drugs for psychotropic or euphoric effects (abuse) or excessive self-dosing (misuse).

About 25% of exposures require health professional evaluation, and 5% of all exposures require hospitalization. Poisonings account for 5–10% of all ambulance transports, emergency department visits, and intensive care unit admissions. Up to 30% of psychiatric admissions are prompted by attempted suicide via overdosage. Overall, the mortality rate is low: 0.4% of all exposures. It is much higher (1–2%) in hospitalized patients with intentional (suicidal) overdose, who account for the majority of serious poisonings. Acetaminophen is the pharmaceutical agent most often implicated in fatal poisoning. Overall, carbon monoxide is the leading cause of death from poisoning, but this is not reflected in hospital or poison center statistics because patients with such poisoning are typically dead when discovered and are referred directly to medical examiners.

Poisoning and Drug Overdosage

2008-12-18T20:13:00.000-08:00

Poisoning refers to the development of dose-related adverse effects following exposure to chemicals, drugs, or other xenobiotics. To paraphrase Paracelsus, the dose makes the poison. In excessive amounts, substances that are usually innocuous, such as oxygen and water, can cause poisoning. Conversely, in small doses, substances commonly regarded as poisons, such as arsenic and cyanide, can be consumed without ill effect. There is, however, substantial individual variability in the response to, and disposition of, a given dose. Some of this variability is genetic, and some is acquired on the basis of enzyme induction or inhibition, or because of tolerance. Poisoning may be local (e.g., skin, eyes, or lungs) or systemic depending on the chemical and physical properties of the poison, its mechanism of action, and the route of exposure. The severity and reversibility of poisoning also depend on the functional reserve of the individual or target organ, which is influenced by age and preexisting disease.

The Science and ART of Medicine

2008-12-18T20:11:00.000-08:00

Science-based technology and deductive reasoning form the foundation for the solution to many clinical problems. Spectacular advances in biochemistry, cell biology, and genomics, coupled with newly developed imaging techniques, allow access to the innermost parts of the cell and provide a window to the most remote recesses of the body. Revelations about the nature of genes and single cells have opened the portal for formulating a new molecular basis for the physiology of systems. Increasingly, we are understanding how subtle changes in many different genes can affect the function of cells and organisms. We are beginning to decipher the complex mechanisms by which genes are regulated. We have developed a new appreciation of the role of stem cells in normal tissue function and in the development of cancer, degenerative disease, and other disorders. The knowledge gleaned from the science of medicine has already improved and undoubtedly will further improve our understanding of complex disease processes and provide new approaches to disease treatment and prevention. Yet skill in the most sophisticated application of laboratory technology and in the use of the latest therapeutic modality alone does not make a good physician.

When a patient poses challenging clinical problems, an effective physician must be able to identify the crucial elements in a complex history and physical examination, to order the appropriate laboratory tests, and to extract the key results from the crowded computer printouts of data to determine whether to "treat" or to "watch." Deciding whether a clinical clue is worth pursuing or should be dismissed as a "red herring" and weighing whether a proposed treatment entails a greater risk than the disease itself are essential judgments that the skilled clinician must make many times each day. This combination of medical knowledge, intuition, experience, and judgment defines the art of medicine, which is as necessary to the practice of medicine as is a sound scientific base.

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2008-12-11T08:54:00.001-08:00

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Efficacy of RTS,S/AS01E Vaccine against Malaria in Children 5 to 17 Months of Age

2008-12-10T01:38:00.000-08:00

ABSTRACT

Background Plasmodium falciparum malaria is a pressing global health problem. A previous study of the malaria vaccine RTS,S (which targets the circumsporozoite protein), given with an adjuvant system (AS02A), showed a 30% rate of protection against clinical malaria in children 1 to 4 years of age. We evaluated the efficacy of RTS,S given with a more immunogenic adjuvant system (AS01E) in children 5 to 17 months of age, a target population for vaccine licensure.

Methods We conducted a double-blind, randomized trial of RTS,S/AS01E vaccine as compared with rabies vaccine in children in Kilifi, Kenya, and Korogwe, Tanzania. The primary end point was fever with a falciparum parasitemia density of more than 2500 parasites per microliter, and the mean duration of follow-up was 7.9 months (range, 4.5 to 10.5).

Results A total of 894 children were randomly assigned to receive the RTS,S/AS01E vaccine or the control (rabies) vaccine. Among the 809 children who completed the study procedures according to the protocol, the cumulative number in whom clinical malaria developed was 32 of 402 assigned to receive RTS,S/AS01E and 66 of 407 assigned to receive the rabies vaccine; the adjusted efficacy rate for RTS,S/AS01E was 53% (95% confidence interval [CI], 28 to 69; P<0.001) on the basis of Cox regression. Overall, there were 38 episodes of clinical malaria among recipients of RTS,S/AS01E, as compared with 86 episodes among recipients of the rabies vaccine, with an adjusted rate of efficacy against all malarial episodes of 56% (95% CI, 31 to 72; P<0.001). All 894 children were included in the intention-to-treat analysis, which showed an unadjusted efficacy rate of 49% (95% CI, 26 to 65; P<0.001). There were fewer serious adverse events among recipients of RTS,S/AS01E, and this reduction was not only due to a difference in the number of admissions directly attributable to malaria.

Conclusions RTS,S/AS01E shows promise as a candidate malaria vaccine. (ClinicalTrials.gov number, NCT00380393 [ClinicalTrials.gov] .)
Philip Bejon, Ph.D., John Lusingu, Ph.D., Ally Olotu, M.B., Ch.B., Amanda Leach, M.R.C.P.C.H., Marc Lievens, M.Sc., Johan Vekemans, Ph.D., Salum Mshamu, M.D., Trudie Lang, Ph.D., Jayne Gould, Ph.D., Marie-Claude Dubois, M.Sc., Marie-Ange Demoitié, M.Sc., Jean-Francois Stallaert, B.Sc., Preeti Vansadia, M.H.S., Terrell Carter, M.H.S., Patricia Njuguna, M.D., Ken O. Awuondo, H.N.D., Anangisye Malabeja, M.D., Omar Abdul, M.D., Samwel Gesase, M.D., Neema Mturi, M.R.C.Paed., Chris J. Drakeley, Ph.D., Barbara Savarese, R.N., Tonya Villafana, Ph.D., W. Ripley Ballou, M.D., Joe Cohen, Ph.D., Eleanor M. Riley, Ph.D., Martha M. Lemnge, Ph.D., Kevin Marsh, F.R.C.P., and Lorenz von Seidlein, Ph.D.

Can you explain what happens to food after we eat it?

2008-12-10T01:22:00.001-08:00

I would just look at it very simply.

