Hypertension in 90% of Americans

Lancet focuses on blood pressure: Hypertension "uncontrolled and conquering the world" August 22, 2007 Michael O'Riordan New York, NY - With an estimated 1.5 billion people expected to be hypertensive by 2025, an argument making the case that hypertension is "uncontrolled and conquering the world" is not hyperbole. This staggering number, as well as the fact that the risk of becoming hypertensive is greater than 90% for individuals in developed countries, highlights the growing problem of uncontrolled hypertension, both in developed as well as undeveloped countries, according to an editorial appearing in the August 18, 2007 issue of the Lancet [1]. "Many people still believe that hypertension is a disease that can be cured, and stop or reduce medication when blood-pressure levels fall," the Lancet editorialists write. "Physicians need to convey the message that hypertension is the first and easily measurable irreversible sign that many organs in the body are under attack. Perhaps this message will also make people think more carefully about the consequences of an unhealthy lifestyle and help to give preventive measures a real chance of success." Hypertension, according to the Lancet, remains a problematic disorder, despite functioning healthcare systems, a large number of available effective treatments, and overwhelming evidence in various patient populations. Screening for hypertension, they point out, is not done systematically, and diagnosis is often made at a late stage when target-organ damage has already started. In addition, the optimum time to start treatment remains "under discussion." Both the editorial and seminar authors point out that compliance remains one of the biggest barriers to treating hypertension, despite very effective and cost-effective treatments. Even a Rhodes scholar, such as former President Bill Clinton, was under the false impression that medication can be stopped once blood pressure is lowered. While lifestyle interventions—low-salt diet, weight loss, exercise, and alcohol restriction—remain the preferred means of lowering blood-pressure levels, adherence to these changes is "notoriously poor," and antihypertensive medications might need to be considered in even some normotensive individuals, argue Messerli, Williams, and Ritz. The authors note that patients respond differently to the drug classes and that the most "important question to ask when selecting initial drug treatment is which class of drug will deliver the most effective blood-pressure lowering." For patients with blood pressure 20 mm Hg or more above goal, the guidelines recommend two-drug combinations, as monotherapy is likely to be insufficient. High-risk hypertensive patients not only should receive combination therapy for optimum blood-pressure control but also should receive a statin and low-dose aspirin, add Messerli and colleagues.

New Test for Spreading Breast Cancer

FDA Approves First Molecular-Based Lab Test to Detect Metastatic Breast Cancer The U.S. Food and Drug Administration today approved the first molecular-based laboratory test for detecting whether breast cancer has spread (metastasized) to nearby lymph nodes. The GeneSearch BLN Assay detects molecules that are abundant in breast tissue but scarce in a normal lymph node. The presence or absence of breast cancer cells in underarm lymph nodes is a powerful predictor of whether the cancer has spread and is used to help decide appropriate therapy for a woman with metastatic breast cancer. Lymph nodes are part of the system that helps protect the body against infection. The first lymph node that filters fluid from the breast is called the “sentinel node,” because that is where breast cancer cells are likely to spread first. During a lumpectomy or mastectomy to remove a breast tumor, surgeons commonly remove the sentinel node for examination under a microscope. Sometimes the sentinel node is examined immediately and if tumor cells are found, additional lymph nodes are removed. A more extensive microscopic examination, requiring one to two days for results, is almost always performed. If tumor cells are only found with the later microscopic examination, the patient may require a second surgery to remove the remaining lymph nodes. “The GeneSearch BLN Assay offers a new approach to sentinel node testing,” said Daniel Schultz, M.D., director of the FDA’s Center for Devices and Radiological Health. “Results of this rapid test are available while patients are on the operating table, providing a way for some women to avoid a second operation.” In a clinical trial, the GeneSearch BLN Assay showed strong agreement with results from extensive microscopic examination of the lymph nodes of 416 patients. The test accurately predicted that breast cancer had spread nearly 88 percent of the time in women with metastasis. Patients without metastasis were identified accurately 94 percent of the time. Most of the women were also studied to compare the BLN Assay with immediate microscopic examination during surgery. The test gave fewer false negative results, but slightly more false positive results. A false negative test result, when the cancer has actually spread, may delay the needed removal of additional lymph nodes. A false positive test, indicating metastasis when there is none, may result in a more extensive surgery and puts the women at risk of unnecessary lymphedema (swelling due to fluid build-up following lymph node removal) and other side effects. The GeneSearch BLN Assay is manufactured by Veridex, a Johnson & Johnson Company, of Warren, N.J.

