Health Thread (nutrition, medical, longevity, etc)

[Crafty_Dog]

 

Hospital Infections:
Preventable and Unacceptable
By BETSY MCCAUGHEY
August 14, 2008; Page A11

On July 30, a jury awarded over $2.5 million to James Klotz and his wife Mary in a medical malpractice lawsuit against a heart surgeon, his group practice and St. Anthony's Medical Center in St. Louis, Mo. In 2004 Mr. Klotz, now 69, was rushed to the hospital with a heart attack and a pacemaker was surgically implanted. He developed a drug-resistant staph infection called methicillin-resistant Staphylococcus aureus (MRSA). It was so severe that he underwent 15 additional operations, spent 84 days in the hospital and lost his right leg, part of his left foot, a kidney and most of his hearing.

This verdict should send a warning to physicians, hospitals and hospital board members. Until recently, infection was considered an unavoidable risk. But now there is proof that nearly all hospital infections are avoidable when doctors and staff clean their hands and rigorously practice proper hygiene and other preventive measures.

Hospital infections will cause the next wave of class-action lawsuits, bigger than the litigation over asbestos. The germ that Mr. Klotz contracted, hospital-acquired MRSA, infects about 880,000 patients a year and accounts for only 8% of all hospital infections. Hospital infections caused by all kinds of bacteria sicken millions.

The Klotz verdict is not the first sign that hospitals are in a new legal environment. In 2004, Tenet Healthcare Corporation agreed to pay $31 million to settle 106 lawsuits by patients who contracted infections after heart surgery at Palm Beach Gardens Medical Center in Florida. Since then, numerous lawsuits have been filed against hospitals in Florida, Kentucky and elsewhere by infected patients. Hospitals being sued are saying that their infection rates are within national norms. But for most infections, the only acceptable rate is zero.

Medicare calls certain device-related bloodstream infections, urinary tract infections and surgical infections after orthopedic and heart surgery "never events." Starting in October, Medicare will stop reimbursing hospitals for treatment of these infections. Hospitals will be barred from billing patients for what Medicare doesn't pay, forcing them to take a loss. Next year Medicare will add other types of infections to the list of "never events."

The evidence justifying Medicare's new policy is compelling. Central line bloodstream infections, caused by the contamination of certain devices, are preventable. Hospital patients in intensive care are commonly medicated through a tube inserted into a vein. The risk is that bacteria will invade the tube and enter the bloodstream. Rigorous hygiene, including clean hands, sterile drapes, and careful cleaning of the insertion site with chlorhexidine soap, can keep bacteria away from the tube.

Beth Israel Medical Center in New York City reports that it hasn't had a central line bloodstream infection in the cardiac intensive care unit in over 1,000 days. Dr. Brian Koll, chief of infection control there, explains that the key is using a checklist that doctors and nurses must follow. Implementing the checklist cost $30,000 and saved $1.5 million in treatment costs. Lives saved: priceless.

Other hospitals -- from Johns Hopkins Medical Center in Baltimore to Sutter Roseville Medical Center in Sacramento -- have reached the goal of zero central line bloodstream infections. No wonder Medicare calls these infections "never events." Why should jurors reach a different conclusion in a lawsuit?

We have the knowledge to prevent infections. What has been lacking is the will. A recent survey from the patient-safety organization Leapfrog found that 87% of hospitals fail to consistently practice infection prevention measures. Insurance companies that sell liability coverage to hospitals could change that by offering lower premiums to hospitals that rigorously follow infection-prevention protocols.

To be sure, lawsuits are not the best way to improve patient care. Many verdicts are unjustified, and few truly injured patients find a lawyer to take their case. Still, the coming wave of lawsuits, as well as financial incentives from Medicare and insurers, will fight complacency about hospital hygiene.

Ms. McCaughey, a former lieutenant governor of New York State, is chairman of the Committee to Reduce Infection Deaths.

See all of today's editorials and op-eds, plus video commentary, on Opinion Journal.
 

[Crafty_Dog]

Herbal Legends
By SCOTT GOTTLIEB
August 19, 2008; Page A15

 
Trick or Treatment
By Simon Singh and Edzard Ernst, M.D.
(Norton, 342 pages, $24.95)

When I was practicing medicine in the Elmhurst section of New York about five years ago, my colleagues and I confronted an epidemic of liver damage among the recently arrived Chinese immigrants who live there. We put these patients through an exhaustive battery of tests for conventional sources of hepatitis, the most likely culprit, but found none. The mysterious illness, we decided, must have been caused by the folk therapies, usually herbal, that our patients often used but rarely disclosed to their doctors. There was little we could do but counsel them to stop. Instead of following our professional advice, though, they usually just added new herbs to their regimen, hoping to solve their liver problems but sometimes making themselves even more ill.

The Elmhurst epidemic was a classic example of the clash -- both cultural and scientific -- between "alternative" and conventional medicine. In this case, the inability of doctors to treat a liver ailment strengthened the false faith of patients in other cures. Usually, alternative medicine is a harmless distraction. And some treatments actually do offer benefits. But going outside modern medical practice also carries dangers.

Luckily, hundreds of studies have examined the purported benefits of various alternative-medicine treatments. In "Trick or Treatment," Simon Singh and Dr. Edzard Ernst report on the results. Ginseng has been proposed as a cure-all for everything from cancer to common colds, but there's no evidence that it does any good. Shiatsu massage appears to be a "waste of effort and expense," the authors say. Many aspects of traditional Chinese medicine, like the use of the herbs aristolochia and liquorice, are potentially harmful. Aromatherapy can relieve stress, but there is not a lick of evidence that it can treat a specific illness. Chelation therapy -- a legitimate method of removing heavy metals such as lead or mercury from the body, but now pitched in alternative-medicine circles as a cure for heart disease and other ailments -- is "disproven, expensive, and dangerous," according to Mr. Singh and Dr. Ernst. They urge patients "not to use this treatment."

Some alternative remedies, it should be said, do appear to have value. There is evidence that St. John's Wort can help mild depression, although probably not as well as conventional antidepressants. Echinacea may be able to help relieve symptoms of the common cold, and perhaps reduce the length of illness, but so can many better understood conventional remedies that are sold over the counter. "It seems bizarre," the authors note, in light of the disappointing results, "that alternative treatments are touted as though they offer marvelous benefits."

Dr. Ernst is not a dispassionate observer. He is a pioneer in the field of complementary medicine -- a branch of the medical profession whose practitioners prescribe selective alternative treatments. But he is also a scourge of too-large claims made for his field. Based at the University of Exeter in England, he leads a research group that has spent 15 years studying alternative remedies, trying to separate snake oil from science. Mr. Singh, his co-author, is a science journalist whose books include "Fermat's Enigma" and "Big Bang." Together they conclude, after cataloging the evidence, that most of the popular forms of alternative medicine are "a throwback to the dark ages." Too many alternative practitioners, they say, are "uninterested in determining the safety and efficacy of their interventions."

And safety is a real concern. "Chiropractors who manipulate the neck can cause a stroke . . . some herbs can cause adverse reactions or can interfere with conventional drugs." The authors are particularly hard on homeopathy, the practice of using ultradilute solutions of common substances. The solutions are so dilute, though, that they are often little more than water. "Homeopathic remedies, which of course contain no active ingredient, can be dangerous if they delay or replace a more orthodox treatment," Mr. Singh and Dr. Ernst write, calling homeopathy "the worst therapy encountered so far -- it is an implausible therapy that has failed to prove itself after two centuries and some 200 clinical studies."

"Trick or Treatment" includes a brisk history of our evidence-based approach to medicine, tracing the development of the modern clinical trial from its earliest days, when scurvy was shown to be caused by insufficient vitamin C and bleeding was debunked as a medical cure. Unfortunately, the evidence of clinical trials is largely ignored when it comes to alternative medicine.

So the treatments persist: Americans spend an astonishing $3 billion annually on chiropractors and about $1.5 billion on homeopathy, not to mention billions more for herbal remedies. Government is complicit: Most states mandate health-insurance coverage for chiropractic visits, and many states direct insurers to cover the cost of acupuncture -- another remedy with far fewer benefits than are commonly claimed for it.

Why is there so much blind faith? Mr. Singh and Dr. Ernst blame media hype, celebrities and even certain doctors -- complementary-medicine doctors for shading facts but also, importantly, conventional doctors whose high-handedness breeds patient frustration, opening the door to the seductions of alternative medicine.

"Alternative medicine is not so much about the treatments we discuss in this book," the authors write, "but about the therapeutic relationship. Many alternative practitioners develop an excellent relationship with their patients that helps to maximize the placebo effect of an otherwise useless treatment." To bring all treatments in line with rigorous science, an "excellent relationship" between doctor and patient is a good place to start.

Dr. Gottlieb, a resident fellow at the American Enterprise Institute, is a former official at the Food and Drug Administration and the Centers for Medicare and Medicaid Services.

[Body-by-Guinness]

Scientists Reprogram Adult Cells' Function
Advance Stirs Up Debate on Embryos
By Rob Stein
Washington Post Staff Writer
Thursday, August 28, 2008; A01

Scientists have transformed one type of fully developed adult cell directly into another inside a living animal, a startling advance that could lead to cures for a variety of illnesses and sidestep the political and ethical quagmires

associated with embryonic stem cell research.

Through a series of painstaking experiments involving mice, the Harvard biologists pinpointed three crucial molecular switches that, when flipped, completely convert a common cell in the pancreas into the more precious insulin-producing ones that diabetics need to survive.

The experiments, detailed online yesterday in the journal Nature, raise the prospect that patients suffering from not only diabetes but also heart disease, strokes and many other ailments could eventually have some of their cells reprogrammed to cure their afflictions without the need for drugs, transplants or other therapies.

"It's kind of an extreme makeover of a cell," said Douglas A. Melton, co-director of the Harvard Stem Cell Institute, who led the research. "The goal is to create cells that are missing or defective in people. It's very exciting."

The work was hailed as a welcome development even by critics of research involving embryonic stem cells, which can be coaxed to become any tissue in the body but are highly controversial because they are obtained by destroying embryos.

"I see no moral problem in this basic technique," said Richard Doerflinger of the U.S. Conference of Catholic Bishops, a leading opponent of embryonic stems cell research. "This is a 'win-win' situation for medicine and ethics."

Researchers in the field, who have become accustomed to rapid advances, said they, too, were surprised by the advance.

"I'm stunned," said Robert Lanza, chief scientific officer of Advanced Cell Technology in Worcester, Mass., a developer of stem cell therapies. "It introduces a whole new paradigm for treating disease."

Melton and other researchers cautioned that many years of research lay ahead to prove whether the development would translate into cures.

"It's an important proof of concept," said Lawrence Goldstein, a stem cell researcher at the University of California at San Diego. "But these things always look easier on the blackboard than when you have to do them in actual patients."

Although the experiment involved mice, Melton and other researchers were optimistic that the approach would work in people.

"You never know for sure -- mice aren't humans," said George Q. Daley, a stem cell researcher at Children's Hospital in Boston. "But the biology of pancreatic development is very closely related in mice and humans."

Melton has already started experimenting with human cells in the laboratory and hopes that within a year he can start planning the first studies involving people with diabetes. "I would say within five years, we could be ready to start human trials," Melton said.

Other scientists have begun trying the approach on other cells, including those that could be used to treat spinal cord injuries and neurodegenerative disorders such as Lou Gehrig's disease.

"The idea to be able to reprogram one adult neuron type into another for repair in the nervous system is very exciting," said Paola Arlotta, who is working in the Center for Regenerative Medicine at Massachusetts General Hospital-Harvard Medical School in Boston.

The research is the latest development in the explosive field of regenerative medicine, which seeks to create replacement tissues and body parts tailored to patients. That objective appeared within reach after scientists discovered stem cells. But stem cell research has been hampered by objections from President Bush and others who believe that the earliest stages of human life have moral standing.

Scientists last year shocked the field when they announced they had discovered how to manipulate the genes of adult cells to turn them back into the equivalent of embryonic cells -- entities dubbed "induced pluripotent stem" or "iPS" cells -- which could then be coaxed into any type of cell in the body.

The new work takes further advantage of the increasing ability scientists have developed in harnessing the once-mysterious inner workings of cells -- this time to skip the intermediary step of iPS cells and directly transform adult cells.

"This experiment proves you don't have to go all the way back to an embryonic state," Daley said. "You can use a related cell. That may be easier to do and more practical to do."

Doerflinger argued that the discovery was the latest evidence that research involving human embryos is no longer necessary. "This adds to the large and growing list of studies helping to make embryonic stem cells irrelevant to medical progress," Doerflinger wrote in an e-mail.

But other researchers disputed that, saying it remains unclear which approach will ultimately prove most useful.

"Embryonic stem cells offer a unique window in human disease and remain a key to the long-term progress of regenerative medicine," Melton said.

For their work, Melton and his colleagues systematically studied cells from the pancreas of adult mice, slowly winnowing the list of genes necessary to make a "beta" cell that produces insulin. After narrowing the candidate genes to nine, the researchers genetically engineered viruses known as adenoviruses to ferry the genes into other pancreatic cells, known as exocrine cells, which normally secrete enzymes to help digest food. That finally enabled the researchers to identify the three crucial genes needed take control of the rest of the cell's genes to convert an exocrine cell into a beta cell.

"It was a mixture of work, luck and guessing," Melton said. "We achieved a complete transformation, or re-purposing, of cells from one type to another. We were delighted."

When the scientists tried the approach on diabetic mice, the animals became able to control their blood sugar levels.

"It didn't cure the mouse, but they were able to reduce their blood sugar levels to near-normal," Melton said.

Melton and others said it remains to be seen whether it will be necessary to use genetically engineered viruses, which could face obstacles obtaining regulatory approval because of concerns about unforeseen risks, or whether chemicals might be found to do the same thing.

If preliminary studies in the laboratory are promising, Melton said he might first try converting liver cells to insulin-producing pancreatic cells, because that would be safer than using the pancreas. An alternative strategy would be to use the approach to grow beta cells in the laboratory and transplant them into patients.

Lanza said he is optimistic.

"One day, this may allow the doctor to replace the scalpel with a sort of genetic surgery," Lanza said. "If this can be perfected, it would represent one of the holy grails of medicine."

http://www.washingtonpost.com/wp-dyn/content/article/2008/08/27/AR2008082701829.html?hpid%3Dmoreheadlines&sub=AR

[Crafty_Dog]

WOW.

Any way to invest in this?

[Crafty_Dog]

Sorry, I lost the URL for this:

Does Fructose Make You Fatter?
High-fructose corn syrup is a sweetener used in many processed foods ranging
from sodas to baked goods. While the ingredient is cheaper and sweeter than
regular sugar, new research suggests that it can also make you fatter.

In a small study, Texas researchers showed that the body converts fructose
to body fat with "surprising speed,'' said Elizabeth Parks, associate
professor of clinical nutrition at the University of Texas Southwestern
Medical Center in Dallas. The study, which appears in The Journal of
Nutrition, shows how glucose and fructose, which are forms of sugar, are
metabolized differently.

In humans, triglycerides, which are a type of fat in the blood, are mostly
formed in the liver. Dr. Parks said the liver acts like "a traffic cop" who
coordinates how the body uses dietary sugars. When the liver encounters
glucose, it decides whether the body needs to store it, burn it for energy
or turn it into triglycerides.

But when fructose enters the body, it bypasses the process and ends up being
quickly converted to body fat.

"It's basically sneaking into the rock concert through the fence," Dr. Parks
said. "It's a less-controlled movement of fructose through these pathways
that causes it to contribute to greater triglyceride synthesis. The bottom
line of this study is that fructose very quickly gets made into fat in the
body."

For the study, six people were given three different drinks. In one test,
the breakfast drink was 100 percent glucose. In the second test, they drank
half glucose and half fructose; and in the third, they drank 25 percent
glucose and 75 percent fructose. The drinks were given at random, and
neither the study subjects nor the evaluators were aware who was drinking
what. The subjects ate a regular lunch about four hours later.

The researchers found that lipogenesis, the process by which sugars are
turned into body fat, increased significantly when the study subjects drank
the drinks with fructose. When fructose was given at breakfast, the body was
more likely to store the fats eaten at lunch.

Dr. Parks noted that the study likely underestimates the fat-building effect
of fructose because the study subjects were lean and healthy. In overweight
people, the effect may be amplified.

Although fruit contains fructose, it also contains many beneficial
nutrients, so dieters shouldn't eliminate fruit from their diets. But
limiting processed foods containing high-fructose corn syrup as well as
curbing calories is a good idea, Dr. Parks said.

"There are lots of people out there who want to demonize fructose as the
cause of the obesity epidemic," she said. "I think it may be a contributor,
but it's not the only problem. Americans are eating too many calories for
their activity level. We're overeating fat, we're overeating protein and we're
overeating all sugars."

[ccp]

Kind of funny actually.  From the new New England Journal of Medicine and very aprepo (sp?) with the times of public outrage against the corporate executive now demoted to the status below that of used car salesman:
 
 
****Executive Physicals — Bad Medicine on Three Counts

Brian Rank, M.D.
 
In corporate boardrooms throughout the United States, executives are wrestling with the management of health care costs. They are demanding health care services that are effective and evidence-based and that don't entail excess or unjust costs. They are meticulously assessing insurers and providers on all these counts as never before. And rightly so. There's some irony, then, in the fact that many of these executives leave these boardrooms for days at a time to take part in one of modern medicine's most expensive and least proven approaches to care: the executive physical.

If you want to have an executive physical (and have the money to pay for one), you won't have to look far. These services are marketed heavily by many of the country's largest and most highly regarded health systems and hospitals, including the Mayo Clinic, the Cleveland Clinic, and dozens of others. Although the specific components of these programs vary, certain traits are common. Most involve a dedicated block of time — a day or two — during which the executive undergoes an extensive and comprehensive battery of in-depth medical tests and evaluations, with results made available immediately. Most such physicals are marketed as a yearly event. Most cost thousands of dollars and are not covered by insurance. Many of the centers that provide them tout an environment of exclusivity, personal attention, and luxury of the type one might expect to see at a four-star hotel or high-end resort. Those who undergo these physicals clearly appreciate the indulgent touches, such as complimentary bathrobes and slippers or the performance of the whole process in a so-called VIP area.1

It's easy to understand the appeal of the executive physical to companies and their executives. With executive compensation high and competition for top talent fierce, it's not surprising that companies want to do everything they can to protect the investment they make in senior management. Nor is it surprising that the executives themselves, with heavy demands on their time, would be drawn to the convenience of one-stop shopping, the pampering, and the peace of mind that the executive physical seems to represent. Like a four-star hotel, the executive physical is, at least outwardly, "the best" — just what executives are accustomed to getting.

It's also easy to understand why the executive physical appeals to the hospitals and systems that offer it. The physical represents an opportunity for the provider to show off its ability to serve high-profile patients with the most advanced testing available. It also represents a new and attractive revenue stream.

Nevertheless, in my view, the emergence of executive physicals is not a good thing. It's not good for the patients who undergo them, it's not good for the companies that pay for them, and it's not good for the health care system overall. As an example of progressive medicine, the executive physical fails on three important counts: efficacy, cost, and equity.

Inherent in the provision of this service is the notion that the most health care is the best health care. If a standard physical exam entails three tests, the thinking goes, then an exam with a dozen tests must be better. Similarly, an exam that takes 2 days must be better than one that takes an hour. Of course, there is no evidence for either premise, and indeed a growing body of research suggests quite the opposite — that unnecessary testing may cause more harm than good, owing to false positive findings, unwarranted follow-up visits and costs, needless worry, and harmful side effects of the tests themselves.

Consider, for example, the inclusion in many executive physicals of a computed tomographic (CT) scan of the heart to determine the executive's calcium score. Although most patients would probably find information gleaned from this examination interesting, it is rarely meaningful as a predictor of disease. In its current summary of recommendations, the U.S. Preventive Services Task Force concludes that the potential harms of routine screening for coronary heart disease in low-risk adults exceed the potential benefits.2

Among the battery of screening tools that executive physicals include with little regard to medical evidence are whole-body CT scans, electrocardiograms, and chest radiographs. As clinicians, we should be applying increasingly rigorous standards of justification and efficacy to every test we request for our patients. Our goal should be to limit tests to those warranted by medical evidence to improve health, lengthen life, and do more good than harm. The executive physical seeks, by its very structure, to broaden testing, under the false assumption that more is better.

According to a 2006 study by Wennberg et al.,3 evidence-based medicine does not play a role in governing the use of supply-sensitive services — services whose supply has a major influence on their use. Wennberg said of the study, "Three issues drive the differences in the cost and quality of care. Variation is the result of an unmanaged supply of resources, limited evidence about what kind of care really contributes to the health and longevity of the chronically ill, and falsely optimistic assumptions about the benefits of more aggressive treatment of people who are severely ill with medical conditions that must be managed but can't be cured."

Executive physicals also reinforce a related misperception — that costlier is better, that a $3,000 examination must be worth more than one that costs 1/10 of that amount. This is an indefensible idea that should not be promoted by the health care industry. Even as individual hospitals sell these services for exorbitant fees, gratuitously overusing our health care resources, our system as a whole is appropriately straining in precisely the opposite direction, toward cost-effectiveness, transparency, competition, and accountability. With its outrageous cost and unproven efficacy, the executive physical is almost a parody of the high-cost, low-return procedures that prudent companies rightly want clinicians to eliminate for other employees.