When you eat food, the process of digestion breaks food down
into it’s respective nutrients as we discussed before.
Carbohydrates into monosaccharides (single units of sugars),
protein into amino acids and fats into fatty acids. This process
starts when you actually chew the food, the food then travels
down into the stomach through the esophagus where it is
liquified. When it reaches your small intestines, this is where the
fun begins. Most of the digestion and absorption of the food
occurs here in your small intestine. Digestive enzymes called
lipase, amylase and protease act on fats, carbohydrates and
protein to break them down into their nutrients for absorption.

Once the food has been broken down into their simple units, they
are then absorbed into the blood stream for further chemical
changes to make other compounds that the body needs, or for
use around the body. Water and small lipids (fats) cross the intestinal wall easily. Some nutrients such as water and fat
soluble vitamins need a carrier to take them across the wall.
Other nutrients such as proteins and glucose move across the
wall and into the blood stream by themselves but use energy to
do so.

Does functional food convert differently into energy than normal food?

2008-12-10T01:10:00.000-08:00

No, functional food behaves the same way as normal food as far
as converting into energy. Functional foods are still broken down
into their respective nutrients and provide energy, it’s just that
their specific nutrients have been seen to be beneficial in certain
areas for certain members of the population.

http://neurocyb.blogspot.com

We have discussed foods in general, but what are “functional foods”?

2008-12-10T01:00:00.000-08:00

It is a term that gets bantered about by people who are food
scientists or food companies that are talking about different kinds
of foods. Usually when they are talking about a functional food it
is a food analog, which is a food that has been put together by a
food manufacturer. It might also be called a nutraceutical.
Functional foods can also be natural foods which have been found
to be beneficial for a specific purpose.

Some companies manufacture internal tube feeding formulas for
hospital use. The composition of the product contains all the
nutrition in the right proportions for protein and amino acids plus
fat with the right fatty acids and the right vitamins and minerals
and you put all that together and it has a particular food
functionality.

There are foods that are designed to resolve particular health problems. Let’s take something common like lactose intolerance,
people have trouble digesting the lactose because they are
missing an enzyme called lactaid. So an example of a functional
food would be a food that was put together without any milk
protein or lactose sugar. It functions with that person who is
lactose intolerant. You can take that example and apply it to
anyone else who has special feeding needs.

http://neurocyb.blogspot.com

Do we become hungry because our stomach is empty or is it because of something else?

2008-12-10T00:59:00.000-08:00

That is a tricky question. There are people who have studied this
and can boil it right down to all kinds of enzymes and
mechanisms that kick into play, stimulating appetite or
depressing appetite.

When I go out to exercise and I get back and sit down, I need to
replenish my water intake. The next thing that I find is I find a combination of fruits to eat, primarily because they are made up
of water, and sugar carbohydrates. But the digestive process is
pretty rapid when it comes to breaking down sugars into glucose.
I can consume a lot of fresh fruits and it doesn’t satisfy my
hunger.

I will still have hunger pains because the digestion is completed
so rapidly as opposed to protein, which takes longer. It almost
seems like exercise can suppress appetite but I think you have to
balance that whole idea with how much exercise you are doing
and how many calories your body needs to replace and what
kinds of food you are going to consume.

It is complex and is another whole area to think about as to why
people are gaining weight, whether it is emotional or whether it is
the amount of exercise they have done.

Everyone studying this issue, trying to help people lose weight,
may have their own theories and their own recommendations.
They all study it in a different way - some try to understand the
psychology and some try to understand the nutritional aspects of
it. If it was well understood, we probably wouldn’t be having the problems we are having today.

Why is it that we sometimes crave certain foods? Can it be that your body is sending you a message?

2008-12-10T00:53:00.001-08:00

The theory is that people will have a craving for certain things
that will provide a nutrient that is lacking.

In our culture I don’t think there is a metabolic reason for food
cravings. You know if you are used to consuming sugary sweets
and that is all you eat, your metabolism adapts and your body guides you to the foods you are used to consuming.

An example of that would be someone who has gone on a
vegetarian diet and eliminated meat from their diet temporarily.
Then they start to reintroduce meat and their stomach is upset.
Their stomach is not used to digesting that kind of food. They
have adapted to digesting just non-meat items. There are food
digestive adaptations to the kinds of food that you eat. One
would have to believe that those are the kinds of foods that you
get used to.
http://neurocyb.blogspot.com

What is a well balanced diet and How Do I Get One ?

2008-12-10T00:51:00.000-08:00

Following the food pyramid is a good place to start and maybe it’s
a good place to end for some people. If you take all the food
somebody eats at the end of the week and then add them all up
and how much variety there was, you will find that there really wasn’t that much variety.

People generally have a dozen foods they like to eat and they will
end up eating the same foods day after day for most of their life
and that is where you run into problems. You get stuck in a rut
and fail to incorporate a vast variety into your diet and fail to get
the nutritional balance that you should be getting.

If you know nothing about food but incorporate a lot of variety of
fresh fruit and vegetables, cereals, dairy, protein sources, small
amount of “good” fats, and legumes and nuts into your diet the
chances of your missing out on the right nutrients essential for
good health are lowered.

When it comes to fresh fruit and vegetables, some people like to
use a diet out there called the Rainbow diet. It’s based on all the
different colors of fruits and vegetables. So I will take purple
grapes and onions and garlic and sprinkle some lettuce and if we
have fresh strawberries I will add those to cantaloupe and really
your imagination is your only limitation. Just basically add all
your favorite fruits and vegetables and season it to taste. Mix it
all up and you have an incorporation of all of that variety. You get all of the vitamins and the nutrients and the minerals that
you need in just one meal instead of just ingesting one kind of
food.
My point is the more variety you can get in your diet the greater
the possibility that if you are lacking in something that you are
going to get it. I am an advocate of getting variety in your diet. It
all comes down to looking at your budget and having some
knowledge of getting what you need and looking at the food
labels.

With just a little bit of knowledge of how to read food labels and
what you need you can make the right choices with the money
that you have to work with.

Even the restaurants and the fast food chains are starting to offer
more nutritious choices, likes salads. Subway is one that has
really jumped on the bandwagon. You know the one with Jared
standing there saying this deep fat fried sandwich contains 45
plus grams of fat and compare it to the subway sandwich.

I saw an interview where they were talking with the producer of Sesame Street and they were talking about the Cookie Monster
and how it was presented inadvertently to get kids to eat more
junk food and more cookies. Now they have repositioned that
whole program to where they are starting to teach kids more
about nutrition. I am hoping that one of the things that is
happening is that there is increased awareness about nutrition
and the obesity epidemic. Some people are just succumbing to
obesity and the things that come with it like cancer and heart
disease and diabetes. It’s good to see some positive changes
taking place.

What about alcohol? First they say that one drink is okay or two drinks are okay and now they say it’s just red wine.

2008-12-10T00:50:00.000-08:00

Red wine may be preferred because of the antioxidants that you
get and the other chemicals that come along with the wine.
Obviously there is something in the red wine as opposed to the
white that makes it more beneficial.

Alcohol is the second highest source of calories, behind fat. The
higher the level of alcohol in the beverage the higher the caloric
intake is. One gram of alcohol supplies 29 kcal’s. It isn’t as high
as fat but not as low as protein and carbohydrates.