Death Rate of Hip Fracture Higher than Breast Cancer in Elderly

May 18, 2007 — Older women are at greater risk for death after hip fracture than after breast cancer, according to a presentation at the American Geriatrics Society (AGS) annual meeting held in Seattle, Washington. The investigators suggest that increased awareness of mortality associated with hip fracture is needed to improve preventive measures. "This study should raise the general level of awareness of the impact of hip fracture on the lives of elderly women," coauthor Jane A. Cauley, DrPH, a professor of epidemiology at the University of Pittsburgh in Pennsylvania, told Medscape. "There is already a greater general level of awareness of the public health impact of breast cancer, but, in fact, our study showed that the mortality of breast cancer in this population was less than that of hip fracture. The public health impact on mortality was much greater for hip fracture than for breast cancer, even after adjustment." The authors concluded that older women are at a greater risk for death after hip fracture than after breast cancer diagnosis, and that increased awareness of mortality associated with hip fracture is needed to promote preventive measures. "The implications of this study are that we should aim more studies at the correct treatment of the patient with a hip fracture," S. K. Bulstra, MD, a professor of orthopaedic surgery at the University Medical Center Groiningen in the Netherlands, told Medscape. Dr. Bulstra was not involved with this study but was asked by Medscape to provide independent commentary. "Of course it is important to know whether these patients also had more comorbidity than the breast cancer patients," Dr. Bulstra said. "The reduced weight of the hip fracture group suggests a higher frequency of osteoporosis. It is also important to know if patients came from a home situation or a nursing home and how the mental status was assessed, because indeed there is a connection between survival and mental status." Dr. Bulstra's own research and experience suggest an increased mortality rate for 10 years or more after hip fracture, although the survival rate stabilizes after 2 years. Many patients are no longer able to live at home after hip fracture, which is related to their walking ability both before and after the fracture. Congestive heart failure, renal failure, liver disease, lymphoma, and weight loss each increased the 1-year mortality risk by approximately 2-fold. "Future studies should compare the effect of hip fracture and of breast cancer on quality of life in this population, in terms of functional disability, pain, mobility, and other outcomes," Dr. Cauley concluded.

Treatment at End of Life in Cancer Patients

Laurie Barclay, MD May 3, 2007 — For patients with advanced cancer, aggressive treatment in the last week of life is linked to a worse quality of death and less likelihood of dying in the place of the patient's choice, according to a presentation on May 3 at the American Geriatrics Society (AGS) annual meeting in Seattle, Washington. "We found that the greater the number of aggressive treatments these advanced cancer patients received in their last week of life, the more psychological and physical distress they experienced, as reported by family members or nurses who were with them at that time," presenter and lead author Gabriel K. Silverman, MS, an MD/PhD student at the Department of Social and Decision Sciences, Carnegie Mellon University, and the University of Pittsburgh School of Medicine in Pennsylvania, told Medscape. "Of patients who received no aggressive treatments in the days preceding their death, nearly 90% died in their preferred location, while this was true of only about a third of patients receiving two or more of these treatments. We found the reverse pattern of outcomes associated with duration of hospice use." "This study shows an association between aggressive treatment and psychological and physical distress, but that might be because people who are more distressed ask for more treatment, rather than because the treatment itself is causing distress," Dr. Arnold said. "More research is clearly needed, as is greater use of palliative care doctors at the end of life." Mr. Silverman pointed out that discussions about prognosis, goals of care, and treatment preferences, including the option of hospice care, should occur with more patients and earlier in the course of the disease. His group is now prospectively evaluating whether doctor-patient communication predicts aggressiveness of care at the end of life, and whether these treatments, in turn, affect the bereavement adjustment of close family members. "As a doctor, if I had a patient or family who wanted aggressive, life-sustaining care toward the end of their life, I would view it as a red flag warning of patient or caregiver distress," Dr. Arnold concluded. "Often patients and their families are suffering, sad, or distressed at the end of life, and when dying occurs in medical settings they may hope that aggressive treatment will help the suffering, but often it doesn't." The National Institute of Mental Health, National Cancer Institute, a predoctoral National Institutes of Health training grant in aging research, and the Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, supported this study. Mr. Silverman and Dr. Arnold report no relevant financial relationships. AGS 2007 Annual Scientific Meeting: Abstract P4. Presented May 3, 2007.