But perhaps the most lamentable idea perpetuated by the executive physical is the implication that some patients — namely, those who have the ability to pay out of pocket or with company resources — are more worthy of effective, respectful, and personalized treatment than others. Much good work is being done these days to identify and reduce health care disparities that are based on income, race, geography, or other demographic factors. The executive physical runs exactly counter to these efforts, suggesting that a company is justified in paying thousands of dollars to maintain the health of its wealthy senior executives while relegating the masses to something less.

As efforts to reform the health care system continue, the executive physical is a perfect example of what American medicine should be working to expunge: the expensive, the ineffective, and the inequitable. Perhaps if it didn't fail on all three of these counts, allowances could be made for it as a whimsical extravagance that satisfies certain people's need for exclusivity. As it stands, however, there is little to excuse it. As an industry, we can't expect to get credit for working to make health care affordable and effective for all if we're offering the "best" health care, for a price, to a few — when it isn't.

Dr. Rank is the medical director of HealthPartners Medical Group and Clinics, Minneapolis. The HealthPartners Medical Group does not have an executive physical program.

References


Brink S. For the busy exec, a $2000 physical. Los Angeles Times. February 18, 2008:F1.
Screening for coronary heart disease. Rockville, MD: Agency for Healthcare Research and Quality, February 2004. (Accessed September 12, 2008, at http://www.ahrq.gov/clinic/uspstf/uspsacad.htm.)
Wennberg JE, Fisher ES, Sharp SM, McAndrew M, Bronner KK. The care of patients with severe chronic illness: a report on the Medicare program by the Dartmouth Atlas Project. Lebanon, NH: The Trustees of Dartmouth College, 2006. (Accessed September 12, 2008, at http://www.dartmouthatlas.org/atlases/2006_Chronic_Care_Atlas.pdf.)

 The New England Journal of Medicine is owned, published, and copyrighted © 2008 Massachusetts Medical Society. All rights reserved. *********
 

[Crafty_Dog]

Staph Germs Are Getting More Difficult to Treat, Studies Say
Associated Press
 
WASHINGTON -- Drug-resistant staph bacteria picked up in ordinary community settings are increasingly acquiring "superbug" powers and causing far more serious illnesses than they have in the past, doctors reported Monday.

These widespread germs used to be easier to treat than the dangerous forms of staph found in hospitals and nursing homes.

"Until recently we rarely thought of it as a problem among healthy people in the community," said Rachel Gorwitz of the federal Centers for Disease Control and Prevention.

Now, the germs causing outbreaks in schools, on sports teams and in other social situations are posing a growing threat. A CDC study found that at least 10% of cases involving the most common community strain were able to evade the antibiotics typically used to treat them.

"They're becoming more resistant and they're coming into the hospitals," where they swap gene components with other bacteria and grow even more dangerous, said Keith Klugman, an infectious disease expert at Emory University. "It's really a major epidemic."

The germ is methicillin-resistant Staphylococcus aureus, or MRSA. People can carry it on their skin or in their noses with no symptoms and still infect others -- the reason many hospitals isolate and test new patients to see if they harbor the bug.

MRSA mostly causes skin infections. Cleveland Browns tight end Kellen Winslow was just hospitalized for a staph infection, his second in recent years, and the team reportedly has had at least six cases in the past three years.

But the germ can be life-threatening if it gets into the bloodstream, lungs or organs. Pneumonia, sinus infections and even "flesh-eating" wounds due to MRSA are on the rise, doctors reported Monday at an infectious diseases conference in Washington.

About 95,000 serious infections and 20,000 deaths due to drug-resistant staph bacteria occur in the United States each year.

To treat them, "we've had to dust off antibiotics so old that they've lost their patent," said Robert Daum, a pediatrician at the University of Chicago.

The CDC used a network of hospitals in nine cities and states to test samples of the most common community MRSA strain, USA300, over the last few years.

MRSA usually is resistant only to penicillin-type drugs. But 10% of the 824 samples checked also could evade clindamycin, tetracycline, Bactrim or other antibiotics.

"The drugs that doctors have typically used to treat staph infections are not effective against MRSA," and family doctors increasingly are seeing a problem only hospital infection specialists once did, Dr. Gorwitz said.

Even more worrisome: many of these community strains had features allowing them to easily swap genes and become even hardier.

Also at the conference:

-Doctors from Spain reported the first hospital outbreak of MRSA resistant to linezolid, a last-resort drug sold by Pfizer Inc. as Zyvox in the U.S. and Zyvoxid in Europe. A dozen intensive care patients got pneumonia and bloodstream infections last spring and the outbreak was controlled after use of the antibiotic was severely curbed, said Dr. Miguel Sanchez of Hospital Clinico San Carlos in Madrid.

-Georgetown University saw a spike in sinus infections due to MRSA. The germ accounted for 69% of the staph-caused cases in the hospital between 2004 and 2006 compared with 30% from 2001 to 2003.

-Henry Ford Hospital in Detroit found that more than half of staph-caused pneumonia cases from 2005 through 2007 were due to MRSA.

-Doctors from Case Western Reserve University and the VA Medical Center in Cleveland found that by the time hospitals isolated and tested new patients to see if they harbored MRSA, many had already contaminated their skin and surroundings. Within about a day of being admitted, roughly a third had already started to spread the germ.

Hospital screening is controversial, and has had mixed success, said M. Lindsay Grayson, an infectious diseases expert at the University of Melbourne in Australia.

The nation's Veterans Affairs hospitals began universal MRSA testing in 2007. Illinois and some other states have adopted or are considering laws requiring hospitals to test high-risk and intensive-care patients for MRSA.

The conference is a joint meeting of the American Society for Microbiology and the Infectious Diseases Society of America.

Copyright © 2008 Associated Press\
=========================
Experts Say Staph Is Common Problem for Athletes
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By KATIE THOMAS
Published: October 24, 2008
The news in football this week often seemed ripped from the pages of a journal on infectious disease.

Skip to next paragraph
 
Tony Dejak/Associated Press
The Browns’ Kellen Winslow had his second staph infection in three years.



Analysis and discussion of the N.F.L. on the New York Times pro football blog.

Go to The Fifth Down Blog »

N.F.L.
Scoreboard
Schedules: A.F.C. | N.F.C.
Standings: A.F.C. | N.F.C.
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Injuries: A.F.C. | N.F.C.
Giants
Schedule/Results
Statistics | Roster
Depth Chart
Jets
Schedule/Results
Statistics | Roster
Depth Chart
First there was Kellen Winslow, who received a one-game suspension after accusing the Browns of concealing his staph infection. Then there was the news that Peyton Manning had developed a similar condition in his left knee earlier this year. Finally, there was Tom Brady, whose rehabilitation from knee surgery has reportedly been delayed because of an unidentified infection, also in his left knee.

Despite the outbreak of headlines, several experts in sports medicine and epidemiology said the news only served to highlight how prevalent infections — especially staph infections — are among professional athletes and in the community at large.

“It seems like most of these are single-case episodes,” said Jeff Hageman, an epidemiologist for the Centers for Disease Control and Prevention. “What we know is that staph is one of the most common causes of skin infection in the community,” he said, accounting for between 12 million to 14 million doctor visits a year.

Like athletes in other contact sports, football players are prone to staph infections because of their sport’s skin-on-skin contact, the frequency of cuts and the warm, moist conditions in locker rooms, which encourage the growth of bacteria. Because they are regulars in surgery wards, athletes are susceptible to infections there, too.

Garden-variety versions of the staphylococcus bacteria are easily treated and have lurked in locker rooms for years, but the problem has received heightened attention in recent years because of the emergence of a strain known as MRSA, or methicillin-resistant Staphylococcus aureus, which is resistant to some types of antibiotics. Serious cases of MRSA have derailed the careers of a handful of N.F.L. players, including Brandon Noble, a former defensive tackle for the Washington Redskins, and Jeff Novak, a guard for the Jacksonville Jaguars who later sued the team doctor for malpractice.

“These things are here, they’re very serious,” said Noble, who had two bouts of MRSA in 2005 and is now the defensive line coach at West Chester University in Pennsylvania. With high-profile players in the news, he said, “maybe it’ll wake some people up and get the ball rolling.”

Winslow has not said whether his staph infection — his second in three years — was MRSA, but Manning’s infection was not, according to a statement the Colts released Friday. Brady, who contracted his infection after surgery, has not categorized it.

Greg Aiello, a spokesman for the National Football League, said the teams’ trainers and doctors met annually to discuss infections and other health concerns. “It’s an issue across the country,” he said. “It’s not an N.F.L. or a football player issue.”

A 2005 survey by the N.F.L. Team Physicians Society found that of the 30 teams that responded, 13 said a player had contracted a MRSA infection in recent years, for a total of 60 infections across the league. Andrew Tucker, the president of the society and the team doctor for the Ravens, said teams had access to information about staph infections through an internal injury reporting database, but the N.F.L. declined to release the data.

Football teams increased their efforts to battle staph after 2003, when a MRSA outbreak among the Rams resulted in eight infections. The Rams invited the C.D.C. to investigate their facility, and a 2005 study revealed some nose-wrinkling results — towels were being shared by as many as three players on the field, trainers did not always wash their hands when treating wounds, and players did not take showers before entering whirlpools. Football players were also taking antimicrobial drugs at 10 times the rate of the general public.

Jim Anderson, the Rams’ head trainer, said he was surprised when MRSA even turned up on ultrasound equipment and in the cold pools. Since then, the Rams have been more diligent about disinfecting surfaces in the locker rooms and other facilities. Like other teams, they speak to players before each season about sanitary practices, imparting common-sense advice like washing one’s hands, treating open cuts, and not sharing drinks.

“The biggest thing was making them aware of it,” Anderson said. Since then, although a handful of Rams players have developed staph, none have been MRSA.

After Winslow criticized the Browns for concealing his illness from teammates — a claim the team denies and that led to his suspension, which he is appealing — several news media reports noted that the Browns have had six cases of staph infections since 2005. Bill Bonsiewicz, a Browns spokesman, said in an e-mail message that Browns players have contracted seven cases of staph since 1999, including two MRSA cases separated by a few years. “Both players were aggressively treated and each returned to the field within a few weeks,” Bonsiewicz said. He declined to name the players, citing privacy reasons.

Tucker and Hageman said the frequency of staph infections among Browns players — spread over so many years — did not appear to be out of the ordinary. “You’re talking about one or two per year,” Tucker said. “That’s not a lot.”

Noble said that although teams were making an effort to prevent MRSA, eradicating the bacteria was nearly impossible. Locker rooms, after all, are filthy places. “There’s mud, there’s blood, there’s sweat, there’s spit,” he said. “It’s just a bunch of big, gross guys in a room together.”

[Crafty_Dog]

Drug Traces Common in Tap Water
--------------------------------------------------------------------------------

Drug Traces Common in Tap Water

By THE ASSOCIATED PRESS
Published: March 10, 2008 Filed at 9:18 a.m. ET

A vast array of pharmaceuticals -- including antibiotics, anti-convulsants,
mood stabilizers and sex hormones -- have been found in the drinking water
supplies of at least 41 million Americans, an Associated Press investigation
shows.

To be sure, the concentrations of these pharmaceuticals are tiny, measured
in quantities of parts per billion or trillion, far below the levels of a
medical dose. Also, utilities insist their water is safe.

But the presence of so many prescription drugs -- and over-the-counter
medicines like acetaminophen and ibuprofen -- in so much of our drinking
water is heightening worries among scientists of long-term consequences to
human health.

In the course of a five-month inquiry, the AP discovered that drugs have
been detected in the drinking water supplies of 24 major metropolitan
areas -- from Southern California to Northern New Jersey, from Detroit to
Louisville, Ky.

Water providers rarely disclose results of pharmaceutical screenings, unless
pressed, the AP found. For example, the head of a group representing major
California suppliers said the public ''doesn't know how to interpret the
information'' and might be unduly alarmed.

How do the drugs get into the water?

People take pills. Their bodies absorb some of the medication, but the rest
of it passes through and is flushed down the toilet. The wastewater is
treated before it is discharged into reservoirs, rivers or lakes. Then, some
of the water is cleansed again at drinking water treatment plants and piped
to consumers. But most treatments do not remove all drug residue.

And while researchers do not yet understand the exact risks from decades of
persistent exposure to random combinations of low levels of pharmaceuticals,
recent studies -- which have gone virtually unnoticed by the general
public -- have found alarming effects on human cells and wildlife.

''We recognize it is a growing concern and we're taking it very seriously,''
said Benjamin H. Grumbles, assistant administrator for water at the U.S.
Environmental Protection Agency.

Members of the AP National Investigative Team reviewed hundreds of
scientific reports, analyzed federal drinking water databases, visited
environmental study sites and treatment plants and interviewed more than 230
officials, academics and scientists. They also surveyed the nation's 50
largest cities and a dozen other major water providers, as well as smaller
community water providers in all 50 states.

Here are some of the key test results obtained by the AP:

--Officials in Philadelphia said testing there discovered 56 pharmaceuticals
or byproducts in treated drinking water, including medicines for pain,
infection, high cholesterol, asthma, epilepsy, mental illness and heart
problems. Sixty-three pharmaceuticals or byproducts were found in the city's
watersheds.

--Anti-epileptic and anti-anxiety medications were detected in a portion of
the treated drinking water for 18.5 million people in Southern California.

--Researchers at the U.S. Geological Survey analyzed a Passaic Valley Water
Commission drinking water treatment plant, which serves 850,000 people in
Northern New Jersey, and found a metabolized angina medicine and the
mood-stabilizing carbamazepine in drinking water.

--A sex hormone was detected in San Francisco's drinking water.

--The drinking water for Washington, D.C., and surrounding areas tested
positive for six pharmaceuticals.

--Three medications, including an antibiotic, were found in drinking water
supplied to Tucson, Ariz.

The situation is undoubtedly worse than suggested by the positive test
results in the major population centers documented by the AP.

The federal government doesn't require any testing and hasn't set safety
limits for drugs in water. Of the 62 major water providers contacted, the
drinking water for only 28 was tested. Among the 34 that haven't: Houston,
Chicago, Miami, Baltimore, Phoenix, Boston and New York City's Department of
Environmental Protection, which delivers water to 9 million people.

Some providers screen only for one or two pharmaceuticals, leaving open the
possibility that others are present.

The AP's investigation also indicates that watersheds, the natural sources
of most of the nation's water supply, also are contaminated. Tests were
conducted in the watersheds of 35 of the 62 major providers surveyed by the
AP, and pharmaceuticals were detected in 28.

http://www.nytimes.com/aponline/us/A...pagewanted=all
===============

Cont.

Yet officials in six of those 28 metropolitan areas said they did not go on
to test their drinking water -- Fairfax, Va.; Montgomery County in Maryland;
Omaha, Neb.; Oklahoma City; Santa Clara, Calif., and New York City.

The New York state health department and the USGS tested the source of the
city's water, upstate. They found trace concentrations of heart medicine,
infection fighters, estrogen, anti-convulsants, a mood stabilizer and a
tranquilizer.

City water officials declined repeated requests for an interview. In a
statement, they insisted that ''New York City's drinking water continues to
meet all federal and state regulations regarding drinking water quality in
the watershed and the distribution system'' -- regulations that do not
address trace pharmaceuticals.

In several cases, officials at municipal or regional water providers told
the AP that pharmaceuticals had not been detected, but the AP obtained the
results of tests conducted by independent researchers that showed otherwise.
For example, water department officials in New Orleans said their water had
not been tested for pharmaceuticals, but a Tulane University researcher and
his students have published a study that found the pain reliever naproxen,
the sex hormone estrone and the anti-cholesterol drug byproduct clofibric
acid in treated drinking water.

Of the 28 major metropolitan areas where tests were performed on drinking
water supplies, only Albuquerque; Austin, Texas; and Virginia Beach, Va.;
said tests were negative. The drinking water in Dallas has been tested, but
officials are awaiting results. Arlington, Texas, acknowledged that traces
of a pharmaceutical were detected in its drinking water but cited post-9/11
security concerns in refusing to identify the drug.

The AP also contacted 52 small water providers -- one in each state, and two
each in Missouri and Texas -- that serve communities with populations around
25,000. All but one said their drinking water had not been screened for
pharmaceuticals; officials in Emporia, Kan., refused to answer AP's
questions, also citing post-9/11 issues.

Rural consumers who draw water from their own wells aren't in the clear
either, experts say.

The Stroud Water Research Center, in Avondale, Pa., has measured water
samples from New York City's upstate watershed for caffeine, a common
contaminant that scientists often look for as a possible signal for the
presence of other pharmaceuticals. Though more caffeine was detected at
suburban sites, researcher Anthony Aufdenkampe was struck by the relatively
high levels even in less populated areas.

He suspects it escapes from failed septic tanks, maybe with other drugs.
''Septic systems are essentially small treatment plants that are essentially
unmanaged and therefore tend to fail,'' Aufdenkampe said.

Even users of bottled water and home filtration systems don't necessarily
avoid exposure. Bottlers, some of which simply repackage tap water, do not
typically treat or test for pharmaceuticals, according to the industry's
main trade group. The same goes for the makers of home filtration systems.

Contamination is not confined to the United States. More than 100 different
pharmaceuticals have been detected in lakes, rivers, reservoirs and streams
throughout the world. Studies have detected pharmaceuticals in waters
throughout Asia, Australia, Canada and Europe -- even in Swiss lakes and the
North Sea.

For example, in Canada, a study of 20 Ontario drinking water treatment
plants by a national research institute found nine different drugs in water
samples. Japanese health officials in December called for human health
impact studies after detecting prescription drugs in drinking water at seven
different sites.

In the United States, the problem isn't confined to surface waters.
Pharmaceuticals also permeate aquifers deep underground, source of 40
percent of the nation's water supply. Federal scientists who drew water in
24 states from aquifers near contaminant sources such as landfills and
animal feed lots found minuscule levels of hormones, antibiotics and other
drugs.

Perhaps it's because Americans have been taking drugs -- and flushing them
unmetabolized or unused -- in growing amounts. Over the past five years, the
number of U.S. prescriptions rose 12 percent to a record 3.7 billion, while
nonprescription drug purchases held steady around 3.3 billion, according to
IMS Health and The Nielsen Co.
=========
Cont.

''People think that if they take a medication, their body absorbs it and it
disappears, but of course that's not the case,'' said EPA scientist
Christian Daughton, one of the first to draw attention to the issue of
pharmaceuticals in water in the United States.

Some drugs, including widely used cholesterol fighters, tranquilizers and
anti-epileptic medications, resist modern drinking water and wastewater
treatment processes. Plus, the EPA says there are no sewage treatment
systems specifically engineered to remove pharmaceuticals.

One technology, reverse osmosis, removes virtually all pharmaceutical
contaminants but is very expensive for large-scale use and leaves several
gallons of polluted water for every one that is made drinkable.

Another issue: There's evidence that adding chlorine, a common process in
conventional drinking water treatment plants, makes some pharmaceuticals
more toxic.

Human waste isn't the only source of contamination. Cattle, for example, are
given ear implants that provide a slow release of trenbolone, an anabolic
steroid used by some bodybuilders, which causes cattle to bulk up. But not
all the trenbolone circulating in a steer is metabolized. A German study
showed 10 percent of the steroid passed right through the animals.

Water sampled downstream of a Nebraska feedlot had steroid levels four times
as high as the water taken upstream. Male fathead minnows living in that
downstream area had low testosterone levels and small heads.

Other veterinary drugs also play a role. Pets are now treated for arthritis,
cancer, heart disease, diabetes, allergies, dementia, and even obesity -- 
sometimes with the same drugs as humans. The inflation-adjusted value of
veterinary drugs rose by 8 percent, to $5.2 billion, over the past five
years, according to an analysis of data from the Animal Health Institute.

Ask the pharmaceutical industry whether the contamination of water supplies
is a problem, and officials will tell you no. ''Based on what we now know, I
would say we find there's little or no risk from pharmaceuticals in the
environment to human health,'' said microbiologist Thomas White, a
consultant for the Pharmaceutical Research and Manufacturers of America.

But at a conference last summer, Mary Buzby -- director of environmental
technology for drug maker Merck & Co. Inc. -- said: ''There's no doubt about
it, pharmaceuticals are being detected in the environment and there is
genuine concern that these compounds, in the small concentrations that
they're at, could be causing impacts to human health or to aquatic
organisms.''

Recent laboratory research has found that small amounts of medication have
affected human embryonic kidney cells, human blood cells and human breast
cancer cells. The cancer cells proliferated too quickly; the kidney cells
grew too slowly; and the blood cells showed biological activity associated
with inflammation.

Also, pharmaceuticals in waterways are damaging wildlife across the nation
and around the globe, research shows. Notably, male fish are being
feminized, creating egg yolk proteins, a process usually restricted to
females. Pharmaceuticals also are affecting sentinel species at the
foundation of the pyramid of life -- such as earth worms in the wild and
zooplankton in the laboratory, studies show.

Some scientists stress that the research is extremely limited, and there are
too many unknowns. They say, though, that the documented health problems in
wildlife are disconcerting.

''It brings a question to people's minds that if the fish were affected ...
might there be a potential problem for humans?'' EPA research biologist
Vickie Wilson told the AP. ''It could be that the fish are just exquisitely
sensitive because of their physiology or something. We haven't gotten far
enough along.''