There are other aspects of that to think about, if you are trying to lose weight you need to question whether you need the extra
calories. There are many other beverages that would provide
many more nutrients. If you are trying to lose weight you need to
question whether or not you need those extra calories from
something that basically has no nutritional value. I would tend to
be more negative about consuming alcohol because, besides the
dangers of alcoholism, there is the obvious danger of drinking too
much and consuming way too many calories.
So I am not an advocate of drinking alcohol because it has no
nutritional value or health value, particularly because any
nutritional benefit that you can get from alcohol, can also be
found elsewhere in our food

Then what should we be counting? Should we be counting calories, carbohydrates or fat?

2008-12-10T00:45:00.000-08:00

If you look at carbohydrates and fat, it is the same scenario.
Each gram of carbohydrates contains 16 kcal of energy, while fat
contains 37 kcal of energy. This is why watching how much fat you’re eating is so important. It is almost twice that of protein
and carbohydrates.

Much of the research on low carb diets such as the Atkins diet
found that people lost more weight initially and that the diet was
more effective than the other diets. Research has also found
that people who are on high protein diets also experience higher
satiety levels, that is, they are not as hungry. One of the main
reasons that low carb diets induce weight loss is because of the
simple fact that they are just consuming less calories, but more
protein and fat than carbohydrates.

What it seems to boil down to is that some low carb diets restrict
your intake to mainly fat and protein, by eliminating
carbohydrates from the diet. This has the effect of taking away
so many of the food choices that are available, as well as vital
nutrients that your body needs.

You know, even lovers of protein and fat, find that the variety
and choices are taken away and what you are actually doing is
actually limiting your caloric intake. So it works initially and that
is one of the reasons why people are so attracted to it.
The fact is however that 95% of diets fail and what it really
comes down to is if you want to lose weight, lifestyle change is
the only way. A diet is only temporary, you go on it and you lose
weight.

But what are you going to do eventually? You are going to go
off it.

In my definition, that is not a lifestyle change that is a temporary
fix. That is human nature. You go on the diet and eventually you
are going to go off it and revert back to your old eating habits
and gain the weight back.

It all comes down to understanding a little bit more about the
foods that you are eating and a choice to make a lifestyle change.
Also almost all of these diet plans introduce a new way of eating,
a way that is abnormal to the way that you are used to eating
and we are creatures of habit and we like the foods that we are
used to.

Because we are creatures of habit we don’t adapt very well to changes like that. We can go on it for a while and because it is
so abnormal it just doesn’t fit. It all comes down to the fact that
you have to make a decision that you are going to change the
way you eat.

One of the things that I have noticed is that if you do something
as simple as go out and walk 15 minutes a day, it will be easier
for you not to be tempted by unhealthy food. The healthier your
lifestyle choices, the easier it will be to stick to your healthy food
choices.

It’s almost like the unhealthy choices don’t fit anymore. They are
incompatible with the healthy choices. You know, I have quoted
that adage that the rich get richer and the poor get poorer. Well
it’s almost the same applied to health and nutrition.

As I kick around health and nutrition with people that are into it
like I am, I find that if you do exercise and have more muscle
mass you burn more calories when you are at rest. Lean muscle
mass has a higher metabolic requirement. When you are just
sitting around doing nothing and your body has more lean muscle
mass you are going to burn more calories than if your body contains fatty tissue.

It’s kind of a cruel injustice but the fitter you get even at rest,
you are burning more calories.

Tell me are there any specific foods that burn fat?

2008-12-09T20:10:00.001-08:00

No. Basically, if you want to burn fat or lose or maintain your
weight everything comes down to energy balance.
Researchers are constantly looking for foods that could burn fat.
Some of them concentrate on milk and dairy products that have
been theorized to burn fat through increasing inadequate calcium
intake. Some concentrate on finding a specific diet that will burn
fat like a high protein diet. While there is evidence for and
against – it has never been proven beyond a doubt that there is
any one type of food or type of eating that can burn fat.
When it comes down to it, it is a marketing myth that just got so
large that everyone started to talk about it, and pretty soon,
people started to believe that food could burn fat.

In reality food provides energy and nutrients, but cannot burn
fat. You can read more at the website about this subject at
Savvy Fat Burning Food.

Is it true that you can eat more and lose weight by combining different foods?

2008-12-09T20:09:00.000-08:00

No. People say that there are certain foods that take more
calories to burn than they provide or that certain food items are
going to cause more calories to be burned. It is a misconception
and I can fully understand why people think the way they do.

People don’t want to put the time and the energy or the money
into losing weight. It is a lot of work. People want to lose weight
and they know that some of the food they eat is unhealthy and they don’t want to put the time and energy into changing things.

It takes planning and time. Instead of visiting the fast food
restaurant on the corner on the way home you go to the produce
aisle in the grocery store. It might take you a little more time and
cost you a little more money but it’s worth it.

You know the fast food restaurants super size everything. The
artists and executives that design the ads know that our
mentality is that the more food we can get for our buck, the
better we are going to like it. It wasn’t so long ago that you
would go in and order a pop and you would get 8 oz or 12 oz and
now it’s not uncommon to get 24 or 36oz because they super size
everything.

What are fats and protein?

2008-12-09T20:08:00.002-08:00

A fat is a waxy, oily substance and is essential for good health.
Fat has double the amount of calories and so poses a problem to
individuals who find it difficult to exercise.

If you break down a fat you break it down into something called a
fatty acid and glycerol.

Proteins are made up of chains of amino acids and are necessary
for your body to build enzymes, antibodies and haemoglobin.
When you eat protein, your body breaks the protein down into
amino acids and then tries to re-assemble them into other
configurations to make other needed proteins for use around the
body.
Carbohydrates, fats and protein can all be broken down into
smaller units.

Each one of those macronutrients can be sub-divided. In the case
of proteins, proteins are made up of amino acids. Not all proteins
have the eight essential amino acids that the body needs. If you
are consuming protein and you miss out the essential ones for
long periods of time, you are putting yourself at risk of becoming
malnourished. In some cultures around the world where food
isn’t so plentiful, children can become malnourished and develop
diseases such as Kwashiorkor. The children have the distended
tummies, however the rest of their bodies are fine, this
unfortunately is caused by a protein deficiency.
Scientists can actually measure the quality of nutrients that
people are getting. People will volunteer to be involved in a
clinical feeding trial and they will hook these people up to all
kinds of measuring devices to measure everything from body
temperature to how much moisture they exhale.

They weigh and eliminate brine in their feces and record everything they can about these patients. They will feed these
people a controlled diet – controlling the amount of protein
consumed. They can measure how much is excreted, how much
weight a person gains and basically they can determine how
much of that protein is utilized by the body.

When they do that they can determine the quality of the protein
and the amino acids that makes up the protein. They can
determine how well the body absorbs protein and assign a
number value to the protein as to how well it is absorbed.