Blood Pressure Meds Reduce Memory Loss in Elderly

May 5, 2007 — Compared with other antihypertensive agents, centrally active angiotensin-converting enzyme inhibitors (ACEIs) are associated with slower rates of cognitive decline over 6 years in elderly people free of dementia at baseline, according to findings from the Cardiovascular Health Study (CHS) presented on May 5 at the annual meeting of the American Geriatrics Society in Seattle, Washington. "ACE inhibitors that cross the blood-brain barrier reduce cognitive decline by 50% compared [with] the decline seen in people on other blood pressure medications," presenter and lead author Kaycee M. Sink, MD, MAS, an assistant professor of internal medicine in gerontology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, told Medscape.

Blood Clots During Travel

The chances of developing deep vein thrombosis double after traveling for four hours or more, the World Health Organization (WHO) said on Friday. Its study estimates that 1 in 6,000 long-haul passengers is at risk. Tall people whose legs are jammed in economy class and the very short whose feet do not touch the ground are particularly vulnerable to potentially dangerous blood clots linked to immobility during travel, the United Nations agency said. The obese, women on birth control pills and those with blood clotting disorders are also more susceptible, as are frequent travelers and those who take very long journeys. "There is an increased risk of venous thromboembolism during travel where the passenger is seated and immobile over four hours, whether in a plane, train, bus or car," said Catherine Le Gales-Camus, WHO assistant director-general for non-communicable disease and mental health. "What causes the risk is immobility," she told a news conference. "The risk is not only true for people flying." About 2 billion people travel by air each year and many more take overland trips where they sit still for prolonged periods. Health experts said the overall prevalence of deep vein thrombosis is relatively low, noting that the 1 in 6,000 ratio includes those with small or asymptomatic clots. Still, it means an average of one person is affected for every 20 long-haul flights carrying 300 passengers. To reduce the chance of developing blood clots, WHO special advisor Shanthi Mendis said travelers should exercise their calf muscles with up-and-down movements of the feet and ankle joints, and leave their seats for a few minutes when possible. Mendis cautioned air passengers against taking sleeping pills or drinking too much alcohol. People should also avoid wearing tight clothing that can constrict circulation, she said.

Patients with Diabetes - Best Way to Follow?

Heartwire 2007. © 2007 Medscape July 3, 2007(Chicago, IL) - A small but clinically relevant change appears to be coming to the management of patients with diabetes mellitus. Hemoglobin A1c (HbA1c) levels, used to assess long-term glycemic control, might soon be replaced with average blood glucose, a change experts say will add clarity for diabetic patients looking to manage their disease. Discussing the expected change here at the American Diabetes Association (ADA) 2007 Scientific Sessions last week, Dr David Nathan (Harvard University Medical School, Boston, MA) said that "patients have a glucose problem, not a hemoglobin problem" and that fasting glucose would be a better measure, as this new value "would help them understand their disease better." Reporting glycohemoglobin results as an A1c-derived average glucose, said Nathan, would have the advantage of reporting chronic glycemia in the same units as the patients' self-monitoring of daily glycemia. Nathan is the lead investigator of the international ADAGE trial, a study performed to confirm the relationship between average glucose and HbA1c levels. To date, only a few studies with relatively infrequent glucose monitoring support a strong mathematical relationship between average glucose and HbA1c, but if a switch is to be made from HbA1c to average glucose levels, an international study is needed to establish the relationship across diabetes type, races, and ethnicities, said Nathan.