With limited research funds, said Shane Snyder, research and development
project manager at the Southern Nevada Water Authority, a greater emphasis
should be put on studying the effects of drugs in water.
==============
Cont.

''I think it's a shame that so much money is going into monitoring to figure
out if these things are out there, and so little is being spent on human
health,'' said Snyder. ''They need to just accept that these things are
everywhere -- every chemical and pharmaceutical could be there. It's time
for the EPA to step up to the plate and make a statement about the need to
study effects, both human and environmental.''

To the degree that the EPA is focused on the issue, it appears to be looking
at detection. Grumbles acknowledged that just late last year the agency
developed three new methods to ''detect and quantify pharmaceuticals'' in
wastewater. ''We realize that we have a limited amount of data on the
concentrations,'' he said. ''We're going to be able to learn a lot more.''

While Grumbles said the EPA had analyzed 287 pharmaceuticals for possible
inclusion on a draft list of candidates for regulation under the Safe
Drinking Water Act, he said only one, nitroglycerin, was on the list.
Nitroglycerin can be used as a drug for heart problems, but the key reason
it's being considered is its widespread use in making explosives.

So much is unknown. Many independent scientists are skeptical that trace
concentrations will ultimately prove to be harmful to humans. Confidence
about human safety is based largely on studies that poison lab animals with
much higher amounts.

There's growing concern in the scientific community, meanwhile, that certain
drugs -- or combinations of drugs -- may harm humans over decades because
water, unlike most specific foods, is consumed in sizable amounts every day.

Our bodies may shrug off a relatively big one-time dose, yet suffer from a
smaller amount delivered continuously over a half century, perhaps subtly
stirring allergies or nerve damage. Pregnant women, the elderly and the very
ill might be more sensitive.

Many concerns about chronic low-level exposure focus on certain drug
classes: chemotherapy that can act as a powerful poison; hormones that can
hamper reproduction or development; medicines for depression and epilepsy
that can damage the brain or change behavior; antibiotics that can allow
human germs to mutate into more dangerous forms; pain relievers and
blood-pressure diuretics.

For several decades, federal environmental officials and nonprofit watchdog
environmental groups have focused on regulated contaminants -- pesticides,
lead, PCBs -- which are present in higher concentrations and clearly pose a
health risk.

However, some experts say medications may pose a unique danger because,
unlike most pollutants, they were crafted to act on the human body.

''These are chemicals that are designed to have very specific effects at
very low concentrations. That's what pharmaceuticals do. So when they get
out to the environment, it should not be a shock to people that they have
effects,'' says zoologist John Sumpter at Brunel University in London, who
has studied trace hormones, heart medicine and other drugs.

And while drugs are tested to be safe for humans, the timeframe is usually
over a matter of months, not a lifetime. Pharmaceuticals also can produce
side effects and interact with other drugs at normal medical doses. That's
why -- aside from therapeutic doses of fluoride injected into potable water
supplies -- pharmaceuticals are prescribed to people who need them, not
delivered to everyone in their drinking water.

''We know we are being exposed to other people's drugs through our drinking
water, and that can't be good,'' says Dr. David Carpenter, who directs the
Institute for Health and the Environment of the State University of New York
at Albany.

http://www.nytimes.com/aponline/us/A...pagewanted=all

[Crafty_Dog]

A Food and Drug Administration advisory panel this week will consider three proposed antibiotics designed to treat serious skin infections, including some caused by a type of staph bacterium resistant to many antibiotics.

The bacterium -- methicillin-resistant staph aureus, or MRSA -- has sparked concern as the super bug has moved into community settings like schools and locker rooms in recent years after once being largely confined to hospital settings. But it's not clear if any of the three drugs will reach the bar for FDA approval because of safety concerns or questions about how well the drugs work compared with other available medications.

On Wednesday the panel is expected to vote on Theravance Inc.'s telavancin and Targanta Therapeutics Corp.'s oritavancin before considering iclaprim by Swiss biotech company Arpida Ltd. Thursday.

The FDA posted a review Monday of telavancin and oritavancin ahead of the meeting. Iclaprim's review is expected Tuesday.

Telavancin has already faced trouble gaining FDA approval. Last year, the agency refused to approve the drug and asked for additional clinical data. Earlier this year, the agency canceled an advisory panel meeting for telavancin after it had discovered violations of good clinical practice at some study sites involved in telavancin's clinical trials.

On Monday, the FDA said that, after tossing data from five sites out of about 200 study sites, the rest of the study information used to evaluate telavancin was "reliable," thereby allowing the agency to consider it as part of the drug application submitted by Theravance.

Overall, the agency said both telavancin and oritavancin met study goals of being at least as good as a vancomycin -- an older, generic antibiotic -- at treating skin infections.

However, the FDA said it was concerned about an "imbalance" in the number of serious adverse events that involved the kidneys, with more patients receiving Theravance's telavancin having some problems when compared with those receiving vancomycin.

The agency also said it would ask the FDA panel for advice about whether a risk-management program would be needed to keep pregnant women from receiving the drug because of concerns about the drug's effect on a developing fetus, based on results from animal studies. The agency also noted that 18 patients receiving telavancin or vancomycin died during studies and said some deaths in both groups were possibly drug-related.

Theravance said in a statement that "the safety profile of telavancin in these studies was compatible with treatment of patients with serious infections."

In a review of Targanta's oritavancin, the FDA looked at the impact of the drug on 11 types of bacteria -- including MRSA -- compared with vancomycin's effects. The agency said one of the studies showed that a lower percentage of oritavancin patients were considered a treatment success for MRSA, and it will ask the panel to comment on that finding.

Targanta, in briefing documents posted on FDA's Web site, said oritavancin was "safe and well-tolerated."

Write to Jennifer Corbett Dooren at jennifer.corbett-dooren@dowjones.com

[Crafty_Dog]

New Products Bring Side Effect: Nanophobia

By NATASHA SINGER
Published: December 3, 2008
IT sounds like a plot straight out of a science-fiction novel by Michael Crichton. Toiletry companies formulate new cutting-edge creams and lotions that contain tiny components designed to work more effectively. But those minuscule building blocks have an unexpected drawback: the ability to penetrate the skin, swarm through the body and overwhelm organs like the liver.


Humans have long lived in dread of such nightmare scenarios in which swarms of creatures attack. Alfred Hitchcock envisioned menacing flocks in “The Birds.” In the 1990 film “Arachnophobia” a killer spider arrives in the United States, where it attacks and multiplies.

And now comes nanophobia, the fear that tiny components engineered on the nanoscale — that is, 100 nanometers or less — could run amok inside the body. A human hair, for example, is 50,000 to 100,000 nanometers in diameter. A nanoparticle of titanium dioxide in a sunscreen could be as small as 15 nanometers. (One nanometer equals a billionth of a meter.)

“The smaller a particle, the further it can travel through tissue, along airways or in blood vessels,” said Dr. Adnan Nasir, a clinical assistant professor of dermatology at the University of North Carolina at Chapel Hill. “Especially if the nanoparticles are indestructible and accumulate and are not metabolized, if you accumulate them in the organs, the organs could fail.”

Indeed, some doctors, scientists and consumer advocates are concerned that many industries are adopting nanotechnology ahead of studies that would establish whether regular ingestion, inhalation or dermal penetration of these particles constitute a health or environmental hazard. Personal care products are simply the lowest hanging fruit.

But people are already exposed to nanoparticles. Stoves and toaster ovens emit ultrafine particles of 2 to 30 nanometers, according to the National Institute of Standards and Technology; the researchers reported last month that long-term contact with such appliances could constitute a large exposure to the smallest of nanoparticles.

Several products already use nano-engineered materials. There are “nano pants,” stain-resistant chinos and jeans whose fabric contain nano-sized whiskers that repel oil and dirt, and nanocycles made from carbon nanotubes that are stronger and lighter than standard steel bicycles. And in lotions and creams, the use of nanocomponents may create a more cosmetically elegant effect — like uniformity or spreadability.

Some ingredients may behave differently as nanoparticles than they do in larger forms. Nano-sized silver, for example, can act as an antibacterial agent on the skin. Larger particles of zinc oxide and titanium dioxide result in white pasty sunscreens; but as nanoparticles, they appear more transparent.

When it comes to beauty products, however, some consumer advocates are concerned that dynamic nanoparticles could pose risks to the skin or, if they penetrate the skin, to other parts of the body. Mineral sunscreens have attracted the most attention.

“Substances that are perfectly benign could be toxic at the nano scale,” said Michael Hansen, a senior scientist at Consumers Union, the company behind Consumer Reports. “Because they are so small, they could go places in the body that could not be done before.”

This month, the magazine published a study it had commissioned that found mineral nanoparticles in five sunscreens, even though four of the companies had denied using them. In October, Dr. Hansen sent a letter to the Food and Drug Administration commissioner, asking the agency to require cosmetics and sunscreen manufacturers to run safety tests on nano scale ingredients. In the letter, he cited a few studies published in scientific journals that reported that exposure to nanoparticles of titanium dioxide caused damage to the organs of laboratory animals and human cell cultures.

But cosmetics industry representatives said there was no evidence that personal care products that contain nano-size components constitute a health hazard. Furthermore, no rigorous clinical trials have been published showing that cosmetics with nanocomponents caused health problems. A review of the potential risks of nanomaterials, carried out for the European Center for Toxicology in 2006, concluded that sunscreens with metal nanoparticles were unlikely to penetrate healthy skin, but it did raise the question of whether safety studies should examine if such materials may penetrate damaged skin.

“It’s very difficult to get anything through the skin,” said John Bailey, the executive vice president for science of the Personal Care Products Council, an industry trade group in Washington. “The skin is a very effective barrier.”

Indeed, some nanotechnology researchers said it was illogical to assume that a nano-size component inherently carries greater risk than a larger component. Furthermore, some say cosmetics may contain molecules like a silicone fluid called cyclopentasiloxane that are even smaller than nanomaterials.


===================
New Products Bring Side Effect: Nanophobia
(Page 2 of 2)



“I think it’s a double standard because nanoparticles are less likely to go through the skin than solutions where you are using single molecules,” said Robert S. Langer, a chemical engineering professor at the Massachusetts Institute of Technology in Cambridge. He is developing nanoparticles for the targeted delivery of cancer medications, and is a founder of Living Proof, a cosmetics company that makes hair products. “The molecules in a cream are certainly going to be smaller than a nanoparticle.”

The Food and Drug Administration does not require manufacturers to list the format of ingredients on labels. The agency does require cosmetics manufacturers to ensure that their products are safe for use; in 2006, the agency created its own task force to investigate the safety of engineered nanomaterials.

Ken Marenus, the senior vice president of regulatory affairs worldwide at the Estée Lauder companies, said nanomaterials had to undergo the same kind of assessment for exposure, risk and dosage levels as any other cosmetic component. “The same toxicological standards for every chemical will apply to nano,” he said.

Dr. Bailey of the Personal Care Products Council estimated that several thousand sunscreens and cosmetics currently use some kind of nanoscale component.

Cor soap, for example, uses 50-nanometer particles of silver combined with silica that are smaller than the size of a skin pore. The material is designed to enter the pores and kill bacteria.

“The silver suffocates the bacteria and then you rinse it off with water,” said Jennifer McKinley, the chief executive of Cor. Although a study has shown that nanosilver can permeate broken skin, Ms. McKinley said the soap was safe because it contains only a limited amount of nanosilver and the particles do not remain on the skin.

Indeed, using nanoderivatives of precious metals is becoming a trend. Last year, Chantecaille introduced Nano Gold Energizing Cream, a $420 face cream that contains 5-nanometer particles of 24-carat gold encapsulated in silk fibers. Sylvie Chantecaille, the chief executive of the company, said the capsules delivered the gold particles, which work as an antioxidant, into the surface layers of the skin. “It’s a very effective way to transport beneficial ingredients,” she said.

But many beauty companies are shying away from discussing minuscule particles in their cosmetics. And that kind of avoidance may itself stoke nanophobia. For example, when La Prairie introduced its Cellular Cream Platinum Rare earlier this year, the company sent out press materials promoting “nano-sized Hesperidin Smart Crystals to protect DNA” in the formula. But, in a phone interview, Sven Gohla, the company’s vice president for research and development, distanced the brand from nanotechnology. Just because the particles of hesperidin, a flavonoid, in the formula are small does not mean they are manufactured nanotechnology, he said.

Last month, a consumer group in London called Which? published a survey it had conducted of 67 cosmetics companies on the prevalence and safety testing of nanomaterials in personal care products. Only 17 companies responded, of which eight acknowledged using nanomaterials.

“When nanotechnology was hot, everybody wanted to talk about ‘nano this, nano that.’ Look at the iPod nano,” said Dr. Hansen of Consumers Union. “But now that the concerns have come out, people are not so sure the word nano is a good thing to be touted.”

[Crafty_Dog]

A Coat of Many Proteins May Be This Parasite’s Downfall
NYT
By NICHOLAS WADE
Published: December 15, 2008

If you return from a trip abroad to find you have projectile vomiting, roaring flatulence, sulfurous belching and explosive diarrhea, the bad news is that you won’t die; you just have an attack of giardiasis, a form of purgatory devised by the single-celled parasite known as giardia.

SHIFTY When giardia must wear all its 190 coat proteins at once instead of selecting one and changing it often, it cannot hide from the immune system.

Giardia infections can linger for months because the parasite plays a cunning defense against the body’s immune system. In its genomic wardrobe, it has 190 coats to choose from. As soon as the immune system has generated antibodies against one coat, giardia switches to another. Because of the parasite’s persistence and infectivity, some 280 million cases of giardiasis occur in the world each year, the World Health Organization estimates, though most of these are in developing countries where people are more inured to the disease.

Giardia’s offensive game could have a fatal weakness, however. Biologists led by Hugo D. Luján at the Catholic University of Córdoba in Argentina have gained a striking insight into its coat-shuffling stratagem.

With this knowledge, they have accomplished a cunning counterploy: they have forced the parasite to make and wear all its coat proteins at the same time. This altered parasite, they hope, should serve as the perfect vaccine, because it immunizes the body to the full repertoire of giardia’s coat proteins all at once. The idea has worked well in animal tests, Dr. Luján said.

He thinks the same general approach — forcing expression of all coat proteins simultaneously — might help produce vaccines against the other protozoan parasites that rely on coat switching to dodge the immune system. These include malaria and the trypanosomes that cause sleeping sickness and Leishmaniasis.

Dr. Luján and his team have identified the mechanism by which giardia controls its coat proteins, they report in the current issue of Nature. Each of the parasite’s 190 coat genes is the recipe for making a different protein, and the parasite switches its coat every 10 generations or so. To produce the coat, giardia does not switch these genes on one at a time, as might be expected. Instead, it seems to leave them all turned on, allowing each to generate a messenger RNA copy of itself. Usually the messenger RNAs would direct the synthesis of proteins, but giardia then destroys all but one of the messengers, and the survivor makes the coat of the day.

To kill its messenger RNAs, giardia has adapted an ancient cellular system known as RNA interference. The system is designed to destroy foreign RNA, like that of invading viruses, so it was surprising to find it regulating a cell’s own RNAs, Dr. Luján said.

He proved this was the case by disrupting giardia’s production of enzymes, like those known as Dicer and Argonaute, that are components of the RNA interference system. With its RNA selection system out of business, giardia produces many — Dr. Luján believes probably all — of the coat proteins in its repertoire and inserts them into its outer covering.

He said he did not yet know how the organism shifted between coats but suspected that the RNA interference system favored whichever messenger RNA happened to be the most abundant at the time, and destroyed all others.

In an experiment that has not yet been published, Dr. Luján has tested gerbils, the laboratory animal often used in giardia work, with a vaccine consisting just of giardia with its RNA interference system blocked. “We saw complete protection,” he said.

Dr. Theodore E. Nash, a leading expert on giardia at the National Institutes of Health, said the new report was “a major advance in the field.” Since 1979, Dr. Nash has developed many of the methods to study giardia and its coat shuffling, several of which were used by Dr. Luján, who worked for five years in Dr. Nash’s lab.

Another giardia expert, Dr. Rodney Adam of the University of Arizona, said Dr. Luján’s work on giardia’s coat gene control was interesting “but not the whole story.” As for making a vaccine, he said that “this is not an organism to which natural infection will confer immunity.” People in developing countries may get one infection after another, although they do get a much less severe form of the disease.

Malaria also evades the immune system by switching its protein coat. Dr. Kirk Deitsch, an expert on malaria coat genes at the Weill Cornell Medical College, said Dr. Luján’s new finding “may be conceptually applicable to malaria,” although the malaria parasite does not use RNA interference and no one yet knows how to make it display all its 60 coat protein genes at once.

A human vaccine for giardia could be of great benefit if the many mild cases in the developing world do in fact undermine health. Some experts believe persistent giardia infection causes malnutrition, but others are less sure of this.

For the much smaller number of Westerners who are not inured to the disease, a vaccine would be a welcome addition to the few available drugs. It would have been a godsend for the Crusaders, who are known from historical accounts to have suffered terribly from a variety of intestinal diseases that had no respect for rank. In 1249 King Louis IX, who led the Seventh Crusade, had such serious diarrhea that part of the monarch’s breeches were cut away to ease his personal hygiene. Giardia may well have been his tormentor. Using a sensitive immunological test, researchers who excavated a medieval latrine in the city of Acre, once part of the Crusader kingdom of Jerusalem, detected the presence of giardia, they reported in the July issue of The Journal of Archaeological Science.

Giardia itself is far more ancient than any Crusader kingdom. Though a single-celled organism, it belongs to the eukaryotes, the domain that includes all plants and animals. In the tree of eukaryotic life, giardia belongs to one of the earliest branches. It lacks mitochondria, the energy-producing organelles that are almost a badge of eukaryote identity. Even stranger, each giardia cell possesses two nuclei; no one knows what benefit offsets the cost of maintaining the second. Before this enigmatic microbe plagued people, it was doubtless the scourge of many earlier species. Dr. Luján’s discovery may be a critical step in curbing giardia’s merciless torment of its fellow eukaryotes.

[Body-by-Guinness]

Predicting pandemics: HealthMap.org tracks emerging hot spots in real time
December 24th, 2008 in Medicine & Health / Diseases

Enlarge

Disease outbreaks appear on the HealthMap as yellow push-pins. When the user clicks on a particular push-pin, a window opens with links to information about a disease outbreak report.
(PhysOrg.com) -- At the end of July 2008, major news agencies reported an outbreak of jalapeño-related salmonella that sickened more than 1,000 people in Mexico and the United States. It was the biggest outbreak of its kind in decades.
Two months earlier, HealthMap.org had flagged the uptick in gastrointestinal illness, which signaled the emergence of a novel strain of salmonella. HealthMap had culled the information from a story that appeared in a local newspaper in New Mexico. HealthMap’s warning was a little yellow balloon that popped onto the site’s map, linking it to the news story. The Centers for Disease Control and Prevention (CDC) had yet to make an announcement.
HealthMap.org was launched in 2006 by epidemiologist John Brownstein, a Harvard Medical School assistant professor of pediatrics based in the Informatics Program at Children’s Hospital Boston, and software developer Clark Freifeld of the Informatics Program. Today it combs 24,000 Web sites per hour, tracking and mapping 75 infectious diseases, including malaria, cholera, plague, Ebola, avian flu, and the ominous-sounding “not yet classified.” Receiving about 30,000 hits a month, HealthMap’s most frequent visitors are the World Health Organization and the CDC, who check the site daily.
A visit to the site reveals red and yellow warnings popping up across the continents. “If you look at the map, you see that no place is protected from diseases,” said Brownstein. “Infectious disease is a major problem in the developing world, but the emergence of diseases is a huge public health threat everywhere, especially with the impact of being able to travel to any point in the world in a day. Diseases don’t respect borders.”
Brownstein and Freifeld started HealthMap as an unfunded side project. Frustrated by privacy issues regarding the use of clinical data, Brownstein approached Freifeld to see how they could tap into publicly accessible information to paint a real-time picture of outbreaks of contagious disease.
“We were thinking about all the information that exists on the Web in an unorganized sense,” said Brownstein. “Information is distributed across different types of data sources and different types of Web sites, and we thought, what if we tried to organize that information and make it freely available on a simple interface like a map?”
Freifeld built a Web-crawler that seeks key words about diseases, symptoms, and locations from local newspapers, news feeds, and blogs. One of the biggest tasks was creating a dictionary of diseases, names, and locations.
“The dictionaries needed constant refining,” said Freifeld. “For example, Crimean-Congo hemorrhagic fever is a tick-borne disease. Initially, when the program picked up any references to the disease, it put the alert in the Congo. To avoid this problem, we created a string of words to label the disease, so the program would not confuse the disease with the location.”
The site merges this data with clinical reports created by content partner ProMED-mail. ProMED members all over the world generate and upload public health information. By blending clinical data from the frontlines with automatically generated information, the site achieves Brownstein’s goals of timeliness and accuracy. The map interface displays emerging patterns geographically, giving visitors greater insight into where epidemics are most likely to spread.
With so much information being processed so rapidly, there are bound to be a few quirks. “A horse named Antarctica had equine herpes,” said Brownstein, “which led the program to detect an outbreak of herpes in Antarctica, which of course was wrong.”
Soon after the site launched, it generated attention when an article titled “Get Your Daily Plague Forecast” appeared in Wired Magazine (Oct. 19, 2006). Brownstein and Freifeld landed a grant from Google.org and obtained funding from the CDC to expand the site. They added new diseases and more news sources and increased the number of searched languages, a feature that was necessary to create a global tool. Today, the program searches for information in English, French, Spanish, Chinese, and Russian. Portuguese and Arabic will be added in the next few months, followed by Khmer, Malay, and Thai.
The CDC is one of the site’s biggest users. The agency incorporates information from HealthMap into the daily reports they distribute to public health leaders all over the world. Jean O’Connor, policy officer for the Office of Critical Information Integration and Exchange at the CDC, is enthusiastic about HealthMap’s potential to aid public health officials in prevention efforts. “HealthMap was really the first Web site to take informal public health information and anecdotal reports and make it possible for a public health leader to look at all of those pieces of information globally,” said O’Connor. O’Connor also noted that the site’s display of disease outbreaks among domesticated animals and wildlife can help pinpoint potential threats, since many diseases spread from animals to people.
The New England Journal of Medicine started using the site recently. "We just added HealthMap to the tools we use for gathering health-related news from around the world," said Stephen Morrissey, managing editor of the New England Journal of Medicine. "The geographic interface is extremely useful, and we look forward to seeing whether this approach will alert us earlier to important events that should be brought to the attention of physicians and health policy experts."
Brownstein and Freifeld are off to Geneva this month to consult with the World Health Organization on another project, and hope to gain insight into how that organization is using HealthMap while they’re there.
Brownstein’s passion for public health was ignited during a semester spent in Africa as an undergraduate in 1998. “I went to Kenya and Uganda, where I spent a lot of time in the field studying wildlife,” said Brownstein. “I began to realize the incredible impact infectious diseases have on human populations, things like malaria and HIV, the linkage between infectious diseases and the environment, and how human encroachment into wildlife areas led to the emergence of infectious diseases. Almost every infectious disease you can look at, at one point came out of an animal population.”
Today, with a second Google grant, Brownstein envisions the site moving beyond its role as an information provider to becoming an engaged, online community. “Everyone is talking about social networks like Facebook. HealthMap will be a social network of disease experts engaged in the global public health good,” said Brownstein. “The real vision is that we are going to be much more integrated with our user base. We will be relying on people reporting, commenting, and verifying outbreaks that are happening. They will really be interacting with the data, collaborating with the data, and making use of it.”
On the Web: http://www.healthmap.org/en
Provided by Harvard University

[ccp]

World's oldest woman dies in Portugal aged 115
 
I keep telling my elderly we are going for the record of 122 and take back the title for world's oldest person (a woman) from the French (oldest man was Japanese).   But...