Some proteins are absorbed extremely well, an example would be
egg albumin, which is a protein found in the white of an egg
rather than the yolk. The egg white protein has an extremely
high biological availability and all of the essential amino acids in
the right balance.

Gelatin though has many of the essential amino acids however
does not have an amino acid called tryptophan and because it is
lacking - it isn’t considered a complete form of protein. If it is
combined with other sources of protein it is okay.
The bottom line is if you are looking at carbohydrates, fat or
protein, it is important to look at the composition of them. You
can read the declarations of the food labels. Often snack foods
will contain inefficient protein, or protein that does not contain all
the essential amino acids.

It is important to know that all carbohydrates, fat and proteins
are made up of these building blocks and it is important to know
to have a balance of all of these building blocks for good health.

How about a carbohydrate, what is a carbohydrate?

2008-12-09T20:08:00.001-08:00

Carbohydrates are made up of carbon and water. Atoms of
carbon, hydrogen and oxygen form carbohydrate compounds
such as sugar and starch. There are five types of carbohydrate
sugars, glucose, fructose, sucrose, maltose and lactose.
Carbohydrates are the body’s preferred source of energy and in
fact your brain needs a constant supply of carbohydrates.
Carbohydrates are broken down into glucose by the body and as
you may know, is absorbed into the blood stream. It can also be
stored in your muscles and liver as glycogen.

You need about 40 – 50 per cent of your diet to be made up of
carbohydrates for good health.

So what is a calorie (cal)? What is a kilocalorie(Kcal) ?

2008-12-09T20:07:00.000-08:00

I will keep it pretty simple. A calorie is the amount of heat that is
required to raise one cubic centimeter of water one degree.
A kilocalorie is the amount of heat that is required to raise one
kilogram of water one degree. You can see more information on
calories and kilocalories here

Are much of our lifestyle habits linked to emotions?

2008-12-09T20:06:00.002-08:00

Sure. Emotions and stress - all those things get factored into it.
Everybody has times of emotional need.

I know from watching myself. When I get depressed and
overworked, I lose sleep because I’m trying to get work done, or
something has happened that I feel bad about. When I get into
these situations, I definitely end up simply eating more than I
would have normally, partly to try and make myself feel better
and partly because I’m so tired, that my body is craving more
energy (food).

The way to avoid allowing yourself to be controlled by emotional
eating is knowing what to eat, how much to eat, what is healthy
and maintaining enough down time and sleep. These all factor
into just having a healthy lifestyle.
http://neurocyb.blogspot.com

Why do you think overweight children come from families with parents who are also overweight?

2008-12-09T20:06:00.001-08:00

In a way it is endorsement to the children that their eating habits
and lifestyle habits are acceptable. Just like any of us what better
role models than your parents. If they snack and eat unhealthily
then the children will as well.

However having said this, there are other considerations to take
into account. For example there is some tentative evidence that
people who are obese are genetically pre-disposed to it. So if
this were the case, these families may have an underlying reason
for their weight problems. This does not necessarily mean that
there is nothing that they can do to lose weight. Families who
may have these genes who eat eat wisely and exercise will be
showing their children how to eat, how much fun it is to exercise,
and can maintain normal weights. So while genes don’t excuse
bad lifestyle choices, it may be a reason why they are more likely
to become overweight.

The Best Way To Change Bad Eating Habits

2008-12-09T20:05:00.000-08:00

The best way to change your bad eating habits is to do it very
slowly. If you try to change everything all at once, it will seem
too hard to maintain. Try changing one thing at a time. For example, perhaps you like a morning cappuccino. Decide to stop
drinking your morning cappuccino and drink bottled water
instead. Don’t change anything else about your eating habits
until you feel totally comfortable about that dietary change.
Then move on to something else, like healthy snacks. Instead of
that chocolate energy bar, pack a piece of fruit and a small tub of
yogurt. Essentially fruit is natures snack food, it’s also cheaper.

Once you’re comfortable with this change, then move onto
something else. You get the picture. When you’ve got your diet
sorted out, then you can move on to getting some exercise into
your lifestyle.

So it doesn’t have to be an abrupt change you just need to
understand more about what you are eating and what the energy
value is and the nutrient value of the foods you are consuming,
and make slow but sure changes to your lifestyle.

How does one go about breaking years and years of bad eating habits? What is the starting point for someone who wants to start eating healthier?

2008-12-09T20:04:00.000-08:00

If there were an easy answer to the question we wouldn’t have
the problems we have today like obesity. Right now in the US
60% of the population has a weight problem. “Morbidly Obese” is
clinically defined as being 100 pounds or more overweight. In
our population, the number of people being morbidly obese is
increasing year after year.
Changing a person’s perception of food starts at an early age.
You can show a person in black and white what foods are good
for them and what isn’t and it pretty much comes down to a
conscious decision to consume healthy foods or not.
It certainly helps to have a mentor or life coach or fitness trainer
or just a friend where there is some kind of relationship when it
comes to dealing with eating healthily.
The fact is that you need support and one of the reasons there
are so many weight loss programs is that they do something a
little different, they have meetings and people get together and
support each other.

When you gauge how much weight people lose on weight loss
programs like Optifast or Atkins and whether they keep it off, all
of those people probably within a 5 year period have gained all
that weight back because they have lost their support group.

It speaks volumes to me that if people are going to lose weight
and keep it off they need a support group. You should not be on a
diet to lose weight, you need to be making a lifestyle change.

It means finding new ways of eating and develop new habits even
for your everyday activities so that the new way you are eating
becomes your new lifestyle.

What is the difference between nutrients and food stuffs?

2008-12-09T20:03:00.002-08:00

In the big picture, there is no difference between the two. You
can look at anything that provides nutrients to the body like
carbohydrates, protein, and fats. Food in general is just a carrier
for nutrients. For example, take a loaf of bread – it has starch in
it and protein and non-fat dry milk, the non-fat dry milk also
contains lactose. It will also contain a high amount of minerals.
The non-fat dry milk will contain casein, which is a non-fat milk
protein. When you eat food, you break down the food to get
nutrients for the body.

Is good nutrition based on certain food stuffs?

2008-12-09T20:03:00.001-08:00

Nutrition is based on getting all the right balance of nutrients
necessary for good health. A food stuff is a raw material that
can be made into a food. Only eating particular foods or foods
stuffs will not help you be healthier.

What is nutrition?

2008-12-09T20:02:00.001-08:00

Nutrition starts with eating food and drinking drink. The body
then breaks down the food and drink into its respective nutrients.
These nutrients then travel around the body to be used wherever
necessary. Carbohydrates are converted into glucose or fuel for
the body, protein is broken down into amino acids and fats are
broken down into fatty acids. For a person to be healthy, a
person must eat enough food to get a good supply of all the key
nutrients.

There is a set of guidelines that the government publishes for 20
or so different vitamins, minerals and nutrients and those values
are based on population studies, where they go out and look at
the health of the general population and consider what people
consume on a regular basis.