Safe Fish and Concerns

EWG’s Fish List What Women Should Know About Mercury In Fish Avoid If Pregnant Shark Swordfish King mackerel Tilefish Tuna steaks Canned tuna Sea bass Gulf Coast Oysters Marlin Halibut Pike Walleye White croaker Largemouth bass Eat No More Than One Serving From This List Per Month Mahi mahi Blue mussel Eastern oyster Cod Pollock Great Lakes salmon Gulf Coast blue crab Channel catfish (wild) Lake whitefish Lowest In Mercury Blue crab (mid-Atlantic) Croaker Fish Sticks Flounder (summer) Haddock Trout (farmed) Salmon (wild Pacific) Shrimp * * Shrimp fishing and farming practices have raised serious environmental concerns. ** Farmed catfish have low mercury levels but may contain PCBs in amounts of concern for pregnant women. Data From The 1970s Show High Concentrations (No Recent Data Available) Porgy Orange Roughy Snapper Lake Trout Bluefish Bonito Rockfish

Agribusiness/Power Subsidies

POWER DRAIN OAKLAND - Some of America's richest and largest farms are paying pennies for the vast amounts of electricity needed to deliver irrigation water to California's arid Central Valley. In 2002 and 2003, agribusinesses in the Central Valley Project (CVP) paid only about one cent per kilowatt-hour for electricity to transport irrigation water, according to a 15-month investigation by Environmental Working Group (EWG). Compared to Pacific Gas & Electric's agricultural rate, that's an annual subsidy of more than $100 million from U.S. taxpayers. EWG's report is available at www.ewg.org. It shows both the price paid by each CVP irrigation district in the years studied and the amount of energy the district used. Every year the CVP, the nation's largest federally subsidized irrigation system., moves more than 2 trillion gallons of water through 1,500 miles of canals. The electricity needed to move water around the CVP would power every home in Chico for 18 months. But just as CVP contractors pay heavily subsidized rates for their water, they pay next to nothing for the power that delivers it. Through the federal Freedom of Information Act, EWG obtained U.S. Bureau of Reclamation documents that enabled us to calculate, for the first time, the rate paid by CVP agribusinesses and the value of their power subsidy. We found: CVP power rates were 10 to 15 times lower than PG&E's industrial, agricultural or residential rates. In Westlands Water District, the largest and most politically powerful irrigation district in the CVP, power subsidies in 2002 were worth about $165,000 per farm. The CVP power sold to farms by the U.S. Bureau of Reclamation is essentially unregulated. No government agency, other than the Bureau itself, oversees its rates. "In an era when other Californians have been rocked by volatile electricity prices and the constant threat of rolling blackouts, a few thousand agribusinesses are guranteed dirt-cheap power, courtesy of U.S. taxpayers," said EWG Senior Analyst Renee Sharp, lead investigator for the report. "These subsidies are not helping small farms survive, but padding the profits of the biggest and richest farms." Cheap power is just the tip of the iceberg of federal subsidies to the CVP: Department of Agriculture data show that from 1995 to 2004, CVP agribusinesses received more than $890 million in direct commodity payments, mostly for cotton and rice. An earlier EWG investigation conservatively estimated the value of CVP water subsidies at $416 million in 2002. In total, federal subsidies to the CVP easily top more than half a billion dollars a year and could well reach $1 billion Ð all at taxpayers' expense. The report recommends that CVP agribusinesses should be required to pay prices approximating market rate for the power used to store and move irrigation water. A federal agency should regulate power rates to ensure system fairness, and should make these rates publicly available. CVP contractors, and contractors in other federal water projects, should not be allowed to "double-dip" and "triple-dip" on federal subsidies. # # # EWG is a nonprofit research organization based in Washington, DC that uses the power of information to protect human health and the environment. The group's research on Power Subsidies is available online at http://www.ewg.org/reports/powersubsidies/.