None of my patients want to live that long.   


***LISBON, Portugal (AP) - A woman who lived to see five of her great-great grandchildren born and was believed to have been the world's oldest person living, has died in northwest Portugal at the age of 115, officials said Friday.
Maria de Jesus, who was born September 10, 1893 and was listed by the Guinness Book of World Records and the Gerontology Research Group as the world's oldest person, died in an ambulance near the town of Tomar.

De Jesus, who outlived three of her six children, had 11 grandchildren and 16 great-grandchildren, had eaten breakfast normally but was being taken to hospital because of a swelling, her daughter Maria Madalena told state news agency Lusa.

Corvelo Sousa, president of the town council of Tomar, 66 kilometers (40 miles) north of the port city of Porto, confirmed the death.

"I regret the death of this lady, she really was the sweetest person," said Tomar town councilor Ivo Santos.

De Jesus was left a widow when she was 57 and lived to reach 115 years and 114 days.***

 

[Crafty_Dog]

Personal Health
Babies Know: A Little Dirt Is Good for You
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By JANE E. BRODY
Published: January 26, 2009

Ask mothers why babies are constantly picking things up from the floor or ground and putting them in their mouths, and chances are they’ll say that it’s instinctive — that that’s how babies explore the world. But why the mouth, when sight, hearing, touch and even scent are far better at identifying things?

When my young sons were exploring the streets of Brooklyn, I couldn’t help but wonder how good crushed rock or dried dog droppings could taste when delicious mashed potatoes were routinely rejected.

Since all instinctive behaviors have an evolutionary advantage or they would not have been retained for millions of years, chances are that this one too has helped us survive as a species. And, indeed, accumulating evidence strongly suggests that eating dirt is good for you.

In studies of what is called the hygiene hypothesis, researchers are concluding that organisms like the millions of bacteria, viruses and especially worms that enter the body along with “dirt” spur the development of a healthy immune system. Several continuing studies suggest that worms may help to redirect an immune system that has gone awry and resulted in autoimmune disorders, allergies and asthma.

These studies, along with epidemiological observations, seem to explain why immune system disorders like multiple sclerosis, Type 1 diabetes, inflammatory bowel disease, asthma and allergies have risen significantly in the United States and other developed countries.

Training the Immune System

“What a child is doing when he puts things in his mouth is allowing his immune response to explore his environment,” Mary Ruebush, a microbiology and immunology instructor, wrote in her new book, “Why Dirt Is Good” (Kaplan). “Not only does this allow for ‘practice’ of immune responses, which will be necessary for protection, but it also plays a critical role in teaching the immature immune response what is best ignored.”

One leading researcher, Dr. Joel V. Weinstock, the director of gastroenterology and hepatology at Tufts Medical Center in Boston, said in an interview that the immune system at birth “is like an unprogrammed computer. It needs instruction.”

He said that public health measures like cleaning up contaminated water and food have saved the lives of countless children, but they “also eliminated exposure to many organisms that are probably good for us.”

“Children raised in an ultraclean environment,” he added, “are not being exposed to organisms that help them develop appropriate immune regulatory circuits.”

Studies he has conducted with Dr. David Elliott, a gastroenterologist and immunologist at the University of Iowa, indicate that intestinal worms, which have been all but eliminated in developed countries, are “likely to be the biggest player” in regulating the immune system to respond appropriately, Dr. Elliott said in an interview. He added that bacterial and viral infections seem to influence the immune system in the same way, but not as forcefully.

Most worms are harmless, especially in well-nourished people, Dr. Weinstock said.

“There are very few diseases that people get from worms,” he said. “Humans have adapted to the presence of most of them.”

Worms for Health

In studies in mice, Dr. Weinstock and Dr. Elliott have used worms to both prevent and reverse autoimmune disease. Dr. Elliott said that in Argentina, researchers found that patients with multiple sclerosis who were infected with the human whipworm had milder cases and fewer flare-ups of their disease over a period of four and a half years. At the University of Wisconsin, Madison, Dr. John Fleming, a neurologist, is testing whether the pig whipworm can temper the effects of multiple sclerosis.

In Gambia, the eradication of worms in some villages led to children’s having increased skin reactions to allergens, Dr. Elliott said. And pig whipworms, which reside only briefly in the human intestinal tract, have had “good effects” in treating the inflammatory bowel diseases, Crohn’s disease and ulcerative colitis, he said.

How may worms affect the immune system? Dr. Elliott explained that immune regulation is now known to be more complex than scientists thought when the hygiene hypothesis was first introduced by a British epidemiologist, David P. Strachan, in 1989. Dr. Strachan noted an association between large family size and reduced rates of asthma and allergies. Immunologists now recognize a four-point response system of helper T cells: Th 1, Th 2, Th 17 and regulatory T cells. Th 1 inhibits Th 2 and Th 17; Th 2 inhibits Th 1 and Th 17; and regulatory T cells inhibit all three, Dr. Elliott said.

“A lot of inflammatory diseases — multiple sclerosis, Crohn’s disease, ulcerative colitis and asthma — are due to the activity of Th 17,” he explained. “If you infect mice with worms, Th 17 drops dramatically, and the activity of regulatory T cells is augmented.”

In answer to the question, “Are we too clean?” Dr. Elliott said: “Dirtiness comes with a price. But cleanliness comes with a price, too. We’re not proposing a return to the germ-filled environment of the 1850s. But if we properly understand how organisms in the environment protect us, maybe we can give a vaccine or mimic their effects with some innocuous stimulus.”

Wash in Moderation

Dr. Ruebush, the “Why Dirt Is Good” author, does not suggest a return to filth, either. But she correctly points out that bacteria are everywhere: on us, in us and all around us. Most of these micro-organisms cause no problem, and many, like the ones that normally live in the digestive tract and produce life-sustaining nutrients, are essential to good health.

“The typical human probably harbors some 90 trillion microbes,” she wrote. “The very fact that you have so many microbes of so many different kinds is what keeps you healthy most of the time.”

Dr. Ruebush deplores the current fetish for the hundreds of antibacterial products that convey a false sense of security and may actually foster the development of antibiotic-resistant, disease-causing bacteria. Plain soap and water are all that are needed to become clean, she noted.

“I certainly recommend washing your hands after using the bathroom, before eating, after changing a diaper, before and after handling food,” and whenever they’re visibly soiled, she wrote. When no running water is available and cleaning hands is essential, she suggests an alcohol-based hand sanitizer.

Dr. Weinstock goes even further. “Children should be allowed to go barefoot in the dirt, play in the dirt, and not have to wash their hands when they come in to eat,” he said. He and Dr. Elliott pointed out that children who grow up on farms and are frequently exposed to worms and other organisms from farm animals are much less likely to develop allergies and autoimmune diseases.

Also helpful, he said, is to “let kids have two dogs and a cat,” which will expose them to intestinal worms that can promote a healthy immune system.

[Body-by-Guinness]

Coming health care "reforms" will likely be couched in comparative outcome schemes that pretend an empirical methodology, but which in fact fully embrace the perverse incentives government regulation already imposes on the health sector. This piece charts how this scheme has impacted other national health systems.

February 4, 2009
Comparative Effectiveness in Health Care Reform: Lessons from Abroad
by Helen Evans, Ph.D.
Backgrounder #2239
President Barack Obama has proposed the creation of an Institute for Comparative Effectiveness as a key component of an ambitious health care reform.[1] The institute would have the authority to make official determinations of the clinical effectiveness and cost-effectiveness of medical treatments, procedures, drugs, and medical devices.

President Obama's initial nominee as Secretary of Health and Human Services (HHS), former Senator Tom Daschle (D-SD), has likewise proposed the creation of a supremely powerful Federal Health Board, which would have similar authority to make decisions that would be binding on health plans and providers financed by federal taxpayers, and potentially on private health insurance coverage.[2] While Senator Daschle has withdrawn his name from Senate consideration, the concept of such a board or institute is strongly indicative of the Obama Administration's policy orientation toward centralized health policy decision-making.

The U.S. House of Representatives has just passed the $850 billion American Recovery and Reinvestment Act (H.R. 1), the so-called economic stimulus bill, which would establish a Federal Coordinating Council for Comparative Effectiveness Research. The bill would provide $1.1 billion for the new council and delegate spending authority to the HHS Secretary to investigate the effectiveness of different drugs and medical devices.[3] The Senate version of the economic stimulus package contains a similar provision.

Of course, there is no reason why private-sector or government officials should not have access to the best information on what works and what doesn't. Nor is there any reason why such scientific evaluations should not be widely available to doctors and patients alike. But studies of the comparative effectiveness of medical devices, drugs, and technology should be conducted primarily within the private sector, and there should be no government monopoly over either the research or the distribution of information. The key issue is the personal freedom of patients to be able to choose the health care that, in the professional judgment of their doctors, best serves their personal needs.

Focus on Medical Technology. Technology, in particular, can be expensive. Over the past 20 years, health technology assessment (HTA)--the synthetic coordination of information assessing medicines and treatments--has become increasingly popular with policymakers and legislators around the world. Advocates of HTA invariably believe that such an approach has the capacity to provide decision-makers in the public and private sectors with objective information on the value of medical technologies, devices, and medicines. Driven by concerned perceptions of "unproven technology," "spiralling costs" and "increasing consumer expectations," its proponents aim to produce synthesized research information that they believe sheds light on the effects and costs of various forms of health technology.

Such an approach, however, would guarantee the incremental advance of government control of private medical decisions. While formally touted as an instrument of efficiency and effectiveness, it would distort scientific research in the service of political or budgetary objectives while denying individual freedom of choice. In that sense, this approach would serve as a propaganda tool designed to legitimize anti-consumerist rationing.

Comparative Effectiveness in Health Care: How It Started

The intellectual roots of effectiveness research can be traced back to mid-18th century Scotland and the "arithmetical medicine" practiced by the graduates of the Edinburgh medical school. It was there that James Lind famously undertook a controlled trial of six separate treatments for scurvy.[4] During the 1830s, Pierre Louis developed the méthode numérique in Paris, whereby he demonstrated that phlebotomy did not actually improve the survival rates of patients suffering from pneumonia.

At the beginning of the 20th century, Ernest Codman, an American physician, founded what is today known as "outcomes management" in patient care. Shunned by established institutions, he set up his own unit, the End Result Hospital. In line with his teachingsand the findings from this unit, end results were made public in a privately published book, A Study in Hospital Efficiency.[5] Of 337 patients discharged from the hospital between 1911 and 1916, Codman recorded and publicized 123 errors.

In England, the 1930s saw the development of health services research. In a world increasingly obsessed with egalitarian uniformity, J. A. Glover found a tenfold variation in tonsillectomy.[6] Subsequently, following several decades of socialized health care in the United Kingdom, the 1970s and 1980s witnessed the release of a range of studies that highlighted wide geographical variations in general medical admissions including operations such as appendectomy, caesarean section, cholecystectomy, hysterectomy, tonsillectomy, and prostatectomy.[7] Such variations not only demonstrated the inequities of the National Health Service (NHS), but also raised questions about the probity and cost-effectiveness of many of its treatments.

Following the publication of Archie Cochrane's Effectiveness and Efficiency: Random Reflections on Health Services[8] in the United States, researchers demonstrated large variations in the rates of prostatectomy for patients with benign prostatic hyperplasia.[9] This work and others suggested that such variations "meant either under-provision in some places and/or over-provision (and possibly ineffective treatment) in others."[10] While "comparative effectiveness" builds on skepticism, the investigation of variations, randomized control trials, and cost-benefit analysis, its reviews purport to be systematic. As such, they attempt to go beyond the more narrative-based reviews that used to dominate the typical review article in medical literature.

Comparative Effectiveness: The Rationale

In recent decades, health care has advanced in significant ways. Across the developed world, not only has medical knowledge progressed, but investment in equipment and drugs has delivered unprecedented gains. Treatments are safer and more effective than ever before. Quality of life and life expectancy have been enhanced. Alongside aging populations has come the world of ever-increasing consumer expectations.

The rapid growth of medical knowledge and technology means it is much harder for doctors and other health care providers to keep up to date. Indeed, the problem of information and practice transference is rendered almost impossible by the fact that health care is now a highly statist and corporatist venture. Today, there is no such thing as a free market in health care, and many of the problems popularly associated with it are in fact the result of state failure.

Today, in virtually every country in the world, health care is heavily influenced by government policy and fosters professional monopoly of supply and strict top-down regulation.[11] While there is nothing inherent in health care that guarantees such an outcome, governments, either actively or passively, grant special legislative favor to interest groups when it comes to people's medical treatments and insurance.

The idea that government is intrinsically a superior agent, over and above a spontaneous and free market, is groundless. As David Friedman, a professor of law at Santa Clara University in California, has argued, both the notion of market failure in health economics and its popularity with most opinion leaders have arisen because many health policy analysts "interpret the problem in terms of fairness rather than efficiency."[12] This almost unconscious adherence to the notion of market failure in health care is rooted in:

the error of judging a system by the comparison between its outcome and the best outcome that can be described, rather than judging it by a comparison between its outcome and the outcome that would actually be produced by the best alternative system available. If, as seems likely, all possible sets of institutions fall short of producing perfect outcomes, then a policy of comparing observed outcomes to ideal ones will reject any existing system…. The question we should ask, and try to answer, is not what outcome would be ideal but what outcome we can expect from each of various alternative sets of institutions, and which, from that limited set of alternatives, we prefer.… My conclusion is that there is no good reason to expect government involvement in the medical market, either the extensive involvement that now exists or the still more extensive involvement that many advocated, to produce desirable results.[13]

Curiously, it is within the context of government control and anti-competitive corporatism that new and innovative medical treatments are met with initiatives for even more rationing by government officials, as well as other highly regulated players including private medical insurers. In recent years, many countries have introduced comparative effectiveness or HTA programs, ostensibly to improve their decision-making and their allocation of relatively scarce medical resources. In reality, many politicians and officials have done so not least because they are trying to get themselves off the hook of past promises they made concerning the provision of comprehensive, unlimited, or, as in the case of the United Kingdom, seemingly "free" health care at the point of service.

Since extensive government intervention has distorted health care markets and has made it impossible for individuals to determine a clear and transparent value of the costs and benefits of health care technology through a normally functioning price system, the proponents of comparative effectiveness, or health technology assessment, have instead resorted to a predictably pseudoscientific methodology to give their bureaucratic determinations a sheen of objectivity. As with other forms of centralized government planning, the practitioners of these bureaucratic arts attempt to capture and mathematically profile and model their assessments; in assessing health technology, they seek "to compare and prioritize new technologies based on different units that aggregate…benefits."[14]

In a study of HTA for the Stockholm Network, a prominent European think tank, research has focused on these assessments in terms of the value of human life:

In HTA, the dominant aggregate natural unit is called quality-adjusted life years (QALYs). Generally, QALYs factor in both the quantity and the quality of life generated by new health care interventions. It is the arithmetic calculation of life expectancy and a measure of the quality of the remaining life years…. To date QALYs are the preferred indicator of HTAs calculations, although one may find additional tools in use by HTA bodies such as HRQol ("health related quality of life," which considers physical function, social function, cognitive function, distress, pain: in brief, anything to do with quality of life), DALYs ("disability life adjusted years"--of life lost due to premature mortality in the population and the years lost due to disability for incidents of the studied health condition), and healthy-year equivalents (HYEs).[15]

Despite the pretense of scientific objectivity, this type of health technology assessment is nothing of the sort. It is designed primarily to provide policymakers with a legitimizing rubric by which they can mimic a few elements of the market and therefore deploy a degree of fake economic rationality in justifying their decisions. In this way, practitioners of HTA attempt to balance the requirement to provide innovative health care technologies with ham-fisted efforts at controlling the costs of those technologies.

Consider the quality of human life and lifespan. The use of QALYs is pseudoscience. It is nothing more than a tool for central planning that attempts to objectify what is inherently subjective. The limited attempts to capture accurately the various "units of healthcare benefit" mean that there is an inevitable gulf between the theoretical underpinnings of QALYs and the actual behavior of ordinary people. Moreover, the artificial prioritization of so-called cost-based considerations by practitioners of health technology assessment is invariably made at the expense of other considerations. As Dr. Meir Pugatch and Francesca Ficai of the Stockholm Network note, "Thus, a decision to prioritize a less therapeutically effective medicine because of cost-based considerations over an effective, but more expensive, medicine could lead to some serious political, social and moral dilemmas."[16]

Not only is this type of health technology assessment methodologically flawed: It is incompatible with personal freedom and contradicts the subjective choices of genuine economic agents. When deployed at the national level through the power of a government agency, it is inevitably subject to additional political pressures. Indeed, in 2009, it is clear that national organizations that conduct these assessments--such as the National Institute for Health and Clinical Excellence in the United Kingdom or the Institute for Quality and Efficiency in Health Care in Germany--are in the business of rationing health care technologies so that they mesh with the politically fixed budgetary allocations of the national government.

Today, it is clear that the political economy of these government bodies means that their structures, processes, and pseudoscientific constructs have a significant and detrimental impact on the practice of, and even the public discourse on, health care. Far from reflecting scientific rationality and economics, health technology assessments often reflect either politically driven social judgments of the decision-makers in these agencies or, worse, a thinly veiled attempt to accommodate whatever political pressures happen to be momentarily dominant.

[Body-by-Guinness]

How Comparative Effectiveness Works in Europe

According to the International Network of Agencies for Health Technology Assessments (INAHTA),[17] many industrialized countries have bodies that are charged with health technology assessments or comparative effectiveness studies. Despite this, the evolution of these bodies and their responsibilities at the national decision-making level has been far from uniform.

For example, some of these bodies have an advisory role. They make reimbursements or pricing recommendations to a national or regional governing body, as is the case in Denmark. Others have a more explicit regulatory role. They are accountable to government ministers and are responsible for listing and pricing medicines and devices. This is the case in France, Germany, and the United Kingdom.

The United Kingdom. The experience of the United Kingdom in making the difficult decisions about what kind of health care technologies, devices, drugs, and medical treatments and procedures should be favored in Britain's National Health Service has been cited favorably by Senator Daschle.

The NHS was established in 1948. It is a single-payer health care system, directly administered by the British government, funded through taxation, and provided mainly by public-sector institutions. Because the NHS is a fully nationalized entity, the central government specifies the capital and current budgets of its regional health authorities and determines the expenditure on drugs by controlling the budgets given to each general practitioner. Overall, NHS health care is rationed through long waiting lists and, in some cases, omission of various treatments.[18]

For the British government, the practice of HTA facilitates rationing by delay. It is a tool that aims to ensure that expensive new technologies are initially provided only in hospitals that have the technical capacity to evaluate them. While the NHS Research and Development Health Technology Assessment Programme is funded by the Department of Health and, according to its criteria, researches the costs, effectiveness, and impact of health technologies, the Medicines and Healthcare Products Regulatory Agency (MHRA) ensures that drugs and devices are safe.[19]

In 1999, the government went a step further and set up the National Institute of Health and Clinical Excellence (NICE).[20] At its heart is the Centre for Health Technology Evaluation that issues formal guidance on the use of new and existing medicines based on rigid and proscriptive "economic" and clinical formulas. With the NHS obliged to adhere to NICE's pronouncements, criticism of NICE has been ceaseless, particularly from various patient organizations.