How about a carbohydrate, what is a carbohydrate?

2008-12-09T18:54:00.000-08:00

Carbohydrates are made up of carbon and water. Atoms of
carbon, hydrogen and oxygen form carbohydrate compounds
such as sugar and starch. There are five types of carbohydrate
sugars, glucose, fructose, sucrose, maltose and lactose.
Carbohydrates are the body’s preferred source of energy and in
fact your brain needs a constant supply of carbohydrates.
Carbohydrates are broken down into glucose by the body and as
you may know, is absorbed into the blood stream. It can also be
stored in your muscles and liver as glycogen.
You need about 40 – 50 per cent of your diet to be made up of
carbohydrates for good health

So what is a calorie (cal)? What is a kilocalorie(Kcal) ?

2008-12-09T18:52:00.000-08:00

What is the difference between nutrients and food stuffs?

2008-12-09T05:57:00.000-08:00

Is good nutrition based on certain food stuffs

2008-12-09T05:51:00.000-08:00

What is nutrition?

2008-12-09T05:44:00.000-08:00

Sources and Metabolism of Vitamin D

2008-12-08T22:55:00.001-08:00

Humans get vitamin D from exposure to sunlight, from their diet, and from dietary
supplements .1-4 A diet high in oily fish prevents vitamin D deficiency.
3 Solar ultraviolet B radiation (wavelength, 290 to 315 nm) penetrates the skin and converts 7-dehydrocholesterol to previtamin D3, which is rapidly converted to vitamin D3 .
1 Because any excess previtamin D3 or vitamin D3 is destroyed by sunlight
(Fig. 1), excessive exposure to sunlight does not cause vitamin D3 intoxication.
2 Few foods naturally contain or are fortified with vitamin D. The “D” represents
D2 or D3 (Fig. 1). Vitamin D2 is manufactured through the ultraviolet irradiation
of ergosterol from yeast, and vitamin D3 through the ultraviolet irradiation of 7-dehydrocholesterol from lanolin. Both are used in over-the-counter vitamin D supplements,but the form available by prescription in the United States is vitamin D2.
Vitamin D from the skin and diet is metabolized in the liver to 25-hydroxyvitamin
D (Fig. 1), which is used to determine a patient’s vitamin D status1-4; 25-hydroxyvi-
tamin D is metabolized in the kidneys by the enzyme 25-hydroxyvitamin D-1α-
hydroxylase (CYP27B1) to its active form, 1,25-dihydroxyvitamin D.
1-4 The renal production of 1,25-dihydroxyvitamin D is tightly regulated by plasma parathyroid hormone levels and serum calcium and phosphorus levels.
1-4 Fibroblast growth factor 23, secreted from the bone, causes the sodium–phosphate cotransporter to be internalized by the cells of the kidney and small intestine and also suppresses 1,25-dihydroxyvitamin D synthesis.
5 The efficiency of the absorption of renal calcium
and of intestinal calcium and phosphorus is increased in the presence of 1,25-dihy-
droxyvitamin D (Fig. 1).
2,3,6 It also induces the
ex pression of the enzyme 25-hydroxyvitamin
D-24-hydroxylase (CYP24), which catabolizes both
25-hydroxyvitamin D and 1,25-dihydroxyvita-
min D into biologically inactive, water-soluble
calcitroic acid.
2-4

Vitamin D Deficiency

2008-12-08T22:50:00.000-08:00

Vitamin D Deficiency
Michael F. Holick, M.D., Ph.D.

Once foods were fortified with vitamin d and rickets appeared
to have been conquered, many health care professionals thought the major
health problems resulting from vitamin D deficiency had been resolved. However, rickets can be considered the tip of the vitamin D–deficiency iceberg. In fact, vitamin D deficiency remains common in children and adults. In utero and during childhood, vitamin D deficiency can cause growth retardation and skeletal deformities and may increase the risk of hip fracture later in life. Vitamin D deficiency in adults can precipitate or exacerbate osteopenia and osteoporosis, cause osteomalacia and muscle weakness, and increase the risk of fracture.
The discovery that most tissues and cells in the body have a vitamin D receptor and
that several possess the enzymatic machinery to convert the primary circulating form
of vitamin D, 25-hydroxyvitamin D, to the active form, 1,25-dihydroxyvitamin D, has
provided new insights into the function of this vitamin. Of great interest is the role it can play in decreasing the risk of many chronic illnesses, including common cancers, autoimmune diseases, infectious diseases, and cardiovascular disease. In this review I consider the nature of vitamin D deficiency, discuss its role in skeletal and nonskeletal health, and suggest strategies for its prevention and treatment.

Prolonged Therapy of Advanced Chronic Hepatitis C with Low-Dose Peginterferon

2008-12-08T00:36:00.000-08:00

Prolonged Therapy of Advanced Chronic Hepatitis C with Low-Dose Peginterferon
Adrian M. Di Bisceglie, M.D., Mitchell L. Shiffman, M.D., Gregory T. Everson, M.D., Karen L. Lindsay, M.D., James E. Everhart, M.D., M.P.H., Elizabeth C. Wright, Ph.D., M.P.H., William M. Lee, M.D., Anna S. Lok, M.D., Herbert L. Bonkovsky, M.D., Timothy R. Morgan, M.D., Marc G. Ghany, M.D., Chihiro Morishima, M.D., Kristin K. Snow, Sc.D., Jules L. Dienstag, M.D., for the HALT-C Trial Investigators

ABSTRACT

Background In patients with chronic hepatitis C who do not have a response to antiviral treatment, the disease may progress to cirrhosis, liver failure, hepatocellular carcinoma, and death. Whether long-term antiviral therapy can prevent progressive liver disease in such patients remains uncertain.

Methods We conducted a randomized, controlled trial of peginterferon alfa-2a at a dosage of 90 µg per week for 3.5 years, as compared with no treatment, in 1050 patients with chronic hepatitis C and advanced fibrosis who had not had a response to previous therapy with peginterferon and ribavirin. The patients, who were stratified according to stage of fibrosis (622 with noncirrhotic fibrosis and 428 with cirrhosis), were seen at 3-month intervals and underwent liver biopsy at 1.5 and 3.5 years after randomization. The primary end point was progression of liver disease, as indicated by death, hepatocellular carcinoma, hepatic decompensation, or, for those with bridging fibrosis at baseline, an increase in the Ishak fibrosis score of 2 or more points.

Results We randomly assigned the patients to receive peginterferon (517 patients) or no therapy (533 patients) for 3.5 years. The level of serum aminotransferases, the level of serum hepatitis C virus RNA, and histologic necroinflammatory scores all decreased significantly (P<0.001) with treatment, but there was no significant difference between the groups in the rate of any primary outcome (34.1% in the treatment group and 33.8% in the control group; hazard ratio, 1.01; 95% confidence interval, 0.81 to 1.27; P=0.90). The percentage of patients with at least one serious adverse event was 38.6% in the treatment group and 31.8% in the control group (P=0.07).
Conclusions Long-term therapy with peginterferon did not reduce the rate of disease progression in patients with chronic hepatitis C and advanced fibrosis, with or without cirrhosis, who had not had a response to initial treatment with peginterferon and ribavirin. (ClinicalTrials.gov number, NCT00006164 [ClinicalTrials.gov] .)

Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients

2008-12-07T23:57:00.000-08:00

Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients
Kenneth Jamerson, M.D., Michael A. Weber, M.D., George L. Bakris, M.D., Björn Dahlöf, M.D., Bertram Pitt, M.D., Victor Shi, M.D., Allen Hester, Ph.D., Jitendra Gupte, M.S., Marjorie Gatlin, M.D., Eric J. Velazquez, M.D., for the ACCOMPLISH Trial Investigators

ABSTRACT

Background The optimal combination drug therapy for hypertension is not established, although current U.S. guidelines recommend inclusion of a diuretic. We hypothesized that treatment with the combination of an angiotensin-converting–enzyme (ACE) inhibitor and a dihydropyridine calcium-channel blocker would be more effective in reducing the rate of cardiovascular events than treatment with an ACE inhibitor plus a thiazide diuretic.

Methods In a randomized, double-blind trial, we assigned 11,506 patients with hypertension who were at high risk for cardiovascular events to receive treatment with either benazepril plus amlodipine or benazepril plus hydrochlorothiazide. The primary end point was the composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, resuscitation after sudden cardiac arrest, and coronary revascularization.

Results The baseline characteristics of the two groups were similar. The trial was terminated early after a mean follow-up of 36 months, when the boundary of the prespecified stopping rule was exceeded. Mean blood pressures after dose adjustment were 131.6/73.3 mm Hg in the benazepril–amlodipine group and 132.5/74.4 mm Hg in the benazepril–hydrochlorothiazide group. There were 552 primary-outcome events in the benazepril–amlodipine group (9.6%) and 679 in the benazepril–hydrochlorothiazide group (11.8%), representing an absolute risk reduction with benazepril–amlodipine therapy of 2.2% and a relative risk reduction of 19.6% (hazard ratio, 0.80, 95% confidence interval [CI], 0.72 to 0.90; P<0.001). For the secondary end point of death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke, the hazard ratio was 0.79 (95% CI, 0.67 to 0.92; P=0.002). Rates of adverse events were consistent with those observed from clinical experience with the study drugs.
Conclusions The benazepril–amlodipine combination was superior to the benazepril–hydrochlorothiazide combination in reducing cardiovascular events in patients with hypertension who were at high risk for such events. (ClinicalTrials.gov number, NCT00170950 [ClinicalTrials.gov] .)

Home Delivery — Bringing Primary Care to the Housebound Elderly

2008-12-07T23:49:00.000-08:00

Home Delivery — Bringing Primary Care to the Housebound Elderly
Susan Okie, M.D.

Nurse practitioner Gail Metcalf toted her medical bag up the steep stairway of a triple-decker house in Dorchester, a low-income neighborhood of Boston, and greeted her patient, Mrs. E, a Jamaican woman in her mid-80s. Mrs. E, who is legally blind and has chronic obstructive pulmonary disease, hypertension, neuropathy, a thoracic aneurysm, and other medical problems, sank into a lift chair and began describing her symptoms as Metcalf examined her. Her back ached and her arms burned, she said, especially at night: "That's the time when it really comes on. Sometimes, I feel life is leaving me."

Mrs. E's agitation during such episodes has often prompted family members to send her to the emergency room, where doctors, alarmed by her medical record, invariably order imaging tests. "I can't even count the number of CT scans she's had," Metcalf said. Recently, however, the nurse practitioner, who regularly visits 120 frail, elderly patients enrolled in House Calls, a program of Boston-based Urban Medical, concluded that Mrs. E's late-night attacks probably stemmed from her fear of death. She discussed her theory with the patient's sister, who proposed a solution: "When she tells me to call 911," she told Metcalf, "I'm going to read her the Bible." So far, that strategy has kept Mrs. E out of the emergency room, and thanks to home delivery of her medications, her chronic conditions remain well controlled.

House Calls, established in late 1999, provides ongoing primary care for more than 500 elderly or disabled Boston patients who can't get to the doctor's office, thereby reducing hospitalizations and emergency room visits and improving patients' quality of life. Metcalf, a calm and optimistic woman who has been doing home visits for 23 years, can expertly size up a situation and order the necessary supplies and services, from prefilled insulin syringes to special furniture to day care. Helping her patients continue to live at home as long as possible "is what gets me up in the morning," she said. "In doing this work, it's not the medicine that's the primary problem. It's the relationship building."

As baby boomers enter their 60s, their increasing medical needs (see graph) combined with a worsening shortage of primary care doctors are expected to fuel a crisis in health care for the elderly.1 Already, many Americans report difficulty finding a primary care physician, and "care coordinators" — some with nursing or social work degrees and some without specific credentials — are advertising their services in states with large retiree populations. Between 2010 and 2030, the number of Americans 65 years of age or older is projected to almost double; people in this age group see their physicians and are hospitalized much more often than the rest of the population (see table). Meeting their medical needs is likely to require increasing reliance on midlevel providers (nurse practitioners and physician's assistants), as well as the use of multidisciplinary teams.
=====================
Urban Medical, founded in 1977, is a team-based practice specializing in primary care of the elderly and chronically ill; its staff — which currently includes 11 physicians and 16 midlevel providers — sees patients in rest homes, assisted living facilities, and nursing homes, as well as at home and in a medical office.2 The average cost of primary care for a House Calls patient is approximately $150 per month, as compared with approximately $40 per month for patients seen in the office. However, an internal evaluation found that among 70 House Calls patients studied, hospital admission rates were reduced by 29% and hospital days by 34% during patients' first year in the program, as compared with the previous year. A detailed study of the program's net effect on health care spending is under way.

In late 2002, Duke University's Department of Community and Family Medicine established a similar program, Just for Us, staffed by a part-time physician and two physician's assistants, to serve several hundred housebound elderly residents of low-income or senior housing in Durham, North Carolina. A recent evaluation found that among Medicaid patients in the program, inpatient hospital expenditures during fiscal 2003–2004 were 68% lower than during the previous fiscal year, and emergency department expenditures were 41% lower; however, these and other hospital-related cost savings were more than offset by increased spending for prescription drugs, home health services, and especially services for the disabled, so that total spending increased by 23%.3 Researchers are conducting further studies of the program's impact on enrollees' health and medical costs.

The reimbursement system makes it easier to design and test innovative programs like these in Medicare and Medicaid populations than in those covered by private insurers. However, new practice models that help to meet the mounting demand for primary care are likely to be replicated — particularly if they also reduce health care spending. JudyAnn Bigby, Massachusetts secretary of Health and Human Services, whose late father was a House Calls patient, argues that "we pay for things that people don't necessarily benefit from. If we were able to divert those expenditures to programs like this, it would be affordable, and I think it would save the entire system money while improving the quality of care."