Asbestos and the Lungs

Disenfranchising Those with Lung Cancer More than 10,000 people a year die from asbestos disease, 5,000 of them from asbestos-caused lung cancer. It is precisely people like these, those most seriously harmed and dying from asbestos disease, that the Senate leadership has claimed to be helping with its series of asbestos trust fund bills. Few proposals have lived up to that claim, but the current proposal is perhaps the cruelest of all to date. The Specter/Leahy asbestos bill delivers unusually harsh treatment to victims of asbestos-caused lung cancer. First, the bill establishes criteria that are not recognized by the American Lung Association or the American Thoracic Society requiring that all lung cancer victims also have advanced-stage non-cancer asbestos disease in order to qualify for any level of assistance. But the more insidious disenfranchisement of lung cancer victims becomes apparent only when the exposure criteria in the bill are applied to a sample applicant. W.R. Grace Company Indicted on Federal Criminal Charges Read More This analysis reveals that the Specter/Leahy bill denies any and all compensation to people with confirmed asbestos-caused lung cancer if they entered the workforce after 1978, just four years after the peak of asbestos use in the U.S. of 1.4 billion pounds annually. Like all asbestos victims seeking justice, they will have their cases thrown out of court. But lung cancer victims whose asbestos exposure started after 1978 will never receive a penny from the fund because it will have expired before they can accumulate enough asbestos exposure under the newly minted exposure criteria in the bill. This disenfranchisement would affect even those people with asbestos-caused lung cancer who worked every year from 1978 through the termination of the fund in 2035 in what is characterized euphemistically as a "moderate" exposure environment, defined as working: "in areas immediate to where asbestos-containing products were being installed, repaired, or removed under circumstances that involved regular airborne emissions of asbestos fibers." (Section 121 (a) 16 (B)) For some lung cancer victims, compensation is even less likely. All individuals with a level VII claim, confirmed asbestos-caused lung cancer with bilateral pleural plaques, will have compensation denied if workplace exposure began after 1974. Lung cancer has a five-year mortality rate of 95 percent. The reason that all of these lung cancer victims receive nothing is the convoluted exposure criteria in the bill. These criteria declare, without any medical substantiation to support them, that every year of continuous daily exposure to asbestos that occurred after 1976 counts as just one half year, and if that exposure occurred after 1986, it counts only as one tenth of a year, or 36.5 days (Section 121 (a) 16 (E)). There is no medical or scientific rationale for devaluing a year of work exposure to "regular airborne emissions of asbestos" by 50 percent if that exposure was between 1976 and 1985 and by 90 percent if exposure took place after 1986. Asbestos use peaked in the U.S. in 1974, at 1.4 billion pounds; use in 1976 was clearly over 1 billion pounds, and workplace safety standards recommended by the National Institute of Occupational Safety and Health (NIOSH) were not adopted by the Occupational Safety and Health Administration (OSHA) until 1994 (NIOSH 2002), a full 18 years after the bill begins to devalue a year's worth of work around asbestos. Nor would full compliance with the OSHA standard mean that workers would not die at an excessively high rate from asbestos-caused lung cancer. The preamble to the OSHA standard itself estimates that one in every 300 workers will develop lung cancer from exposure at the legal limit (OSHA 1986). A more recent assessment concludes that one in every 200 workers will develop lung cancer if they are exposed to a career's worth of asbestos at the OSHA "safe" level. Compliance with OSHA's permissive standard is spotty. In 1999, asbestos air levels exceeded the far weaker pre-1980 "permissible exposure limit" at 13 percent of construction and 5.6 percent of manufacturing sites monitored (NIOSH 2002). This pre-1980 limit, which was established by the Mine Safety and Health Administration (MSHA) and still applies to mining, is 20 times less protective than the 1994 OSHA standard (0.1f/cc vs. 2 f/cc). Between 19 and 91 percent of all mining sites sampled between 1982 and 1991 exceeded the 1994 OSHA standard. In 1991, 32.4 percent of mining sites sampled exceeded this level. An example of the Specter/Leahy criteria The unfairness of the Specter/Leahy criteria are best understood by applying them to a hypothetical applicant to the fund who has lung cancer. For lung cancer level VII (with bilateral pleural disease) a person filing a claim with the trust would need 12 years of weighted exposure (pg 82). If exposure started in 1971, it would take 34 years of continuous exposure to meet the 12-year exposure requirement in the bill. This person, and everyone beginning continuous exposure in 1971 or earlier, would qualify for compensation, assuming all other criteria are met. For every year past 1971 that the person started working with asbestos under the "moderate exposure" criteria described above, it will take an extra 10 years of occupational exposure to meet the criteria for compensation in the bill. Thus, a person with asbestos-caused lung cancer and pleural plaques who began occupational exposure in 1974 would need 52 years of work exposure (through 2035, or "until" 2036) to meet the 12 year weighted exposure criteria in the bill. After that, the fund will have been terminated. 1974 - 1975 each year counts as a full year - total 2 years 1976 - 1985 each year counts as one half year - total 5 years 1986 - 2035 each year counts as one tenth year - total 5 years Example 1 Patient has lung cancer with bilateral pleural disease Example 2 Patient has lung cancer with 1/0 asbestosis Example 3 Patient has lung cancer with 1/1 asbestosis References National Institute for Occupational Safety and Health (NIOSH) (2002). "Work-related lung disease surveillance report." Division of Respiratory Disease Studies. Occupational Safety and Health Administration (OSHA). (1986). "Final Rule: Asbestos." 51 FR 22612. Department of Labor, Occupational Safety and Health Administration. June 20, Federal Register.