NICE is a controversial body. It has tried repeatedly to stop breast cancer patients from receiving the powerful breakthrough drug Herceptin and patients with Alzheimer's disease from receiving the drug Aricept. The criteria by which this agency makes its decisions have been kept largely secret from the public. As is inevitable with any nationalized health care system, life-extending medicines such as those to treat renal cancers are refused on the grounds of limited resources and the need to make decisions based not on genuine market economics but on an artificial assessment of the benefit that may be gained by the patient and society "as a whole."

In 2001, NICE deliberately restricted state-insured sufferers of multiple sclerosis from receiving the innovative medicine Beta Interferon. Claiming that its relatively high price jeopardized the efficacy of the NHS, patients with the more severe forms of the disease were told that they would have to go on suffering in the name of politically defined equity.[21]

In more recent years, patients with painful and debilitating forms of rheumatoid arthritis have been informed by NICE that in many instances they will not be allowed to receive a sequential range of medicines that have often been proved to be of significant benefit. Instead, the institute decreed that "people will be prevented from trying a second anti-TNF treatment if the first does not work for their condition."[22]

Similarly, in August 2008, patients with kidney cancer continued to be denied effective treatments designed to prolong their lives, often by months or even a few years. The calculations used by NICE have been systematically disputed by clinical experts who are more concerned with patient welfare than with vote-seeking, but the institute has also come under fire for not involving doctors who are active on the front line of medicine: "With Sutent for instance, there was just one oncologist on the panel."[23]

In January 2009, patients with osteoporosis also fell foul of NICE. The institute declared that only a small minority of patients with this debilitating disease would receive the medicine Protelos, and even they would receive it only as an extreme last resort. While clinicians and osteoporosis support groups have pointed out that more than 70,000 hip fractures result in 13,000 premature deaths in the U.K. each year and that these otherwise avoidable episodes needlessly cost the NHS billions of pounds, not only are patients being denied necessary treatments, but taxpayers' money is wasted.[24]

Indeed, according to its annual reports and accounts, NICE is now spending more money on communicating its decisions than would be spent if it allowed patients access to many of the medicines it is so busy denying them. The money that the institute now spends on public relations campaigns "could have paid for 5,000 Alzheimer's sufferers to get £2.50-a-day drugs for a year," according to The Daily Mail.[25]

Devoid of a market and the language of price, this top-down system ironically ignores many of the societal costs associated with failure to treat severe illness, such as illness-related unemployment. Moreover, the fact that preventing access to more costly medicines may save money in the short term overlooks the costs for the future. If older medicines lead to more rapid deterioration of a condition, the effect could be a more expensive hospital or nursing home episode later.

Denmark. The Danish health care system is completely state-funded, with public provision of hospital beds representing more than 90 percent of thehospital sector. Under the Healthcare Act, citizens are covered for all or part of expenditures for treatment, including reimbursement for all pharmaceutical products listed with the Danish Medicines Agency. Therefore, there is no need for price regulation of drugs. With central and municipal government having significant control of the funding and provision of health care, the acquisition of new technology is left initially to the five regions that run the hospitals.

Denmark's national HTA system was explicitly established on the basis of its making prioritized resource-allocation decisions. Carried out by the unit known as the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA), it operates within the framework of the National Board of Health (NBH), itself a part of the Danish Ministry of Health.[26] In reality, this means that "[t]he Ministry keeps a close watch on it in order to neutralize 'expensive' healthcare technologies, as their adoption results in requests for extra funding from the regions."[27]

France. In France, health care is a statutory right enshrined in the Constitution of the Fifth Republic. Unlike in Denmark or the United Kingdom, however, French health care is financed mainly by social insurance and delivered by a mixture of public and private providers. While two-thirds of French hospitals are state-owned, one-third are private, with half of the latter group being not-for-profit.

There have been various attempts in recent years to extend government control of health care costs. In 1991, the French government extended its Health Map system by which it controls the capital construction of all hospitals as well as their budgets, the purchase of medical equipment, the rates charged by private hospitals, the number of pharmacies per head, and even the price of drugs.[28]

In 2005, the government went a stage further with the establishment of a centralized High Health Authority. While this body has had only a limited impact--and France continues to enjoy a comparatively higher diffusion rate for new technologies than is found in many other countries in Europe--it is nevertheless designed to stipulate the benefits of medicines and determine their price-reimbursement levels. As such, it is set to raise the focus on cost-containment and bring its decision-making under closer state control.

Germany. As in France, health care in Germany is financed primarily by social insurance and provided by a mixture of public and private providers. While all services are contracted instead of being provided directly by the government, more than 10 percent of Germans opt for full private medical insurance.[29] Providing a potent source of exit from the state, the regulated private sector puts pressure on the government to ensure that the sectoral differences in service do not become so wide that ever-larger numbers of young, high-income consumers defect by going private and delegitimizing a central pillar of the Bismarckian philosophy.

While the pressure to maintain some semblance of parity with the private sector meant that state spending rose dramatically for many years after the introduction of a formal reference pricing system in 1989, the strategic objective of the German Ministry of Health has been to reduce supply, particularly through the use ofpublished positive and negative lists concerning medicines and treatments. Through these lists, pressure is applied to the statutory sick funds to control costs.[30]

It is in this context that health technology assessment has played an ever-greater role in German health policy since the 1990s. In 1990, the Office of Technology Assessment at the German Parliament (TAB) was established, and in 2004, the government set up the Institute for Quality and Economic Efficiency in the Healthcare Sector (IQWiG).

Tasked with the central goal of efficiency, IQWiG investigates and stipulates which therapeutic and diagnostic services are appropriate.[31] Disseminating its pronouncements to various self-governing bodies, its information is used concerning the coverage of technologies in the benefits catalogue. With such ventures being funded primarily by the German Ministry for Health and Social Affairs, assessment bodies can refuse a hospital's claim for reimbursement for the unauthorized use of new technology.

Lessons for American Policymakers

There is a pervasive European mythology: a widespread belief that American health care is rooted in the free market. In reality, much of American health care is a highly planned, regulated, and government-funded system. Through major entitlement and welfare programs such as Medicare and Medicaid, which contribute to rapidly growing American health care costs, government takes a historically higher proportion of gross domestic product than does even the British NHS. Moreover, by virtue of the structure and financing of private-sector health insurance, there is little consumer control over health care dollars.

Nonetheless, the United States is not only a major consumer of health care services, but also the world's largest producer of medical technology. Investment in new medical technology is comparatively high, as is its rate of diffusion: "This is demonstrated by cross-national examinations of the comparative availability of selected medical technologies such as radiation therapy and open-heart surgery. Measured in units per million, the United States experiences levels of availability up to three times greater than in Canada and Germany."[32]

During the presidential campaign, Barack Obama proposed an Institute for Comparative Effectiveness that would make formal recommendations on medical technologies, devices, and drugs. In Congress, champions of comprehensive overhaul of U.S. health care favor policies that would explicitly accelerate America's trajectory downward toward a European-style medical interventionism.

Fearing the impact of the rising costs of Medicare, Medicaid, and the highly regulated arrangements of the private insurance sector, many American legislators and other top policymakers are becoming attracted to the idea of a body that would make top-down pronouncements on the cost-effectiveness of new medical technologies. The idea of a statutorily created agency charged with system-wide cost containment and rationing of medical services and technologies is becoming surprisingly fashionable in Washington policy circles.

[Body-by-Guinness]

The implications of this trend are alarming for U.S. citizens, particularly when one considers that the technology a society uses reflects the wider and underlying incentive structures it adopts for using it: "An incentive structure that encourages providers to trade off the costs and benefits of health care gives providers little incentive to use expensive technologies and thus researchers will have little incentive to create it."[33]

In the long term, a statist, centralized control of medical technology offers little if any regulatory benefit. Through its own logic, it not only stifles innovation, but also, in doing so, ends up precluding those very inventions that could turn out to be of immeasurable benefit to individuals and to society in general.

If comparative effectiveness and health technology assessment especially are to be useful, they must be generated primarily by the private sector on a competitive and non-coercive basis. In avoiding the imposition of a uniformity of rules that comes with government intervention, physicians and other medical professionals would and should remain free to pick and choose from the best practices and professional insights into the treatment of medical conditions as they see fit (with, of course, the informed consent of their patients).

It is only by returning health care to a genuinely patient-centered and consumer-driven health care marketplace that information, innovation, and best practice will permeate the complex array of health care arrangements in both the public and the private sectors. It is only through open competition and the economic discipline of the free market that real progress and productivity can be secured.

Therefore, in framing a policy on comparative effectiveness, America's policymakers should be governed by four principles:

They should reject the statutory creation of a board, council, or institute that would centralize government control of patient access to drugs, devices, medical technologies, treatments, or procedures. This is especially the case if such an agency were to have the power to override the considered judgment of competing professional expertise, especially the professional judgment of a patient's attending physician.
Comparative effectiveness research and health technology assessments should be undertaken primarily by the private sector. While government can contribute to research efforts and promote the widespread availability of the best information, it must not exercise monopoly power over the conduct of research itself or the distribution of information.
Comparative effectiveness research should be patient-centered and supportive of quality and value, not focused simply on cost-containment. In this respect, it should foster scientific advances, health information technology, and the emerging science of personalized medicine.
Comparative effectiveness research must move beyond randomized clinical trials and embrace practical clinical trials. It should include observational data, and its methodologies should fully address issues such as the validity and applicability of findings.
Conclusion

As is clear from the British experience and other international examples, a comparative effectiveness strategy that relies on central planning and coercion would not only be counterproductive in the long run--because it would undermine the incentives for medical innovation--but would also lead to the imposition of cost constraints that would worsen patients' medical conditions and damage the quality of their lives.

Helen Evans, Ph.D., is a citizen of the United Kingdom. A registered general nurse, she is the Director of Nurses for Reform and a Health Fellow with the Adam Smith Institute of London, England.


[1]For a brief discussion of the Obama proposal, see Robert E. Moffit and Nina Owcharenko, "The Obama Health Plan: More Power to Washington," Heritage Foundation Backgrounder No. 2197, October 15, 2008, at http://www.heritage.org/research/healthcare/bg2197.cfm.

[2]For a brief discussion of Daschle's proposed Federal Health Board, see Senator Tom Daschle, with Scott S. Greenberger and Jeanne M. Lambrew, Critical: What We Can Do About the Health Care Crisis (New York: Thomas Dunne Books, 2008). See also Robert E. Moffit, "How a Federal Health Board Will Cancel Private Coverage and Care," Heritage Foundation WebMemo No. 2155, December 4, 2008, at http://www.heritage.org/research/healthcare/wm2155.cfm.

[3]The provision is included in Title IX of Subtitle B of the American Recovery and Reinvestment Act of 2009. According to the report language accompanying the House bill, "By knowing what works best and presenting this information more broadly to patients and health care professionals, those items, procedures, and interventions that are most effective to prevent, control and treat health conditions will be utilized, while those that are found to be less effective and in some cases, more expensive, will no longer be prescribed."

[4]Stephen R. Brown, Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail (New York: St. Martin's Press, 2003).

[5]Ernest A. Codman, A Study in Hospital Efficiency (Boston, Mass.: Privately printed, 1916).

[6]J. A. Glover, "The Incidence of Tonsillectomy in School Children," Proceedings of the Royal Society of Medicine, Vol. XXXI (1938), pp. 1219-1236.

[7]D. Sanders, A. Coulter, K. McPherson, Variations in Hospital Admission Rates: A Review of the Literature (London: King Edward's Hospital Fund for London, 1989), p. 31.

[8]Archie Cochrane, Effectiveness and Efficiency: Random Reflections on Health Services (Leeds: Nuffield Provincial Hospitals Trust, 1972).

[9]J. E. Wennberg, A. G. Mulley, D. Hanley, et al., "An Assessment of Prostatectomy for Benign Urinary Tract Obstruction: Geographic Variations and the Evaluation of Medical Care Outcomes," JAMA, Vol. 259, No. 20 (1988), pp. 3027-3030.

[10]Andrew Stevens, Ruairidh Milne, and Amanda Burls, "Health Technology Assessment: History and Demand," Journal of Public Health Medicine, Vol. 25, No. 2 (1998), p. 99.

[11]Brian Micklethwait, "How and How Not to Demonopolise Medicine," Political Notes No. 56, Libertarian Alliance, London, 1991.

[12]David Friedman, "Should Medicine Be a Commodity? An Economist's Perspective," Philosophy and Medicine: Rights to Health Care, Vol. 38 (1991), at http://www.daviddfriedman.com/Academic/Medicine_Commodity/Me
dicine_Commodity.html (January 29, 2009).

[13]Ibid.

[14]Meir P. Pugatch and Francesca Ficai, "A Healthy Market? An Introduction to Health Technology Assessment," Stockholm Network, London, 2007, p. 5.

[15]Ibid.

[16]Ibid., p. 6.

[17]See INAHTA home page at http://www.inahta.org (January 30, 2009).

[18]Helen Evans, Sixty Years On--Who Cares for the NHS? (London: Institute of Economic Affairs, 2008), pp. 26-54.

[19]See MHRA home page at http://www.mhra.gov.uk (January 30, 2009).

[20]Pugatch and Ficai, "A Healthy Market? An Introduction to Health Technology Assessment," p. 8.

[21]"MS Research Urges End of NHS Bar on Drug," The Daily Telegraph, June 19, 2001.

[22]See press release, "NICE Limits Options for People with Rheumatoid Arthritis," Arthritis Cares, London, July 21, 2008.

[23]"Nasty Truth About NICE: It's the Body that Rations NHS Drugs. But This Leading Cancer Specialist Says Its Decisions Are Deeply Flawed," The Daily Mail, August 8, 2008.

[24]"NICE Decision to Block Osteoporosis Drug Access Was 'Irrational,'" The Daily Telegraph, January 20, 2009.

[25]"Drug Watchdog NICE 'Spends More on "Spin" than Tests on New Treatments,'" The Daily Mail, September 10, 2008, at http://www.dailymail.co.uk/health/article-1054049/Drug-watchdog-N
ICE-spends-spin-tests-new-treatments.html (January 30, 2009).

[26]See National Board of Health home page at http://www.sst.dk (January 30, 2009).

[27]Meir P. Pugatch and Helen Davison, "A Healthy Market? Health Assessment Technology in Context," Stockholm Network, London, 2007, p. 9.

[28]Brian Abel-Smith and Elias Mossialos, "Cost Containment and Health Care Reform: A Study of the European Union," London School of Economics and Political Science Occasional Paper in Health Policy No. 2, 1994, pp. 33-35.

[29]Pugatch and Davison, "A Healthy Market? Health Assessment Technology in Context," p. 10.

[30]Ibid., p. 11.

[31]Ibid.

[32]"American Democracy and Health Care," British Journal of Political Science, Vol. 27, No. 4 (October 1997), p. 573.

[33]Pugatch and Davison, "A Healthy Market? Health Assessment Technology in Context," p. 16.

 
    
http://www.heritage.org/Research/HealthCare/bg2239.cfm

[ccp]

Apparantly there are no laws governing in vitro fertilization.  Usually medical malpractice is a civil liability.  Since the lady with the loose screw has no apparant intention of claiming harn from the doctor who performed the procedure it would be up to the state llicensing board to sanction him or revoke his license as IMO they absolutely should do.

But it appears the "good" doctor is a tax fraud as well.  So fortunately he may, afterall, get the jail time he deserves.  His wife too:

Medical society probes octuplet fertility doctor By SHAYA TAYEFE MOHAJER, Associated Press Writer
Tue Feb 10, 6:55 PM ET
 
LOS ANGELES - A national medical society is investigating whether a fertility doctor followed its guidelines when he implanted six embryos into a Southern California woman who gave birth to octuplets last month.

 The American Society for Reproductive Medicine confirmed Tuesday that it's investigating because Nadya Suleman says she received in-vitro fertilization for all 14 of her children at the same Beverly Hills fertility clinic.

Suleman, 33, told NBC's "Today" show that she was implanted with six embryos in each of her six pregnancies, resulting in four single births, a set of twins and the octuplets. No more than three embryos are considered the norm for a woman her age, and fertility experts and medical ethicists have been critical of the Jan. 26 birth of the octuplets.

The society has contacted Suleman and her doctor, and is prepared to assist the Medical Board of California, which is also looking into the pregnancy, the society's president, Dr. R. Dale McClure, said in a statement.

"Our guidelines provide the flexibility to give each patient treatment individualized to her needs, and her best chance to become pregnant without risking high-order multiple pregnancy," said McClure. "However, it seems that the guidelines may not have been followed in Ms. Suleman's case."

Neither the society or the medical board identified Suleman's physician, Dr. Michael Kamrava.

Kamrava, a specialist who pioneered a method of implantation, was identified Monday as a result of an NBC interview with Suleman, who said she went to the West Coast IVF Clinic in Beverly Hills and that all 14 of her children were conceived with help from the same doctor. In 2006, Los Angeles TV station KTLA ran a story on infertility that showed Kamrava, the center's director, treating Suleman and discussing embryo implantation.

Kamrava, 57, did not return calls seeking comment Monday or Tuesday. When confronted by reporters outside his clinic Monday, he said he had granted a television interview but would not give details.

The state medical board said last week it was looking into the Suleman case to see if there was a "violation of the standard of care." The medical board said it had not taken any previous disciplinary action against Kamrava.

Kamrava's clinic is a member of the Society for Assisted Reproductive Technology, a sister organization of the American Society for Reproductive Medicine.

Clinics that clearly violate guidelines can be kicked out of SART. Neither group is a regulatory agency so a removed doctor could still practice medicine.

The state medical board cannot close the clinic if it is found at fault, but it can censure the doctor, putting the violation on his record.

Kamrava's clinic performed 52 in-vitro procedures in 2006, according to the most recent national report compiled by the Centers for Disease Control and Prevention. Of those, five resulted in pregnancies and two in births. One of the births were Suleman's twins.

Kamrava's pregnancy rate that year was among the lowest in the country. Experts say many factors affect a clinic's success rate, including a patient's health and types of procedures done.

Several lawsuits have been filed against Kamrava over the past two decades, including one in which a former employee accused him and his wife of hiding income to avoid taxes and defrauding insurance companies.

Former office administrator Shirin Afshar sued Kamrava in 1998, claiming discrimination, harassment, wrongful termination and infliction of emotional distress.

Over a seven-year period, Afshar said, Kamrava and his wife didn't report about $400,000 in income to the state and the Internal Revenue Service. Afshar claims Kamrava made patients who had no insurance pay in cash and that money was turned over to Kamrava's wife. The transactions were neither entered into an office computer nor deposited in a bank, the lawsuit said.

She said she was fired when she complained to Kamrava about what was going on.

Afshar also claimed she had an abortion in 1992 because she feared she would lose her job. When she told Kamrava she was pregnant, she claims her boss chastised her.

"How can you take care of this baby with no job, no family and no money?" Afshar claimed Kamrava said.

The lawsuit was settled in 1999 for an undisclosed amount.

___

Associated Press Television News videographer John Mone and Associated Press Writers Alicia Chang, Thomas Watkins and Greg Risling contributed to this report.

[Crafty_Dog]

Vitamin Pills: A False Hope?
By TARA PARKER-POPE
NYT
Published: February 16, 2009

Ever since the Nobel Prize-winning biochemist Linus Pauling first promoted “megadoses” of essential nutrients 40 years ago, Americans have been devoted to their vitamins. Today about half of all adults use some form of dietary supplement, at a cost of $23 billion a year.

But are vitamins worth it? In the past few years, several high-quality studies have failed to show that extra vitamins, at least in pill form, help prevent chronic disease or prolong life.

The latest news came last week after researchers in the Women’s Health Initiative study tracked eight years of multivitamin use among more than 161,000 older women. Despite earlier findings suggesting that multivitamins might lower the risk for heart disease and certain cancers, the study, published in The Archives of Internal Medicine, found no such benefit.

Last year, a study that tracked almost 15,000 male physicians for a decade reported no differences in cancer or heart disease rates among those using vitamins E and C compared with those taking a placebo. And in October, a study of 35,000 men dashed hopes that high doses of vitamin E and selenium could lower the risk of prostate cancer.

Of course, consumers are regularly subjected to conflicting reports and claims about the benefits of vitamins, and they seem undeterred by the news — to the dismay of some experts.

“I’m puzzled why the public in general ignores the results of well-done trials,” said Dr. Eric Klein, national study coordinator for the prostate cancer trial and chairman of the Cleveland Clinic’s Glickman Urological and Kidney Institute. “The public’s belief in the benefits of vitamins and nutrients is not supported by the available scientific data.”

Everyone needs vitamins, which are essential nutrients that the body can’t produce on its own. Inadequate vitamin C leads to scurvy, for instance, and a lack of vitamin D can cause rickets.

But a balanced diet typically provides an adequate level of these nutrients, and today many popular foods are fortified with extra vitamins and minerals. As a result, diseases caused by nutrient deficiency are rare in the United States.