Urban Medical was founded to test the theory that using nurse practitioners as partners with physicians to provide coordinated care for frail elderly or disabled patients could prevent unnecessary hospitalizations. The model worked, leading to changes in Massachusetts law to allow nurse practitioners to practice in settings where a physician is not physically present. But seeing patients where they live is less efficient than seeing them in an office, and its cost-effectiveness depends on their geographic concentration. Metcalf said she checks her messages each morning and first visits anyone who has called during the night to report an illness; then she sees others who live nearby, aiming to visit each of her patients about every 5 weeks. Although each nurse practitioner is paired with a physician, "most doctors and nurse practitioners don't go out on the same day," said nurse practitioner Shona Gibson. Doctors and nurse practitioners can communicate through e-mail, she said, "and we don't need to talk face-to-face."

Observing Gibson as she visited patients one morning, I saw examples of proactive care that may well have headed off the need for hospitalization. In an assisted-living facility, she discovered a tender paronychia on the toe of an elderly man with diabetes and instituted a regimen of warm soaks and antibiotic ointment. Concerned about a woman with dementia whose home health aide insisted she was "just not right," she sweet-talked an aide into helping her obtain a fresh urine sample for culture. In a nursing home, she checked on a retired pastor whose arthritis and early Alzheimer's disease had recently forced him and his family to acknowledge that he could no longer live independently. Gibson and coworkers had engineered a seamless transfer to the nursing home from his apartment at an assisted-living facility. "With a lot of people who are at home, it's not really a mystery why they're failing," Gibson said. "The normal thing would be to wait for something bad to happen and ship them to the emergency room. It's a lot more work to make that not happen."

Keeping the practice economically viable despite all that extra work has always involved getting grants and fund-raising, and managers said it is particularly challenging in the current fee-for-service environment. "Because of the level of chronic illness and frailty of our patients, one 20-minute visit generates 40 minutes of care coordination," said Emily DuHamel Brower, the group's chief operating officer. To compensate primary care providers for such work, which saves money for the health care system as a whole, experts such as Allan Goroll of Massachusetts General Hospital have proposed piloting a system of "risk-adjusted primary care capitation," in which a practice would be paid a specific amount for the care of each patient, with higher payments for those with multiple chronic illnesses.

One such experiment is already under way. The Senior Care Options (SCO) program is a health plan created under a Massachusetts demonstration project, open to state Medicaid recipients 65 years of age or older, most of whom are also covered by Medicare. Enrollees are placed in risk-adjusted categories, and Urban Medical, under a contract with one of the SCO payers, receives monthly capitated payments that are higher for sicker patients with more complicated conditions. It costs Urban Medical an estimated $370 per patient per month to deliver primary care to the highest-risk group, chronically ill elderly patients who are eligible for nursing home care but are still living at home. SCO's capitated payment covers that cost and also enables providers to pay for the services needed to keep the patient at home. "There's built-in payment for care coordination," said Brower. "The medical decision making is done by the medical team, as opposed to somebody in the insurance office."

Despite Urban Medical's reputation for innovation, recruiting new practitioners has gotten much harder in recent years. Fewer medical school graduates are entering primary care, and competition to hire general internists, family practitioners, and midlevel practitioners is fierce. But managers said the practice still attracts idealistic, committed physicians. "It was founded by really visionary people," said Holly Norrod, a general internist who joined the group this past summer. She said recruitment advertisements she received from other practices focused on nearby recreational or cultural opportunities. Urban Medical's ad "really stuck out," said Norrod, "because it was the only one I got that said anything about taking care of people."

At Duke, faculty in the Department of Community and Family Medicine are using Just for Us and other community-based primary care programs as a way both to reach underserved patients and to teach residents and medical students how to practice as part of a multidisciplinary team. The patients in Just for Us have office-based primary care doctors but need frequent monitoring and can't easily get to medical appointments. "We think of ourselves as the outreach arm" for the patients' primary physicians, said J. Lloyd Michener, chairman of the Department of Community and Family Medicine. "A doc cannot do it all."

Michener said the program and various school- and neighborhood-based clinics are also used as educational settings for Duke's newly redesigned family medicine residency. "We can't tell if it's a reignited interest in family medicine or just the approach we have," he said, "but we have more applications to the program than we've had in the last 20 years."

A few years ago, resident Robin Ali agreed to become the primary physician for a panel of elderly members of Just for Us and soon realized that she loved the job. Now the program's part-time medical director, she hopes to combine patient care with research on health disparities. She said many of her students and residents are attracted to primary care but decide against it for financial reasons. "A lot of people have said, `I'd love to do what you're doing, but how do you get paid?'" she said. "It is a sacrifice. But it's a fantastically rewarding experience."

No potential conflict of interest relevant to this article was reported.

Source Information

Dr. Okie is a national correspondent for the Journal.

References

1. Institute of Medicine. Retooling for an aging America: building the health care workforce. Washington, DC: National Academies Press, April 2008. (Accessed November 13, 2008, at http://www.nap.edu.)
2. Master RJ, Feltin M, Jainchill J, et al. A continuum of care for the inner city: assessment of its benefits for Boston's elderly and high-risk populations. N Engl J Med 1980;302:1434-1440. [Abstract]
3. Yaggy SD, Michener JL, Yaggy D, et al. Just for Us: an academic medical center-community partnership to maintain the health of a frail low-income senior population. Gerontologist 2006;46:271-276. [Free Full Text]

Circumcision — A Surgical Strategy for HIV Prevention in Africa

2008-12-07T22:19:00.000-08:00

In a radical departure from earlier strategies, public health officials are now arguing that circumcision of men should be a key weapon in the fight against infection with the human immunodeficiency virus (HIV) in Africa. Recent studies have shown that circumcision reduces infection rates by 50 to 60% among heterosexual African men. Experts estimate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. But skeptics argue that efforts to "scale-up" circumcision programs on the continent that has the fewest physicians per capita may draw funds away from other necessary public health programs, ultimately threatening already tenuous health care systems.

How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa. Early evidence of circumcision's protective effect dates back to the late 1980s. Researchers working in Africa and Asia noticed that HIV-prevalence rates differed dramatically among neighboring regions and were often lowest in areas where circumcision was practiced. More than 40 observational studies followed, but most researchers remained skeptical about the results. Then, in 2002, Bertran Auvert, professor of public health at the University of Versailles, launched one of the first randomized, controlled trials of circumcision in Orange Farm, South Africa, a community with a low rate of circumcision and a high prevalence of HIV infection. After the 12-month interim analysis, the data and safety monitoring board decided to stop the trial. The data were clear: circumcision reduced the rate of HIV infection among heterosexual men by 60%.1

Since then, two other randomized, controlled clinical trials in Kenya and Uganda have confirmed the results from South Africa.2,3 Both were stopped early because of overwhelmingly positive results. The research teams thought it was unethical to require men in the control group to wait 24 months before undergoing circumcision. A few men had already obtained off-protocol circumcisions, but since the study results were released, the demand has skyrocketed. "We have three operating rooms running every day," said Ronald Gray, lead author on the Ugandan study and professor at the Johns Hopkins Bloomberg School of Public Health. "We have done about 1000 surgeries in 3 months — after completing all of the surgeries for trial participants."