Fuel Economy Laws and Failure to Enforce

Real MPG: Putting the Truth in Your Tank The U.S. would have imported about 20 percent less foreign oil in 2005 if automakers met federal fuel efficiency or miles per gallon (MPG) standards based on real world driving conditions. That reduction is equivalent to more than 1.3 times the amount of oil imported from Saudi Arabia in 2005, or about two million barrels of oil per day. For consumers this translates into 33 billion gallons of gasoline saved that year. Instead, over the past 20 years, car company lobbyists and their friends in Congress have dramatically increased US dependence on foreign oil by prohibiting the EPA from requiring MPG tests that reflect how people actually drive. In the car company test for compliance with corporate MPG requirements, cars never exceed 60 miles per hour, never have the air conditioning on, never go up hills, never accelerate rapidly and always drive in perfect weather. According to several EPA analyses, these test results exaggerate real world MPG by about 25 percent for city driving and 30 percent on the highway. Bogus mileage tests are the cornerstone of car company compliance with government MPG standards. Since 1985, car companies have generally been required to meet fleet MPG averages of 27.5 for cars, and between 19.5-22.2 for trucks [†1]. Real world MPG is far lower, at about 21.7 for cars and 16.3 for trucks. Congress publicly identified this problem in 1980. If car company lobbyists, at that time, had not blocked congressional action to base federal fuel efficiency standards on real world driving conditions the U.S. would currently be saving 710 million barrels of oil per year, or about 20 percent of all the United States' imports in 2005. That is the equivalent of more than 1.3 times the 525 million barrels that the United States imported from Saudi Arabia last year. Significant oil savings do not require an increase in MPG standards. Congress could achieve vast savings simply by requiring automakers to stop deceiving the public and instead subject their vehicles to real fuel efficiency tests rather than the inaccurate, outdated tests currently prescribed by law. Many drivers know that the mileage number on their car's window sticker is inaccurate, and that cars rarely get the mileage that is advertised. But few people know that the number on the window is not the one that car companies use to meet corporate gas mileage standards. Instead, car company lobbyists and Congress have created what the Center for Auto Safety calls two sets of books when it comes to gas mileage (CAS 2004). This legally sanctioned deception dates back more than 25 years. In 1980, the U.S. House of Representatives Committee on Government Operations assessed the effectiveness of fuel efficiency standards that Congress had passed in 1975. The Committee found that: ...most new cars sold in this country do not achieve on road the fuel economy standards set by Congress. However, it should be noted that car manufacturers are deemed in compliance with the fuel economy standards mandated by Congress in 1975. American car owners and the entire U.S. economy will both be the losers if that situation is not remedied. Both will pay millions of dollars more, and both will remain more reliant on foreign oil sources, as a direct result of the needless waste of automobile fuel (HCOGO 1980). The Committee found that model year 1978 cars with government rated fuel efficiency of 27.5 miles per gallon achieved only 19 miles per gallon on the road, a shortfall of 30 percent that is essentially the same shortfall that occurs today. In addition, the Committee found that the shortfall between the government mileage ratings and real world driving could cause the U.S. to burn an extra one million barrels of gasoline per day by 1985. How the Automakers Drive/How You Drive The problem, the Committee found, was the grossly inaccurate testing procedures for measuring fuel efficiency; procedures that remain in place today. The city portion of the test is based on a simulated drive to work in Los Angeles in 1965 when congestion was much lower than it is today. The highway portion of the test was developed by the Environmental Protection Agency (EPA) in 1974 and was designed to represent a mix of interstate and freeway driving at a time when the national speed limit was 55 miles per hour. Congress eliminated the national speed limit in 1995 and states have instituted speed limits of 65 or 70 miles per hour (EPA FR 2006). Not surprisingly, neither the highway nor city test reflects real world driving behavior or gas mileage. One major difference is speed. On the highway test, cars average just 49 miles per hour and never exceed 60 miles per hour. Yet according to the EPA, recent reports show that 28 percent of all driving occurs at speeds greater than 60 miles per hour. Higher speed can dramatically reduce fuel efficiency (EPA FR 2006). In addition, the acceleration rates in both the city and highway tests are 3.3 miles-per-hour per second despite recent studies of real world driving which show that acceleration rates can be as high as 12 miles-per-hour per second. Rapid acceleration can seriously cut gas mileage. Even when the tests were developed, acceleration rates were higher in the real world. Yet, at the time, the dynamometers (treadmills for cars) on which the tests were completed did not allow for faster acceleration. Today's dynamometers allow for rapid acceleration even though rapid acceleration is not incorporated in mileage testing (EPA FR 2006). Other significant