In any event, most major vitamin studies in recent years have focused not on deficiencies but on whether high doses of vitamins can prevent or treat a host of chronic illnesses. While people who eat lots of nutrient-rich fruits and vegetables have long been known to have lower rates of heart disease and cancer, it hasn’t been clear whether ingesting high doses of those same nutrients in pill form results in a similar benefit.

In January, an editorial in The Journal of the National Cancer Institute noted that most trials had shown no cancer benefits from vitamins — with a few exceptions, like a finding that calcium appeared to lower the recurrence of precancerous colon polyps by 15 percent.

But some vitamin studies have also shown unexpected harm, like higher lung cancer rates in two studies of beta carotene use. Another study suggested a higher risk of precancerous polyps among users of folic acid compared with those in a placebo group.

In 2007, The Journal of the American Medical Association reviewed mortality rates in randomized trials of antioxidant supplements. In 47 trials of 181,000 participants, the rate was 5 percent higher among the antioxidant users. The main culprits were vitamin A, beta carotene and vitamin E; vitamin C and selenium seemed to have no meaningful effect.

“We call them essential nutrients because they are,” said Marian L. Neuhouser, an associate member in cancer prevention at the Fred Hutchinson Cancer Research Center in Seattle. “But there has been a leap into thinking that vitamins and minerals can prevent anything from fatigue to cancer to Alzheimer’s. That’s where the science didn’t pan out.”

Everyone is struggling to make sense of the conflicting data, said Andrew Shao, vice president for scientific and regulatory affairs at the Council for Responsible Nutrition, a vitamin industry trade group. Consumers and researchers need to “redefine our expectations for these nutrients,” he said. “They aren’t magic bullets.”

Part of the problem, he said, may stem from an inherent flaw in the way vitamins are studied. With drugs, the gold standard for research is a randomized clinical trial in which some patients take a drug and others a placebo. But vitamins are essential nutrients that people ingest in their daily diets; there is no way to withhold them altogether from research subjects.

Vitamins given in high doses may also have effects that science is only beginning to understand. In a test tube, cancer cells gobble up vitamin C, and studies have shown far higher levels of vitamin C in tumor cells than are found in normal tissue.

The selling point of antioxidant vitamins is that they mop up free radicals, the damaging molecular fragments linked to aging and disease. But some free radicals are essential to proper immune function, and wiping them out may inadvertently cause harm.

In a study at the University of North Carolina, mice with brain cancer were given both normal and vitamin-depleted diets. The ones who were deprived of antioxidants had smaller tumors, and 20 percent of the tumor cells were undergoing a type of cell death called apoptosis, which is fueled by free radicals. In the fully nourished mice, only 3 percent of tumor cells were dying.

“Most antioxidants are also pro-oxidants,” said Dr. Peter H. Gann, professor and director of research in the department of pathology at the University of Illinois at Chicago. “In the right context and the right dose, they may be able to cause problems rather than prevent them.”

Scientists suspect that the benefits of a healthful diet come from eating the whole fruit or vegetable, not just the individual vitamins found in it. “There may not be a single component of broccoli or green leafy vegetables that is responsible for the health benefits,” Dr. Gann said. “Why are we taking a reductionist approach and plucking out one or two chemicals given in isolation?”

Even so, some individual vitamin research is continuing. Scientists are beginning to study whether high doses of whole-food extracts can replicate the benefits of a vegetable-rich diet. And Harvard researchers are planning to study whether higher doses of vitamin D in 20,000 men and women can lower risk for cancer and other chronic diseases.

“Vitamin D looks really promising,” said Dr. JoAnn E. Manson, the chief of preventive medicine at Brigham and Women’s Hospital and an investigator on several Harvard vitamin studies. “But we need to learn the lessons from the past. We should wait for large-scale clinical trials before jumping on the vitamin bandwagon and taking high doses.”

[Crafty_Dog]

http://www.sciencedaily.com/releases/2009/02/090222142139.htm

[Crafty_Dog]

Even though this is the LA Times, this is close to my thinking on this.

======================

A healthy resistance to antibiotics
The overuse of the medications in humans and animals is believed to be responsible for the rise of dangerous superbugs. Now the time may be right for some limits in agribusiness.
March 19, 2009


Ayear and a half ago, researchers found that a deadly form of staph infection was prevalent on Canadian pig farms. This year, the superbug was found in both swine and workers at U.S. farms.

The rise of bacteria such as methicillin-resistant Staphylococcus aureus, or MRSA, which kills more people in this country each year than AIDS, is believed to be a consequence of the overuse of antibiotics in humans and animals. Low doses of the medications have become ubiquitous in the livestock industry, mixed into feed to enhance growth and prevent the diseases that sweep through crowded pens.


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A panel of experts found "clear evidence of adverse human health consequences due to resistant organisms resulting from nonhuman usage of antimicrobials," the World Health Organization reported in 2004. "These consequences include infections that would not have otherwise occurred, increased frequency of treatment failures (in some cases death) and increased severity of infections."

The European Union has already banned non-therapeutic use of antibiotics in farm animals, but each year lobbying by agribusiness in this country dooms legislation that would do the same. On Tuesday, Rep. Louise M. Slaughter (D-N.Y.) introduced a bill that would restrict the use of antibiotics that are important to human health in farming operations. The medications could be used to treat illness, but not as a growth promoter or as a substitute for cleaner living conditions. The bill might have a better chance of passing now, with a stronger Democratic majority in Congress.

The timing is right in other ways as well. In January, the Department of Agriculture -- responsible for promoting the meat industry as well as consumer health -- reported that, except during the nursery stage for young pigs, the costs of using preventive or growth-promoting antibiotics slightly outweighed the economic benefits for farms. That's not counting the added costs to consumers in prescription prices for more exotic antibiotics or the $4 billion a year this country spends to combat resistant infections. Some farms are successfully using better sanitation and tracking of illnesses among their herds instead of preventive antibiotics.


It would be a mistake to delay restrictions on antibiotic use until the situation has a chance to reach dire proportions; there is no guarantee that specialized antibiotics could be developed in time to thwart a new wave of drug-resistant bacteria. Humans don't need antibiotics to treat common colds, which are caused by viruses rather than bacteria, and animals don't need them to grow.

[ccp]

As far as I know epidural hematomas are not at all common.  I have never seen or heard of another case in 20 years though I would not usually see any like say a neurosurgeon or ER physician would.  Usually they are from trauma or fracture over the skull near the temple are with rupture to the middle meningeal artery that runs through that vicinity.  Contrast these to  the common subdural or subarachnoid hematomas.

If say someone got a skull fracture over the temple with a club this could be the result.  Any serious blow to this area has to be evaulated with extreme care.

As for the actress it is all too sad.  She, as far as I know, is now much more famous for her death then her life.  I never heard of her before this.

****Autopsy: Richardson died of impact to the head
         NEW YORK – The New York City medical examiner's office says actress Natasha Richardson died of blunt impact to the head. Medical examiner spokeswoman Ellen Borakove said the death was ruled an accident. The cause of death was "epidural hematoma due to blunt impact to the head."

The 45-year-old actress reportedly suffered a head injury after a fall during a private lesson Monday at a resort in Quebec. Richardson was seemingly fine after she fell, but about an hour later, she complained that she didn't feel well. She was hospitalized Tuesday in Montreal and later flown to a hospital in New York, where she died.

Alan Nierob, the Los Angeles-based publicist for Richardson's husband, Liam Neeson, confirmed her death Wednesday without giving details on the cause. There were no details on funeral arrangements.

Funeral arrangements for the 45-year-old actress will be handled by the Greenwich Village Funeral Home.

Broadway theaters will dim their lights Thursday in honor of Richardson. Theater marquees will be dimmed for one minute at 8 p.m. EDT, the traditional starting time for evening performances of Broadway shows.

"The Broadway community is shocked and deeply saddened by the tragic loss of one of our finest young actresses, Natasha Richardson. Her theatrical lineage is legendary, but her own singular talent shined memorably on any stage she appeared," said Charlotte St. Martin, executive director of The Broadway League, the trade organization for Broadway theaters and producers.

Sam Mendes, who directed the Broadway musical "Cabaret" for which Richardson won a Tony, said, "It defies belief that this gifted, brave, tenacious, wonderful woman is gone."

Actress Judi Dench told the BBC that Richardson was "a really great actress" who had "an incredibly luminous quality, that you seldom see, and a great sense of humor."

"It's just so shocking, really shocking, and I hope that everybody leaves the family quietly to somehow pick up the pieces," Dench said.

"She was a wonderful woman and actress and treated me like I was her own," said Lindsay Lohan, who as a preteen starred with Richardson in a remake of "The Parent Trap" in 1998. "My heart goes out to her family. This is a tragic loss."

Neeson and Richardson's sister, actress Joely Richardson, were seen leaving Lenox Hill hospital Wednesday. Actress Lauren Bacall also visited the hospital.

Yves Coderre, director of operations at the emergency services company that sent paramedics to the Mont Tremblant resort where Richardson suffered her fall, told The Globe and Mail newspaper Wednesday the paramedics who responded were told they were not needed.

"They never saw the patient," Coderre told The Globe and Mail. "So they turned around."

Coderre said another ambulance was called later to Richardson's luxury hotel. By that point, her condition had gotten worse and she was rushed to a hospital.

Richardson's career highlights included the film "Patty Hearst" and a Tony-winning performance in a stage revival of "Cabaret."

She was a proper Londoner who came to love the noise of New York, an elegant blonde with large, lively eyes, a bright smile and a hearty laugh.

Jane Fonda on Wednesday recalled meeting a young Richardson on the set of "Julia," the 1977 film Fonda starred in opposite Richardson's mother, Vanessa Redgrave.

"She was a little girl but already beautiful and graceful. It didn't surprise me that she became such a talented actor," Fonda recalled on her blog. "It is hard to even imagine what it must be like for her family. My heart is heavy."

As an actress, Richardson was equally adept at passion and restraint, able to portray besieged women both confessional (Tennessee Williams' Blanche DuBois) and confined (the concubine in the futuristic horror of "The Handmaid's Tale").

Like other family members, she divided her time between stage and screen. On Broadway, she portrayed Sally Bowles in the 1998 revival of "Cabaret." She also appeared in New York in a production of Patrick Marber's "Closer" (1999) as well as the 2005 revival of Tennessee Williams' "A Streetcar Named Desire," in which she played Blanche opposite John C. Reilly's Stanley Kowalski.

She met Neeson when they made their Broadway debuts in 1993, co-starring in "Anna Christie," Eugene O'Neill's drama about a former prostitute and the sailor who falls in love with her.

The New York Times critic Frank Rich called her "astonishing" and said she "gives what may prove to be the performance of the season."

Her most notable film roles came earlier in her career. Richardson played the title character in Paul Schrader's "Patty Hearst," a 1988 biopic about the kidnapped heiress for which the actress became so immersed that even between scenes she wore a blindfold, the better to identify with her real-life counterpart.

Richardson was directed again by Schrader in a 1990 adaptation of Ian McEwan's "The Comfort of Strangers" and, also in 1990, starred in the screen version of Margaret Atwood's "The Handmaid's Tale."

She later co-starred with Neeson in "Nell" and with Mia Farrow in "Widows' Peak." More recent movies, none of them widely seen, included "Wild Child," "Evening" and "Asylum."

Richardson was born in London in 1963, the performing gene inherited not just from her parents (Redgrave and director Tony Richardson), but from her maternal grandparents (Michael Redgrave and Rachel Kempson), an aunt (Lynn Redgrave) and an uncle (Corin Redgrave). Her younger sister, Joely Richardson, also joined the family business.

She also is survived by two sons, Micheal, 13, and Daniel, 12.

Friends and family members remembered Natasha as an unusually poised child, perhaps forced to grow up early when her father left her mother in the late '60s for Jeanne Moreau. (Tony Richardson died in 1991).

Interviewed by The Associated Press in 2001, Natasha Richardson said she related well to her family if only because, "We've all been through it in one way or another and so we've had to be strong. Also we embrace life. We are not cynical about life."

Her screen debut came at 4, when she appeared as a flower girl in "The Charge of the Light Brigade," directed by her father, whose movies included "Tom Jones" and "The Entertainer." The show business wand had already tapped her the year before, when she saw her mother in the 1967 film version of the Broadway show "Camelot."

"She was so beautiful. I still look at that movie and I can't believe it. It still makes me cry, the beauty of it," Richardson said.

She studied at London's Central School of Speech and Drama and was an experienced stage actress by her early 20s, appearing in "On the Razzle," "Charley's Aunt" and "The Seagull," for which the London Drama Critics awarded her most promising newcomer.

She and her mother acted together, most recently on Broadway to play the roles of mother and daughter in a one-night benefit concert version of "A Little Night Music," the Stephen Sondheim-Hugh Wheeler musical.

Before meeting up with Neeson, Richardson was married to producer Robert Fox, whose credits include the 1985 staging of "The Seagull" in which his future wife appeared.

She sometimes remarked on the differences between her and her second husband — she from a theatrical dynasty and he from a working-class background in Northern Ireland.

"He's more laid back, happy to see what happens, whereas I'm a doer and I plan ahead," Richardson told The Independent on Sunday newspaper in 2003. "The differences sometimes get in the way but they can be the very things that feed a marriage, too."

She once said that Neeson's serious injury in a 2000 motorcycle accident — he suffered a crushed pelvis after colliding with a deer in upstate New York — had made her really appreciate life.

"I wake up every morning feeling lucky — which is driven by fear, no doubt, since I know it could all go away," she told The Daily Telegraph newspaper in 2003.****

[Tom Stillman]

CPR WHEN ALONE ~~ NOT A JOKE!
What are you to do if you have a heart attack
while you are alone.
If you've already received this,
it means people care about you.
The Johnson City Medical Center staff
actually discovered this,
and did an in-depth study on it in our ICU.
The two individuals that discovered this
then wrote an article on it, had it published and
have had it incorporated into ACLS and CPR classes.
It is very true - and has, and does, work.
It is called Cough CPR.
If everyone who gets this sends it to 10 people,
you can bet that we'll save at least one life.
It could save your life!
Let's say it's 6:15 p.m. and you're driving home
 (alone of course), after an usually hard day on the job.
 You're really tired, upset and frustrated.
Suddenly you start experiencing severe pain
 in your chest that starts to radiate out
into your arm and up into your jaw.
You are only about five miles from the hospital
nearest your home.
Unfortunately, you don't know
if you'll be able to make it that far.
What can you do?
You've been trained in CPR
but the guy that taught the course didn't tell you
what to do if it happened to yourself.
Since many people are alone when they suffer a heart attack, this article seemed to be in order.
Without help, the person whose heart is
beating improperly and who begins to feel faint,
has only about 10 seconds left before losing consciousness.
However, these victims can help themselves by coughing repeatedly and very vigorously.
A deep breath should be taken before each cough,
and the cough must be deep and prolonged,
as when producing sputum from
deep inside the chest.
A breath and a cough must be repeated
about every two seconds without let up
until help arrives, or until the heart is felt to be beating normally again.
 Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and
keep the blood circulating.
The squeezing pressure on the heart
also helps it regain normal rhythm.
In this way, heart attack victims can get to a hospital.
Tell as many other people as possible about this,
it could save their lives!
From Health Cares, Rochester General Hospital via Chapter 240s newsletter 'AND THE BEAT GOES ON '
 (reprint from The Mended Hearts, Inc. Publication, Heart Response)
BE A FRIEND AND
PLEASE SEND THIS ARTICLE
TO AS MANY FRIENDS AS POSSIBLE 

[ccp]

My opinion:

****"It's one of the classic presentations of head injuries, `talking and dying,' where they may lose consciousness for a minute, but then feel fine," said Razek.****

Yes but banging your head and talking and *not* dying is a thousand times more common.
The classic blame game.  She wasn't instantaneously brought to an operating room right off the slopes in some remote area of Quebec with neurosurgeon (Sanjay Gupta) waiting to do the perfect operation. 

Which one of these good doctors will be the lucky chosen one to be expert witness for the plaintiff's team.
To me this was a tragic accident.  We can always in every single negatvie human outcome ask, "what if"?   Why this has to turn into a lawsuit is beyond me.  And now we will have a billion dollars more in head cat scans as a result.
 
****Doctor: Lack of medical helicopter cost actress
Death: Freak Accident ABC News NEW YORK – As a steady stream of celebrities pay their last respects to Natasha Richardson, questions are arising over whether a medical helicopter might have been able to save the ailing actress.

The province of Quebec lacks a medical helicopter system, common in the United States and other parts of Canada, to airlift stricken patients to major trauma centers. Montreal's top head trauma doctor said Friday that may have played a role in Richardson's death.

"It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States," said Tarek Razek, director of trauma services for the McGill University Health Centre, which represents six of Montreal's hospitals.

While Richardson's initial refusal of medical treatment cost her two hours, she also had to be driven to two hospitals. She didn't arrive at a specialized hospital in Montreal until about four hours after the second 911 call from her hotel room at the Mont Tremblant resort, according to a timeline published by Canada's The Globe and Mail newspaper.

Not being airlifted directly to a trauma center could have cost Richardson crucial moments, Razek said.

"A helicopter is obviously the fastest way to get from Point A to Point B," he said.

After Richardson fell and hit her head on a beginner ski slope at the Mont Tremblant resort in Quebec, the first ambulance crew left upon spotting a sled taking the still-conscious actress away to the resort's on-site clinic.

A second 911 call was made two hours later from Richardson's luxury hotel room as the actress deteriorated. Medics tended to her for a half-hour before taking her to a hospital about a 40-minute drive away.

Centre Hospitalier Laurentien in Ste-Agathe does not specialize in head traumas, so her speedy transfer to Sacre Coeur Hospital in Montreal was critical, said Razek.

"It's one of the classic presentations of head injuries, `talking and dying,' where they may lose consciousness for a minute, but then feel fine," said Razek.

Richardson, 45, died Wednesday at Lenox Hill Hospital in New York. The New York City medical examiner's office ruled her death was an accident.****

[ccp]

this is a very difficult topic. Euthanasia.  I feel very uncomfortable about it.  I have "pulled the plug" with family permission only on patients that were brain dead but the idea of helping someone die even if they are terminal and suffering would be very hard for me to do.  Yet this debate is only going to get bigger.  The worst part is the reason won't be for the goodness of humanity.  But for dollars and cents.  I worked for 30 days with other physicians to keep alive an 85 year old lady.  She made it and went off to the nursing home.  I recently got word she died after two weeks there anyway.

Not only was I saddened by her passing - she was a sweet little old lady - but saddened by the fact she really suffered for a month struggling to survive and pull through - only to die anyway.  that said the issue to society that is going to cause this to be something we will hear about a lot in the near future is the cost>
suppose she died 6 weeks earlier.  100k Would not have been spent.  Something like a quarter of all health care expenditures are for the last 6 months of life.  With a broken system that is going bankrupt and driving us all into the gutter people are going to start to raise the taboo questions we all try to avoid:

http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=587095&sk=a76544f67ebabb8029168ea3bd20baae

[Body-by-Guinness]

Hmm, agreeable + non-neurotic = longevity. I'm doomed.

Researchers identify personality traits

(Boston) - Researchers from Boston University School of Medicine's (BUSM) New England Centenarian Study have noted specific personality traits associated with healthy aging and longevity amongst the children of centenarians. The work was conducted in collaboration with scientists from the National Institute on Aging. These findings currently appear on-line in the Journal of the American Geriatrics Society.

Previous research on siblings and offspring of centenarians have documented that exceptional longevity runs strongly in families. Studies of the offspring of centenarians showed that their mortality is 120 percent lower than other members of their birth cohort and that they also have markedly lower prevalence rates and delayed onsets of cardiovascular disease, hypertension, and diabetes mellitus. Because personality traits have been shown to have substantial heritable components, the researchers hypothesized that certain personality features may be important to the healthy aging observed in the offspring of centenarians.

Using the NEO-Five-Factor Inventory (NEO-FFI) questionnaire, measures of the personality traits for neuroticism, extraversion, openness, agreeableness, and conscientiousness were obtained from 246 (125 women and 121 men) unrelated offspring of centenarians with an average age of 75.

Both the male and female offspring of centenarians scored in the low range of published norms for neuroticism and in the high range for extraversion. The women also scored comparatively high in agreeableness. Otherwise, both sexes scored within normal range for conscientiousness and openness, and the men scored within normal range for agreeableness.

According to the researchers, personality traits in the offspring of centenarians appear to have distinctive characteristics that may have important implications for their longevity. "Interestingly, whereas men and women generally differ substantially in their personality characteristics, the male and female offspring tended to be similar, which speaks to the importance of these traits, irrespective of gender, for health aging and longevity.

It's likely that the low neuroticism and higher extraversion will confer health benefits for these subjects," said senior author Thomas Perls, MD, MPH, director of the New England Centenarian Study. "For example, people who are lower in neuroticism are able to manage or regulate stressful situations more effectively than those with higher neuroticism levels. Similarly, high extraversion levels have been associated with establishing friendships and looking after yourself," he said.

Perl's added, "These findings suggest that personality is an important characteristic to include in studies that assess genetic and environmental determinants of longevity. Such studies are currently underway."

http://www.eurekalert.org/pub_releases/2009-04/bu-rip040309.php

[Crafty_Dog]

Suppose you wanted to test the effects of halving the amount of salt in people’s diets. If you were an academic researcher, you’d have to persuade your institutional review board that you had considered the risks and obtained informed consent from the participants.