Researchers have also found that circumcision provides increased protection against the human papillomavirus, herpes simplex virus, syphilis, and chancroid. But the most compelling evidence is still for HIV prevention, argues Roger Shapiro, a researcher at Harvard School of Public Health who is helping to implement a pilot program to offer infant circumcision in Botswana: "Circumcision isn't a new scientific breakthrough, but it works. It is the only proven medical intervention that can complement condom use and improve protection. If we had this level of data for a vaccine or a microbicide, you can bet there would be a massive push for immediate scale-up."

Key distinctions between penile surgery and less-invasive methods of HIV prevention, however, may hinder momentum. For one thing, some African officials remain wary of circumcision because of concerns about cost and safety. Currently, physicians are performing most circumcisions, but many countries are hoping to decrease costs by training a cadre of lower-level health care workers (such as medical or clinical officers and nurses) to fill the provider gap that many countries face. Adequate training is essential, however, since complication rates ranged from 1.7 to 3.6% among HIV-negative men in the trials (as compared with rates of 0.2 to 2.0% associated with infant circumcision in the United States). Most complications were minor — pain or bleeding — but higher complication rates have been reported outside trial settings. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction.4 Inadequate sterilization procedures and surgical instruments were probably important factors in the higher rates, but Daniel Halperin, senior research scientist at Harvard School of Public Health, argues that high complication rates primarily reflect a problem with training, not with the procedure itself: "Circumcision can be performed safely, with relatively few complications, anywhere in the world, if clinicians are trained properly."

Policymakers are also struggling with complex cultural barriers in societies where circumcision is not part of mainstream practice. In countries such as South Africa, for example, most men are not circumcised, but certain subpopulations, including the Xhosa ethnic group, practice circumcision of boys as a rite of passage into manhood. Many South Africans frown on the practice, and after several young Xhosa boys died from circumcision-related complications, then-President Thabo Mbeki signed a bill banning (with some religious and medical exceptions) circumcision in boys under 16 years of age. Some fear that the deaths associated with traditional circumcision have prevented expansion of the program in South Africa, but others argue that offering clean, safe medical circumcision to these communities could be lifesaving.

Many public health researchers fear that there are deeper reasons for some African governments' skepticism. Some speculate that Africa's colonialist history has left these leaders with lingering suspicions about possible oppression, which have long taken the form of "deep denial regarding HIV treatment and prevention in certain regions of Africa," according to Francois Venter, clinical director of HIV management and reproductive health at the University of the Witwatersrand in South Africa. Others reference the dark history of surgical interventions deployed in the name of public health, citing the Indian sterilization camps of the 1970s. All agree that implementation of circumcision on a national level will require in-country champions and strong political will to succeed. "Currently all of the funding is coming from Western nations," says Venter, "and this makes people suspicious."

To counterbalance perceptions of Western intrusion, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs. "Countries are going to have to scale-up according to their own goals," said Catherine Hankins, chief scientific adviser to the Joint United Nations Program on HIV/AIDS (UNAIDS). "We are not setting any international agendas." UNAIDS, the World Health Organization (WHO), and their partners have set up a Web site (www.malecircumcision.org) to allow interested countries to trade information directly.

Most people involved in scaling up adult male circumcision recognize that the surgery is a costly endeavor and a socially complex intervention that may compromise other public health priorities. Venter argues, "In South Africa, we have many other competing health issues, including maternal and child health and tuberculosis, which still need much more support." Nevertheless, he remains a proponent of circumcision as a means for getting young men into the health care system to help protect them against HIV and educate them about safe sex practices.

Major international funders, including the Bill and Melinda Gates Foundation and PEPFAR, agree that ramped-up circumcision efforts must be funded as add-on services to guarantee that they will not detract from other programs. Although PEPFAR has granted $26 million for circumcision programs in 13 African countries — Botswana, Kenya, Rwanda, Zambia, South Africa, Lesotho, Malawi, Mozambique, Tanzania, Uganda, Namibia, Ethiopia, and Swaziland — implementation has been highly variable.

In order to optimize HIV-prevention measures, officials from WHO and UNAIDS are advising that countries offer a minimum package of services in addition to circumcision, including HIV testing, screening for sexually transmitted infections, promotion of condom use, and counseling on safer sex. Such a comprehensive approach is meant to address concerns that circumcised men may adopt riskier behavior because they feel protected after undergoing the procedure. Despite these concerns, Gray and others have shown that there are no differences between the sexual behaviors of circumcised men and those of uncircumcised men — reassuring news, since many researchers and policymakers see circumcision programs as an opportunity to engage young men and women in HIV prevention. Robert Bailey, lead author on the Kenya study and professor of epidemiology at University of Illinois at Chicago, has noticed more participation of sexual partners in voluntary HIV counseling and testing since circumcision programs started.

Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women. In a small substudy, Ugandan researchers circumcised HIV-positive men and then followed their HIV-negative female partners to see whether their risk of infection was reduced. Data presented earlier this year did not demonstrate a benefit5 — a failure the researchers attributed to a sample size too small to allow differences to reach statistical significance. Indirect evidence from modeling, however, suggests that women will ultimately benefit from circumcision programs that reduce the HIV prevalence among men.

Although circumcision has increasing support from researchers, donors, and politicians, its status as a non–behavior-based intervention may ultimately be its biggest obstacle. Neil Martinson, deputy director of the Perinatal HIV Research Institute at the University of the Witwatersrand in South Africa, summarizes this concern: "People are used to policies that target behaviors, but circumcision is a surgical intervention — it's cold, hard steel — and that doesn't always go down well." Ultimately, as programs move forward, the scale-up of circumcision will require strong political backing, adequate funding, and leaders to champion the cause to ensure that it is a safe, low-cost option available throughout Africa.

No potential conflict of interest relevant to this article was reported.

Source Information

Dr. Katz is a fellow in infectious disease at Beth Israel Deaconess Medical Center and a fellow in global women's health at Brigham and Women's Hospital, and Dr. Wright is a fellow in hematology–oncology at Dana–Farber Cancer Institute — all in Boston.

References

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2. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-666. [CrossRef][ISI][Medline]
3. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-656. [CrossRef][ISI][Medline]
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5. Wawer M, Kigozi G, Serwadda D, et al. Trial of Male Circumcision in HIV+ Men, Rakai, Uganda: effects in HIV+ men and in women partners. Presented at the 15th Conference on Retroviruses and Opportunistic Infections, Boston, February 3–6, 2008.