differences between the driving tests and real world driving are the use of accessories and ambient temperature. Neither the city test nor the highway test uses accessories such as air conditioning, heating or defrosting. Air conditioning in particular can reduce fuel efficiency. In addition, the tests are conducted at 75 degrees F even though only 20 percent of all driving occurs within five degrees of this temperature. Fuel efficiency is lower at temperatures that are above and below 75 degrees. Finally, because the tests are conducted on a dynamometer rather than on the road, the automakers do not have to account for a variety of conditions that can reduce fuel efficiency including roadway roughness, hills, wind, tire pressure, heavier loads (trailers, cargo, multiple passengers), the effects of ethanol in gasoline and others (EPA Preamble 2006). A Band-Aid Approach Despite these discrepancies, Congress and the automakers have resisted real change. In 1980, confronted by inaccuracies in the testing program, automakers General Motors and Ford suggested that the car labels be adjusted so that consumers would have more accurate information. However, the automakers opposed changing the driving test so that they would comply with federal fuel efficiency standards. "That approach is anathema to the auto makers," the Committee on Government Operations reported. Ford argued to the Committee that the testing procedures were fixed by law despite evidence that EPA could have modified the test. The Committee recommended changing the test to accurately reflect mileage for the 1986 and later model years. In 1984, the EPA adopted the approach favored by the automakers. Since that year, the Agency has adjusted the mileage figures produced by the driving test downward before placing the numbers on cars' window stickers (CAS 2004). The agency lowers the city test figure by 10 percent and the highway figure by 22 percent (EPA 2006). This adjustment provides consumers with somewhat more accurate information. But the test for determining compliance with fuel efficiency standards remains grossly inaccurate. Congress Ensures that Automakers are Falling Short The result of the inaccurate driving test is that automakers are failing to meet federal fuel economy standards established by Congress in 1975. Automakers' current fleet of cars must average 27.5 miles per gallon while SUVs and light trucks must average 22.2 miles per gallon. According to EWG's estimate, the true figures are closer to 21.7 miles per gallon for cars and 16.3 miles per gallon for SUVs and light trucks. A recent on-road study by Consumers Union of more than 300 cars and trucks found that 274 delivered lower fuel economy than promised by EPA (CU 2005). Consumers Union found that its estimated mileage for 2003 model year cars was 30 percent lower than that reported to the government for purposes of complying with federal fuel efficiency standards. This discrepancy is the same as that reported by the House Committee on Government Operations for 1978 model year cars. Moving toward Real MPG For more than a quarter century, federal law has required automakers to save oil by meeting mileage standards for their cars. This law grew out of concern over the United States' economic vulnerability to unstable foreign sources of oil. Congress acknowledged that one of the best ways to reduce this vulnerability is simply to use less oil. But as long as the mileage standards have been on the books, the automakers have evaded the spirit of the law by using a bogus driving test. The test allows automakers to claim that they are meeting federal mileage standards when in fact they are not. The losers in this scheme are citizens who must now pay $3.00 a gallon for gasoline to operate vehicles that deliver significantly less gas mileage than advertised. In addition, the U.S. is more dependent on foreign oil than ever before — in no small part because of the automakers' deliberate gas mileage deception. It does not have to be this way. EPA has designed emissions tests that incorporate many of the real-world driving standards and uses them to measure automakers' compliance with pollution emissions standards. For example, EPA tests auto emissions using a cold weather city driving test known as Cold FTP in which fuel efficiency is about 12 percent lower than in the normal city test. EPA also measures car pollution using a test with the air conditioning on known as SC03 that produces fuel efficiency numbers that are about 21 percent lower than in the normal city test. And EPA runs a third test known as the US06 that incorporates rapid acceleration and high speed. Results from this test are about 30 percent lower than mileage results from a composite of the normal city and highway tests. Acting on a petition by Bluewater Network, EPA recently announced that it plans to use these three tests to produce more accurate mileage stickers for consumers. But EPA has said that it will not use the tests to improve automakers' compliance with vehicles' fuel efficiency. Recommendations It's time for Congress to mandate one test for pollution, MPG compliance, and the sticker on the window in the showroom. Test methods similar to those found in Senate Bill 3543 would be a good start. It is outrageous that car companies have been allowed to deceive the American public for decades about the real MPG of their cars. Requiring a real driving test is not a substitute for enacting higher mileage standards for cars, but it is an essential step to making cars more efficient and to reducing dependence on foreign oil.