Skip to next paragraph
TierneyLab
Do you want New York’s mayor and health commissioner leading a nationwide initiative to halve the salt in your food? Join the discussion.

Go to TierneyLab »
Further Reading
Throwing the Book at Salt. Kim Severson, N.Y. Times, 2009.
NYC Starts a Nationwide Initiative. N.Y.C. Department of Health.
The (Political) Science of Salt Gary Taubes, Science, 1998.
A Call for Higher Standards of Evidence for Dietary Guidelines." Marantz PR, Bird ED, Alderman MH. American Journal of Preventive Medicine, 2008.
Effects of Low Sodium Diet Versus High Sodium Diet." G. Jürgens, N.A.Graudal, Cochrane Collaboration, 2003.
The Influence of Dietary Sodium on Blood Pressure. Norman K. Hollenberg, Journal of the American College of Nutrition, 2006.
Salt Craving: The Psychobiology of Pathogenic Sodium Intake." M.J. Morris, E.S. Na, A.K. Johnson. Physiology & Beahvior, 2008.
Reducing the Public Health Burden From Elevated Blood Pressure Levels. S. Havas, E. Roccella, C. Lenfant. American Journal of Public Health, 2004.
More From Dr. Frieden. Diner's Journal, New York Times, 2009.

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Viktor Koen
You might, for instance, take note of a recent clinical trial in which heart patients put on a restricted-sodium diet fared worse than those on a normal diet. In light of new research suggesting that eating salt improves mood and combats depression, you might be alert for psychological effects of the new diet. You might worry that people would react to less-salty food by eating more of it, a trend you could monitor by comparing them with a control group.

But if you are the mayor of New York, no such constraints apply. You can simply announce, as Michael Bloomberg did, that the city is starting a “nationwide initiative” to pressure the food industry and restaurant chains to cut salt intake by half over the next decade. Why bother with consent forms when you can automatically enroll everyone in the experiment?

And why bother with a control group when you already know the experiment’s outcome? The city’s health commissioner, Thomas R. Frieden, has enumerated the results. If the food industry follows the city’s wishes, the health department’s Web site announces, “that action will lower health care costs and prevent 150,000 premature deaths every year.”

But that prediction is based on an estimate based on extrapolations based on assumptions that have yet to be demonstrated despite a half-century of efforts. No one knows how people would react to less-salty food, much less what would happen to their health.

Dr. Frieden has justified the new policy by pointing to the “compelling evidence” for the link between salt and blood pressure. It’s true that lowering salt has been shown to lower blood pressure on average, but that doesn’t mean it has been demonstrated to improve your health, for a couple of reasons.

First, a reduced-salt diet doesn’t lower everyone’s blood pressure. Some individuals’ blood pressure can actually rise in response to less salt, and most people aren’t affected much either way. The more notable drop in blood pressure tends to occur in some — but by no means all — people with hypertension, a condition that affects more than a quarter of American adults.

Second, even though lower blood pressure correlates with less heart disease, scientists haven’t demonstrated that eating less salt leads to better health and longer life. The results from observational studies have too often been inconclusive and contradictory. After reviewing the literature for the Cochrane Collaboration in 2003, researchers from Copenhagen University concluded that “there is little evidence for long-term benefit from reducing salt intake.”

A similar conclusion was reached in 2006 by Norman K. Hollenberg of Harvard Medical School. While it might make sense for some individuals to change their diets, he wrote, “the available evidence shows that the influence of salt intake is too inconsistent and generally too small to mandate policy decisions at the community level.”

In the past year, researchers led by Salvatore Paterna of the University of Palermo have reported one of the most rigorous experiments so far: a randomized clinical trial of heart patients who were put on different diets. Those on a low-sodium diet were more likely to be rehospitalized and to die, results that prompted the researchers to ask, “Is sodium an old enemy or a new friend?”

Those results, while hardly a reason for you to start eating more salt, are a reminder that salt affects a great deal more than blood pressure. Lowering it can cause problems with blood flow to the kidneys and insulin resistance, which can increase the risk of strokes and heart attacks.

Salt deprivation might also darken your mood, according to recent research by Alan Kim Johnson and colleagues at the University of Iowa. After analyzing the behavior and brain chemistry of salt-deprived rats, the psychologists found that salt, like chocolate and cocaine, affected reward circuitry in the brain, and that salt-deprived rats exhibited anhedonia, a symptom of depression characterized by the inability to enjoy normally pleasurable activities.

Dr. Frieden has predicted that people “won’t notice the difference” if salt is gradually reduced, but how can he be sure? What if they respond by eating more food, or a different mix of foods and stimulants? What if the food industry turns to salt substitutes that cause new health problems? “We have no way of knowing the health effects of eating less salt, yet we’re supposed to forge ahead with this new policy that affects the whole population,” said Michael Alderman, an expert in hypertension at the Albert Einstein College of Medicine. Like other critics, he has compared the antisalt campaign to the campaign against fat that began several decades ago.

That antifat campaign, like the antisalt campaign, was endorsed by prominent groups and federal agencies before the campaigners’ theory was tested in rigorous trials. It too seemed quite logical — in theory.

But in practice the results were dismal, as demonstrated eventually by clinical trials and by the expanding waistlines of Americans. People followed the advice in the “food pyramid” to reduce the percentage of fat in the diet, but they got more obese, perhaps because they ate so many other ingredients in foods with “low fat” labels.

You might think that experience would inspire caution among public health officials, but instead they seem to be gaining confidence. When Dr. Frieden and Mr. Bloomberg decided several years ago that trans fats were dangerous, they didn’t simply issue a warning or a set of voluntary guidelines. They insisted on outlawing trans fats in New York’s restaurants.

At the time, it seemed extraordinary for a city to be forbidding its diners to order a legal food product, particularly given the scientific uncertainties about trans fats and the possible harms resulting from the ban (see TierneyLab at nytimes.com/tierneylab).

But that local restaurant policy now seems fairly modest by comparison with Mr. Bloomberg’s and Dr. Frieden’s plans for salt. Soon, wherever you live, wherever you eat, you could be part of their experiment.

[C-Kumu Dog]

[youtube]http://www.youtube.com/watch?v=PPTUXXSV-3w&feature=player_embedded[/youtube]



http://www.straighttothebar.com/therotater/

.
The Rotater is a brilliant thing.

Following years of shoulder abuse and injury (particularly whilst experimenting during training for the OAC), I was more than a little keen to try out The Rotater. And I have to say, it easily exceeded expectations.

Rather than relive my own shoulder-training trials however, here are a couple of thoughts from my father, who has been using The Rotater for a few days now. As you'll see, it really is an incredible piece of equipment.

When Scott asked me to test the Rotater my response was keen but somewhat apprehensive. Following years of bodily abuse in various sporting activities (several breaks, dislocations & tears) I am now, at age 67, suffering early stages of arthritis. One area of concern is my shoulders - not so much because of pain and stiffness but the limitations this places on my ability to exercise on a regular basis.

When I first used The Rotater for a few minutes my feelings were confused. How could such a simple device create the feeling of freedom I was now experiencing? Having now used The Rotater for several days I have come to the following conclusions :

   1. After a few minutes of stretching with The Rotater I can now comfortably exercise my shoulders using my home gym & appropriate free weights.
   2. Until recent years I have done twists on a daily basis using a broomstick across my shoulders. This had become impossible as holding the stick behind my neck was too painful. After a suitable warm up I can now once again twist for as long as I choose.

The results of my test of the Rotater are surprising, amazing, & in my case stimulating.
A look at The Rotater in action

Here's a brief look at The Rotater in action. As you can see, it's an incredibly simple device; yet you can feel a difference almost immediately. If years of squatting have robbed you of a bit of shoulder mobility, you'll be amazed at just how great this feels.

Final Thought on The Rotater

If you've ever experienced shoulder pain, you'll understand just how frustrating it can be. Apart from the pain itself, it's perhaps the fact that it prevents you from doing your normal exercise routine that's the biggest source of aggravation.

In my case - and in my dad's - The Rotater ended that frustration. An incredible feeling.

[ccp]

WHO ready with antivirals to combat swine flu
Fri Apr 24, 2009 5:11pm EDT  Email | Print | Share| Reprints | Single Page[-] Text

By Stephanie Nebehay

GENEVA (Reuters) - The World Health Organization (WHO) said on Friday that it was prepared with rapid containment measures including antivirals if needed to combat the swine flu outbreaks in Mexico and the United States.

The Geneva-based agency has been stockpiling doses of Roche Holding's Tamiflu, known generically as oseltamivir, a pill that can both treat flu and prevent infection.

The new virus, not previously detected in pigs or humans, has proved sensitive to the drug, the WHO said in a statement.

The WHO and its regional office in Washington, D.C., are also sending experts to Mexico to help health authorities with disease surveillance, laboratory diagnosis and clinical management of cases.

Mexican health officials have reported more than 850 cases of pneumonia in the capital, Mexico City, including 59 who died. In San Luis Potosi, in central Mexico, 24 cases including 3 deaths have been detected.

They have also informed the WHO about a third suspected outbreak of swine flu in Mexicali, near the U.S. border, with four suspect cases and no deaths so far.

The U.S. Centers for Disease Control have said there were 8 cases of swine influenza in California and Texas and no deaths.

Health authorities in the two North American countries have the resources required already in place, including Tamiflu, and are "well equipped," according to the WHO.

"WHO is prepared with rapid containment measures should it be necessary to be deployed," WHO spokeswoman Aphaluck Bhatiasevi told Reuters.

The United Nations agency saw no need at this point to issue travel advisories warning travelers not to go to parts of Mexico or the United States. "However, the situation may change depending on what the situation in the field is," she said.

The WHO will convene a meeting of its Emergency Committee on international health regulations, probably on Saturday afternoon, she added.

WHO director-general Margaret Chan was flying back to Geneva overnight from Washington, D.C., for the emergency discussions which would link public health authorities and experts in various parts of world in a virtual meeting, she said.

The emergency committee could make recommendations including whether to change the pandemic alert level, she added.

"Because there are human cases associated with an animal influenza virus, and because of the geographical spread of multiple community outbreaks, plus the somewhat unusual age groups affected, these events are of high concern," the WHO said in a statement.

[C-Kumu Dog]

Im not entirely sure where this fits in it could be environmental but it is also a part of health.  My girlfriend and I have been seriously looking into Aquaponics. Anyone else do / tried this?

http://www.aquaponics.com/index.htm

[youtube]http://www.youtube.com/watch?v=wS3sej53gx0[/youtube]

[Crafty_Dog]

Shaggy Dog does something quite like this too in his backyard in the San Fernando Valley in Los Angeles.  For the fish, he uses Tilapia, which are an excellent clean protein source as well.

[C-Kumu Dog]

Shaggy Dog does something quite like this too in his backyard in the San Fernando Valley in Los Angeles.  For the fish, he uses Tilapia, which are an excellent clean protein source as well.

Actually, I got the idea after reading a post from Shaggy to DogZilla on Facebook.  After doing some research there is a farm here on Oahu that has classes as well as a family on the big island that does it commercially.  I think we will start out with Tilapia but I have also been reading that other people use Koi, Crawdads, Goldfish, and Perch.  Interesting stuff. The more I read the more excited I get. 

A small step to being self sufficient.

(geez, just realized that I totally misspelled the subject)

[pretty_kitty]

I've seen Shaggy's setup.  It's quite impressive.  I wish I'd had my camera with me! 

[C-Kumu Dog]

I've seen Shaggy's setup.  It's quite impressive.  I wish I'd had my camera with me! 

Oooh maybe I can email him for tips and suggestions!

[Crafty_Dog]

I just tried emailing him but it bounced back.   I will have to give him a call.

[C-Kumu Dog]

Awesome, looking forward to hearing \ reading his input.  Thanks Guro Crafty.

[Shaggy Dog]

Hey Robert I would be happy to answer any of your questions. I tried to upload some pics of my system but every time I tried I got an error...

[C-Kumu Dog]

Howzit Shaggy!  I just ordered a DVD "Aquaponics made Easy" or something like that.  I'll post some questions soon!

[Crafty_Dog]

Shaggy:

Please email Cindy and me at info@dogbrothers.com and if Cindy does not have the answer I will forward you it to our webmaster for a solution.

BTW, what you have going has really got me thinking about all this.  Glad to see you here.

[Shaggy Dog]

Well I am here to inspire...

I really believe this is one of the most viable farming methods on earth. In Ca. we are having a major water shortage and becoming a problem for traditional farmers. Most Aquaponic farms use 10% of the water regular farming methods use per acreage and can grow up to 44% more produce. There are no nutrient run off that can go into the environment which regular farming has a major problem with. The system if run by solar power or wind power it has almost 0 impact on the environment other than taking water out of it but in my system I only go thru 15 gallons a day which is less than a shower.

With this system you also have the benefit of harvesting some type of freshwater species. Most systems use Tilapia but you can use any freshwater creature that poops. You can use Trout, Bass, Fresh Water Prawn, Crawfish, Catfish the list goes on. Some people even use gold fish or Koi. Koi is a more viable fish to use because you can sell Koi at a high price but Goldfish are pretty much a waste of space you can't eat them and they don't sell for much.

The system works fairly simple...The fish effluent is pumped into grow beds using some sort of substrate usually pea gravel. Then a bacteria called Notrosomonas converts ammonia into nitrites and another bacteria named Nitrobacter converts the nitrite to nitrate which is consumed by the plants. The water then is drained into a return tank and then pumped back into the fish tank and is 97% pure water when it has gone thru the grow beds.

Tilapia is one of the most popular fish to use because it is a warm water fish and the system does better because the bacteria like it warm. For most of the year average water temp. is around 82 degrees which the bacteria thrive in. Also Tilapia is a very fast growing fish where it can become full size within 7-12 months averaging around a pound and a half.

Well I will leave you with this much info for now if any body has any questions about it feel free to ask.

Shaggy Dog

[Crafty_Dog]

You live in the San Fernando Valley-- which for many months of the year, is A LOT hotter than 82 degrees.  How do you handle this?

[Shaggy Dog]

Shade cloth and fans is how I keep it cool during the summer. Most of the year the tank is solar heated because the tank is black. The water temp. may rise during the day but it falls back down at night. 82 is for most of the year but during the summer the water temp. can get up to 88 degrees.

[C-Kumu Dog]

Well I am here to inspire...

I really believe this is one of the most viable farming methods on earth. In Ca. we are having a major water shortage and becoming a problem for traditional farmers. Most Aquaponic farms use 10% of the water regular farming methods use per acreage and can grow up to 44% more produce. There are no nutrient run off that can go into the environment which regular farming has a major problem with. The system if run by solar power or wind power it has almost 0 impact on the environment other than taking water out of it but in my system I only go thru 15 gallons a day which is less than a shower.

With this system you also have the benefit of harvesting some type of freshwater species. Most systems use Tilapia but you can use any freshwater creature that poops. You can use Trout, Bass, Fresh Water Prawn, Crawfish, Catfish the list goes on. Some people even use gold fish or Koi. Koi is a more viable fish to use because you can sell Koi at a high price but Goldfish are pretty much a waste of space you can't eat them and they don't sell for much.

The system works fairly simple...The fish effluent is pumped into grow beds using some sort of substrate usually pea gravel. Then a bacteria called Notrosomonas converts ammonia into nitrites and another bacteria named Nitrobacter converts the nitrite to nitrate which is consumed by the plants. The water then is drained into a return tank and then pumped back into the fish tank and is 97% pure water when it has gone thru the grow beds.

Tilapia is one of the most popular fish to use because it is a warm water fish and the system does better because the bacteria like it warm. For most of the year average water temp. is around 82 degrees which the bacteria thrive in. Also Tilapia is a very fast growing fish where it can become full size within 7-12 months averaging around a pound and a half.

Well I will leave you with this much info for now if any body has any questions about it feel free to ask.

Shaggy Dog

Ah well.. that answered some questions.  I was wondering why some people used Koi. Fortunately Im in Hawai'i so the weater is usually pretty warm and so I believe well start with Tilapia. Ive seen some kits that have the option of using solar again being in Hawaii I think that would be the obvious choice  I am also interested in trying out some other type of fish too.  

We are also thinking about starting an adult foster home and using the Aquaponic garden to raise most of our vegetables and gardens but first I wanna get a small kit / or make our own and start small.  Eventually once I get going and feel comfortable we thought about contacting homeless shelters (possibly provided some food for the shelter) and / or sell fish and veggies at the farmers market and / or get involved with a co-op.

Oh.. what about the cycle betweeen harvesting the fish and adding new fish i.e. initially start with 15 fish and then maybe 60 days later add in more?

Mahalo Shaggy Dog!

[Shaggy Dog]

There are a couple Yahoo Discussion groups I belong to that are a valuable resource for info the first one you might be interested in is the aeroponics_aquaponics group which has allot of info on Barrelponics which are usually very small systems a good one for you to start out with. Another group I belong to is aquaponicfarm Group which has allot of info on larger systems and homemade equipment such as diagrams for wind powered pumps and such.

Cycling between fish harvest is not really an issue on an established tank. The more problematic one is the initial start of your system. I like to start off with Goldfish, if they die no big deal because they are very cheap. Some aquaponics set ups use a very high ratio of fish per gallon of water. I've seen up to 1 fish per gallon but many things can go wrong quickly with that dense of a population. I have had best results in 1 - 1 1/2 Lb. fish per 4 gallons of water but it differs from the size of fish that is going to be raised.

[C-Kumu Dog]

There are a couple Yahoo Discussion groups I belong to that are a valuable resource for info the first one you might be interested in is the aeroponics_aquaponics group which has allot of info on Barrelponics which are usually very small systems a good one for you to start out with. Another group I belong to is aquaponicfarm Group which has allot of info on larger systems and homemade equipment such as diagrams for wind powered pumps and such.

Cycling between fish harvest is not really an issue on an established tank. The more problematic one is the initial start of your system. I like to start off with Goldfish, if they die no big deal because they are very cheap. Some aquaponics set ups use a very high ratio of fish per gallon of water. I've seen up to 1 fish per gallon but many things can go wrong quickly with that dense of a population. I have had best results in 1 - 1 1/2 Lb. fish per 4 gallons of water but it differs from the size of fish that is going to be raised

.

OK. Ill be checking that out later today, thanks for the info.

[C-Kumu Dog]

This is only a small portion of an informative article @ http://attra.ncat.org/attra-pub/aquaponic.html it is also available in PDF format here - http://attra.ncat.org/attra-pub/PDF/aquaponic.pdf



Aquaponics—Integration of Hydroponics with Aquaculture
By Steve Diver
NCAT Agriculture Specialist
Published 2006
ATTRA Publication #IP163

Abstract


Aquaponic vegetable bed in Australia.
Photo by Joel Malcolm, Backyard Aquaponics. (with permission)
Aquaponics is a bio-integrated system that links recirculating aquaculture with hydroponic vegetable, flower, and/or herb production. Recent advances by researchers and growers alike have turned aquaponics into a working model of sustainable food production. This publication provides an introduction to aquaponics with brief profiles of working units around the country. An extensive list of resources point the reader to print and Web-based educational materials for further technical assistance.

Table of Contents

Introduction
Aquaponics: Key Elements and Considerations
Aquaponic Systems
The North Carolina State University System
The Speraneo System
The University of the Virgin Islands System
The Freshwater Institute System
The Cabbage Hill Farm System
The New Alchemy Institute
Miscellaneous Systems
Organic Aquaculture
Evaluating an Aquaponic Enterprise
References
Resources
Appendix: Bibliography on Aquaponics
Dissertations
Introduction

Aquaponics, also known as the integration of hydroponics with aquaculture, is gaining increased attention as a bio-integrated food production system.

Aquaponics serves as a model of sustainable food production by following certain principles:

The waste products of one biological system serve as nutrients for a second biological system.
The integration of fish and plants results in a polyculture that increases diversity and yields multiple products.
Water is re-used through biological filtration and recirculation.
Local food production provides access to healthy foods and enhances the local economy.
In aquaponics, nutrient-rich effluent from fish tanks is used to fertigate hydroponic production beds. This is good for the fish because plant roots and rhizobacteria remove nutrients from the water. These nutrients – generated from fish manure, algae, and decomposing fish feed – are contaminants that would otherwise build up to toxic levels in the fish tanks, but instead serve as liquid fertilizer to hydroponically grown plants. In turn, the hydroponic beds function as a biofilter – stripping off ammonia, nitrates, nitrites, and phosphorus – so the freshly cleansed water can then be recirculated back into the fish tanks. The nitrifying bacteria living in the gravel and in association with the plant roots play a critical role in nutrient cycling; without these microorganisms the whole system would stop functioning.

Greenhouse growers and farmers are taking note of aquaponics for several reasons:

Hydroponic growers view fish-manured irrigation water as a source of organic fertilizer that enables plants to grow well.

Fish farmers view hydroponics as a biofiltration method to facilitate intensive recirculating aquaculture.

Greenhouse growers view aquaponics as a way to introduce organic hydroponic produce into the marketplace, since the only fertility input is fish feed and all of the nutrients pass through a biological process.

Food-producing greenhouses – yielding two products from one production unit – are naturally appealing for niche marketing and green labeling.

Aquaponics can enable the production of fresh vegetables and fish protein in arid regions and on water-limited farms, since it is a water re-use system.

Aquaponics is a working model of sustainable food production wherein plant and animal agriculture are integrated and recycling of nutrients and water filtration are linked.

In addition to commercial application, aquaponics has become a popular training aid on integrated bio-systems with vocational agriculture programs and high school biology classes.
The technology associated with aquaponics is complex. It requires the ability to simultaneously manage the production and marketing of two different agricultural products. Until the 1980s, most attempts at integrated hydroponics and aquaculture had limited success. However, innovations since the 1980s have transformed aquaponics technology into a viable system of food production. Modern aquaponic systems can be highly successful, but they require intensive management and they have special considerations.

This publication provides an introduction to aquaponics, it profiles successful aquaponic greenhouses, and it provides extensive resources. It does not attempt to describe production methods in comprehensive technical detail, but it does provide a summary of key elements and considerations.

Related ATTRA Publications

Aquaculture Enterprises: Considerations and Strategies Agricultural Business Planning Templates and Resources
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Aquaponics: Key Elements and Considerations

A successful aquaponics enterprise requires special training, skills, and management. The following items point to key elements and considerations to help prospective growers evaluate the integration of hydroponics with aquaculture.

Hydroponics: Hydroponics is the production of plants in a soilless medium whereby all of the nutrients supplied to the crop are dissolved in water. Liquid hydroponic systems employ the nutrient film technique (NFT), floating rafts, and noncirculating water culture. Aggregate hydroponic systems employ inert, organic, and mixed media contained in bag, trough, trench, pipe, or bench setups. Aggregate media used in these systems include perlite, vermiculite, gravel, sand, expanded clay, peat, and sawdust. Normally, hydroponic plants are fertigated (soluble fertilizers injected into irrigation water) on a periodical cycle to maintain moist roots and provide a constant supply of nutrients. These hydroponic nutrients are usually derived from synthetic commercial fertilizers, such as calcium nitrate, that are highly soluble in water. However, hydro-organics – based on soluble organic fertilizers such as fish hydrosylate – is an emerging practice. Hydroponic recipes are based on chemical formulations that deliver precise concentrations of mineral elements. The controlled delivery of nutrients, water, and environmental modifications under greenhouse conditions is a major reason why hydroponics is so successful.

Nutrients in Aquaculture Effluent: Greenhouse growers normally control the delivery of precise quantities of mineral elements to hydroponic plants. However, in aquaponics, nutrients are delivered via aquacultural effluent. Fish effluent contains sufficient levels of ammonia, nitrate, nitrite, phosphorus, potassium, and other secondary and micronutrients to produce hydroponic plants. Naturally, some plant species are better adapted to this system than others. The technical literature on aquaponics provides greater detail on hydroponic nutrient delivery; especially see papers cited in the Bibliography by James Rakocy, PhD.

Plants Adapted to Aquaponics: The selection of plant species adapted to hydroponic culture in aquaponic greenhouses is related to stocking density of fish tanks and subsequent nutrient concentration of aquacultural effluent. Lettuce, herbs, and specialty greens (spinach, chives, basil, and watercress) have low to medium nutritional requirements and are well adapted to aquaponic systems. Plants yielding fruit (tomatoes, bell peppers, and cucumbers) have a higher nutritional demand and perform better in a heavily stocked, well established aquaponic system. Greenhouse varieties of tomatoes are better adapted to low light, high humidity conditions in greenhouses than field varieties.


Male tilapia fish.
AARM - Aquaculture & Aquatic Resources Management Asian Institute of Technology, Thailand.
Fish Species: Several warm-water and cold-water fish species are adapted to recirculating aquaculture systems, including tilapia, trout, perch, Arctic char, and bass. However, most commercial aquaponic systems in North America are based on tilapia. Tilapia is a warm-water species that grows well in a recirculating tank culture. Furthermore, tilapia is tolerant of fluctuating water conditions such as pH, temperature, oxygen, and dissolved solids. Tilapia produces a white-fleshed meat suitable to local and wholesale markets. The literature on tilapia contains extensive technical documentation and cultural procedures. Barramundi and Murray cod fish species are raised in recirculating aquaponic systems in Australia.

Tilapia is a warm-water species that grows well in a recirculating tank culture.
Water Quality Characteristics: Fish raised in recirculating tank culture require good water quality conditions. Water quality testing kits from aquacultural supply companies are fundamental. Critical water quality parameters include dissolved oxygen, carbon dioxide, ammonia, nitrate, nitrite, pH, chlorine, and other characteristics. The stocking density of fish, growth rate of fish, feeding rate and volume, and related environmental fluctuations can elicit rapid changes in water quality; constant and vigilant water quality monitoring is essential.

Biofiltration and Suspended Solids: Aquaculture effluent contains nutrients, dissolved solids, and waste byproducts. Some aquaponic systems are designed with intermediate filters and cartridges to collect suspended solids in fish effluent, and to facilitate conversion of ammonia and other waste products to forms more available to plants prior to delivery to hydroponic vegetable beds. Other systems deliver fish effluent directly to gravel-cultured hydroponic vegetable beds. The gravel functions as a “fluidized bed bioreactor,” removing dissolved solids and providing habitat for nitrifying bacteria involved in nutrient conversions. The design manuals and technical documentation available in the Resources section can help growers decide which system is most appropriate.

Component Ratio: Matching the volume of fish tank water to volume of hydroponic media is known as component ratio. Early aquaponics systems were based on a ratio of 1:1, but 1:2 is now common and tank: bed ratios as high as 1:4 are employed. The variation in range depends on type of hydroponic system (gravel vs. raft), fish species, fish density, feeding rate, plant species, etc. For example, the Speraneo system described below is designed for one cubic foot of water to two cubic feet of grow bed media (pea gravel). Further, when shallow bed systems only three inches in depth are employed for the production of specialty greens such as lettuce and basil, the square footage of grow space will increase four times. Depending on the system design, the component ratio can favor greater outputs of either hydroponic produce or fish protein. A “node” is a configuration that links one fish tank to a certain number of hydroponic beds. Thus, one greenhouse may contain a multiple number of fish tanks and associated growing beds, each arranged in a separate node.

[Shaggy Dog]

Hey Marc I just heard of this thru one of my Aquaponics groups I belong to....Tell me if you know of this tree. I bought some seeds for it online.

The Moringa Oleifera tree

The leaves of this tree have been used to reverse malnutrition in children in India. Excellent stock and fish feed too....


Nature's Most Nutritious Vegetable Tree

    * A Nutritional Miracle - Nature's Best Kept Nutritional Secret

    * Leaves Contain almost ALL the Nutrients Required for Perfect Health

    * One of the few plants on Earth that contain ALL the Essential Amino Acids required for Human Protein Synthesis

    * One of Nature's Richest Sources of Vitamins, Minerals and Anti-Oxidants
    * The Perfect Food for Vegetarians

Imagine leaves that grow ABUNDANTLY on a tree that contain:

    * 27 % Protein (dry weight)

    * 8.5 times more Protein than yogurt (dry weight)

    * Rich Source of Vitamins B, B1, B2, B3

    * 7 times more Vitamin C than Oranges (wet weight)

    * 16.5 times more Calcium than Milk (dry weight)

    * 10.5 times more Vitamin A than Carrots (dry weight)

    * 15 times more Potassium than Bananas

    * 12 times more Iron than Spinach

The Moringa Vegetable Tree is by far the most important Vegetable Tree on Earth.

It is a veritable powerhouse of nutrients, vitamins, minerals and anti-oxidants that have been well-established to enhance and maintain your health and your immune system.

The Leaves, Pods and Flowers of the Moringa Tree are highly nutritious.

Moringa Leaves provide the answer to the perfectly balanced Vegetarian Diet which so often lacks in essential amino acids and other essential nutrients.

The evergreen or deciduous leaves (depending on climate) are 1-2 cm in diameter. They have a lovely soft texture and taste somewhere between lettuce and spinach.

Possibly the most nutritious of all leaf crops, Moringa leaves are 27% protein (dry weight) and have extremely high levels of folates, vitamin C, carotenes, calcium, iron, and niacin.

Moringa leaves make the perfect Green Leaf Base in any salad. Eat them in abundance and you will ensure that your body is receiving excellent nutrition far surpassing any artificial supplements.

As with any food that contains significant amounts of nutrients the leaves are best eaten raw so that the nutritional value remains intact. However, the leaves can also be prepared in the same way as Spinach.

The leaves can also be dried into a powder and used in soups and sauces.

Even though fresh and raw is always best, the nutritional value remains almost perfectly intact in the powdered form  and is the best way to store the Moringa Leaves (avoid direct sunlight when drying them).

If you would like to add the powder to cooked dishes remember the less heat the better.

The Moringa Tree is native to Northern India on the Southern Slopes of the Himalayas.  In Southern India it is said that no meal is complete without Moringa. In Ayurvedic Medicine it is said to cure over 300 `conditions' and was even revered in ancient Sanskrit texts.

The tree has since been intentionally cultivated in Africa and South America and is naturalized all the way down East Africa and has for a long while already been Naturalized in South Africa in the Limpopo and Kwazulu Natal.

The Moringa Tree has many different names in different cultures. Common names include: the Miracle Tree, the Drum Stick Tree (the pods are called Drum Sticks), the Clarifier Tree (referring to the ground seeds use as an amazingly effective flocculant - settling out of particles in fluids such as water, honey, wine, even industrial waste), the Ben-Oil Tree (the pods yield an excellent high quality nutritious oil called Ben-Oil), the Benzolive Tree, the Never-Die Tree, Mother's Best Friend, the Horseradish Tree and many more in different cultures throughout Africa and India.

Seems like a miracle tree...

[Crafty_Dog]

A friend writes:

Never mind that “windows to your soul” stuff—your eyes may reveal your risk of stroke.

In a study of 3,654 people, Australian scientists took retinal photographs of participants’ eyes, then tracked their medical records for seven years. The finding: Those with microscopic damage to their ocular blood vessels were 70 percent more likely to have a hemorrhagic stroke—the type where a blood vessel bursts—than those without any damage.

“Blood vessels in the eyes are structurally similar to those in the brain,” says lead author Paul Mitchell, M.D., speculating that a congenital weakness in one area might be mirrored in the other.

Ask your ophthalmologist to snap a “stereoscopic retinal photograph” at your next eye exam and send the images to a neurologist, especially if you have a family history of stroke.
============
Another friend responds:

We opthalmologists do this analysis for decades ourselves, calling this "fundus hypertonicus"(hypertension). This name was given about 100 years ago when we thought that arterial hypertension was the cause.  Hypertension can be the cause for the damage of the blood vessels, but there are also other causes. The striking point is that blood vessels of the retina are blood vessels of our brains from the anatomical point of view. Usually neurologists ask us for a diagnosis as we see a multiple number of blood vessels than neurologists do. It is routine for literally every patient. Neurologists have problems in diffential diagnosis in relation to opthalmological diseases. And patients with fundus hypertonicus seem to be prone to a variety of non-neurological diseases, which makes the observation not interesting for neurologists alone.
 
If your opthalmologist spots a fundus hypertonicus, he/she won't send you to the neurologist but preferably to a specialist for internal medicine to find the cause of the damage of your vessels. Usually it it not the damage of the retinal vessels alone but a damage of the vessel system. Question No 1: which vessels are affected (between top and toe) Question No 2: Why is that so?
 
From the many thousands of retinal bood vessels I have seen, there were a significant number with fundus hypertonicus. Above a certain age stadium I was quite common but people were usually without a serious disease. Stadium III had the usual mix of hypertension, diabetes, obesity, angina pectoris, very heavy smoking and some more. There was only one patient I remember. He is a friend of mine. There was nothing special, no complaints and he wanted the usual check up. I diagnosed a fundus hypertonicus (I forgot the stadium, guess it was more than II), sent him to the internal medicine department, they diagnosed an aneurisma of the Aorta.  The aneurima was operated and maybe I saved his life. But incidents like this are rare, very rare.
 
And - there are a lot of strokes without fundus hypertonicus.
 
Now a bit statistics: let us presume there are 1,827 patients (of the 3654) with damage of blood vessels and 1,827 without, the same age groups and the same risk groups. The group without damage has 10 stoke in 7 years, the group with damage 17. That is a difference of about 1 stroke per 1827 patients/per year. As these patiens often suffer from other artheriosclerosis diseases the retinal changes are self explaining, just adding another observation. .....
 
For the layman this sounds a bit different than the 70%. Presenting these 70% alone is misleading at best. I would like to see whole the study, the original.
 
The same statistical trap we can observe with breast cancer screening. Just a couple of days ago a review went through the press, a review which was a bit more critical than the usual bla bla.
 
Bob

[ccp]

Well that is the question that everyone asks.  And everyone has their own answer - half wrong and half right.

No one knows but you'd think everyone does listening to the opinions.

Politicians are darned if they do and darned if they don't.

Remember when the Bush haters railed against W for Katrina.  Naturally the whole thing from lack of preparedness to a slow response was his.

So BO could ignore the hypothetical threat of H1N1 and more likely then not it will fizzle out like the previous flu scares.
And risk another great pandemic the likes not seen in 81 years.
Or he can push for preparedness with funds, a vaccine that could pose unknown health risks and take no risk.

Either way there is someone to ciritcize him.



****Hospitals May Face Severe Disruption From Swine Flu 

By Tom Randall and Alex Nussbaum

Aug. 25 (Bloomberg) -- Swine flu may hospitalize 1.8 million patients in the U.S. this year, filling intensive care units to capacity and causing “severe disruptions” during a fall resurgence, scientific advisers to the White House warned.

Swine flu, also known as H1N1, may infect as much as half of the population and kill 30,000 to 90,000 people, double the deaths caused by the typical seasonal flu, according to the planning scenario issued yesterday by the President’s Council of Advisers on Science and Technology. Intensive care units in hospitals, some of which use 80 percent of their space in normal operation, may need every bed for flu cases, the report said.

The virus has sickened more than 1 million people in the U.S., and infections may increase this month as pupils return to school, according to the Centers for Disease Control and Prevention in Atlanta. If swine flu patients fill too many beds, hospitals may be forced to put off elective surgeries such as heart bypass or hernia operations, said James Bentley with the American Hospital Association.

“If you have 1.8 million hospital admissions across six months, that’s a whole lot different than if you have it across six weeks,” said Bentley, a senior vice-president of the Washington-based association, which represents 5,000 hospitals.

The scenario projections were “developed from models put together for planning purposes only,” said Tom Skinner, a spokesman for the CDC, at a briefing in Atlanta today. “At the end of the day, we simply don’t know what this upcoming flu season is going to look like. It could be severe, it could be mild, we just don’t know.”

Past Pandemics

The models were based on past pandemics, and the CDC is working on new projections based on the latest data gathered from swine flu patients, Skinner said. Those estimates should be available “soon,” he said, without further specifying.

President Barack Obama was urged by his scientific advisory council to speed vaccine production as the best way to ease the burden on the health care system. Initial doses should be accelerated to mid-September to provide shots for as many as 40 million people, the panel said in a report released yesterday. Members also recommended Obama name a senior member of the White House staff, preferably the homeland security adviser, to take responsibility for decision-making on the pandemic.

“This isn’t the flu that we’re used to,” said Kathleen Sebelius, U.S. health and human services secretary. “The 2009 H1N1 virus will cause a more serious threat this fall. We won’t know until we’re in the middle of the flu season how serious the threat is, but because it’s a new strain, it’s likely to infect more people than usual.”

Clinical Trials

Data from clinical trials to assess the safety and effectiveness of swine flu vaccines will start to become available in mid-September, health officials reported Aug. 21. Full results from the two-dose trials won’t be available until mid-October.

“We are making every preparation effort assuming a safe and effective vaccine will be available in mid-October,” Sebelius said today at the CDC’s Atlanta offices.

H1N1 has already reached more than 170 countries and territories in the four months since being identified, the Geneva-based World Health Organization said. Swine flu causes similar symptoms as seasonal strains. It has so far resulted in worse than normal flu seasons, with increased hospitalizations and cases of severe illness, the WHO said in an Aug. 12 release.

New Zealand and Australia, in the midst of their normal flu seasons, have reported intensive care units taxed to capacity by swine flu patients. The experience provides clues to what the U.S., Europe and Japan may see when the H1N1 virus returns.

President’s Advisers

The president’s advisory council describes as a “plausible scenario,” that 30 percent to 50 percent of the U.S. population will be infected in the fall and winter. As many as 300,000 patients may be treated in hospital intensive care units, filling 50 percent to 100 percent of the available beds, and 30,000 to 90,000 people may die, the group’s report said.

“This is a planning scenario, not a prediction,” according to the report. “But the scenario illustrates that an H1N1 resurgence could cause serious disruption of social and medical capacities in our country in the coming months.”

Peter Gross, chief medical officer at Hackensack University Medical Center in New Jersey, said if the group’s scenario comes true, “I think every hospital in America is going to be in a crunch. We’ll be hard pressed to deal with those predictions,” he said.

‘Overblown’ Estimates

The estimates seem “overblown,” Gross said, given that swine-flu outbreaks in 1968 and 1957 failed to cause as many deaths, even with medical technology and disease surveillance less advanced than today.

“Influenza, you can make all the predictions you want, but it’s more difficult than predicting the weather,” Gross said yesterday in a telephone interview, after the advisory report was made public. “If influenza was a stock, I wouldn’t touch it.”

The 775-bed hospital is planning for an outbreak, upping its order of flu medications and discussing where to put patients if the worst occurs, Gross said.

The President’s Council of Advisers on Science and Technology is chaired by John Holdren, the director of the White House Office of Science and Technology, Eric Lander, the head of the Broad Institute of Massachusetts Institute of Technology and Harvard University in Cambridge, Massachusetts, and Harold Varmus, the chief executive officer of Memorial Sloan-Kettering Cancer Center in New York.

The 21-member group of scientists and engineers, created by Congress in 1976, advises the president on policy involving scientific matters.

New Estimates

Seasonal flu usually kills about 36,000 Americans, Skinner said. Swine flu causes more severe illness needing hospitalization among younger people than seasonal flu, while leaving people 65 and older relatively unscathed, said Mike Shaw of the CDC.

The median age of those with the pandemic virus has been 12 to 17 years, the WHO said on July 24, citing data from Canada, Chile, Japan, U.K. and the U.S.

“We don’t know whether the number of severe illnesses will be much greater, but we do know that it’s a new virus and therefore people are very vulnerable,” said Anne Schuchat, director of the CDC’s Center for Immunization and Respiratory Diseases, in an interview yesterday.

Disease Burden

About 100 million people in the U.S. get the annual flu shot, Schuchat said. Pregnant women, who have “a disturbingly high burden of disease” from swine flu, only get vaccinated for seasonal flu about 15 percent of the time. Pregnant women are a top priority for vaccinations, she said.

Seasonal flu usually kills about 36,000 Americans. Swine flu causes more severe illness needing hospitalization among younger people than seasonal flu, while leaving people 65 and older relatively unscathed, said Mike Shaw, associate director of laboratory science at the CDC’s flu division.

The median age of those with the pandemic virus has been 12 to 17 years, the WHO said on July 24, citing data from Canada, Chile, Japan, U.K. and the U.S.

“People who get infected with this strain happen to be the healthiest members of our society,” said Shaw in a presentation yesterday at the agency.

The H1N1 strain is genetically related to the 1918 Spanish Flu that killed an estimated 50 million people. Variations of the Spanish Flu circulated widely until about 1957, when they were pushed aside by other flu strains. People whose first exposure to a flu virus was one of those Spanish Flu relatives may have greater immunity to the current pandemic, Shaw said.

To contact the reporters on this story: Tom Randall in New York at trandall6@bloomberg.net; Alex Nussbaum in New York at anussbaum1@bloomberg.net ****

[ccp]

Online antibiotic sales may be fueling drug-resistance trend, researchers report
Antibiotics are widely available for purchase online without a prescription, making it easy for patients to self-medicate and potentially contributing to antibiotic resistance, a recent study found.

Researchers conducted searches on Google and Yahoo using the keywords “purchase antibiotics without a prescription” and “online” and compared vendors according to classes of drugs, quantity, shipping locations and shipping time. Of the 138 vendors found, almost all shipped to the U.S., 36.2% sold antibiotics without a prescription and 63.8% provided an online prescription. Available antibiotics included penicillins (94.2% of sites), macrolides (96.4%), fluoroquinolones (61.6%) and cephalosporins (56.5%), and drugs were often sold in higher quantities than a single course. The results appear in the September-October Annals of Family Medicine.

The findings suggest that many antibiotics taken in the U.S. are not impacted by physician prescribing practices and may be contributing to antibiotic resistance, the authors said. The Web sites studied promote self-diagnosis and self-medication, they added, and drugs are likely to be used in inappropriate dosages. In addition, because the drugs are available in large quantities and take a week or more to be delivered, it is likely that they are being stored for future use or to sell.

The results indicate that the observed decline in overall antibiotic prescribing for viral illnesses may be misleading because patients are able to go online for medications when they can’t get a prescription from their physician. Physicians can play a role in mitigating the problem, the authors continued, by educating patients who self-medicate about antibiotic resistance and potential drug interactions.

Among other limitations, the study does not analyze how customers in the U.S. are using the Web sites and the quantities being purchased, the authors acknowledged. Nonetheless, the results highlight a need for increased regulation of Internet sites beyond controlled substances, they concluded.