California - Toxic Chemicals

Stolen Inventory: Bush Rollback Will Hide Data on 600,000 Pounds of Toxic Chemicals in California The Bush Administration has adopted regulations that will dramatically roll back Americans' right to know about chemical hazards in their neighborhoods, allowing California industries to handle almost 600,000 pounds of toxic chemicals a year without telling the public, according to an investigation of federal data by Environmental Working Group (EWG). For more than 20 years, the U.S. Environmental Protection Agency's Toxics Release Inventory (TRI) program has required industrial facilities to report the release, disposal, incineration, treatment or recycling of 650 chemicals covered by the law. Comprehensive TRI reporting has been required for facilities that handle at least 10,000 pounds a year or manufacture 25,000 pounds per year, and discharge or dispose of at least 500 pounds per year of the listed chemical. But just before Christmas, the EPA gutted the TRI by sharply raising the detailed reporting threshold so that only releases of at least 2,000 pounds of chemicals will be subjected to detailed reporting. Facilities that don't meet the threshold must only indicate that they use a chemical. The agency adopted the rollback over the objections of more than 122,000 American citizens, corporations, government agencies and others who wrote in to protest the change. [OMB Watch 2006] EWG's investigation of TRI data from 2004 found that the proposed EPA rollback deals a crippling blow to Californians' access to information about toxic chemicals in their communities: The rollback will allow 274 industrial facilities in 30 counties to stop detailed reporting on the use or release of 595,422 pounds of hazardous chemicals a year. In Los Angeles County alone, 247,097 pounds of chemicals a year from 107 facilities will no longer be subject to reporting. In Alameda and Contra Costa counties combined, almost 66,000 pounds from 29 facilities will no longer be reported. In Orange County, more than 58,000 pounds from 27 facilities will no longer be reported. EPA Will End Detailed Reporting of nearly 600,000 Lbs. of Waste a Year in California County Facilities reporting releases between 500 and 2000 pounds and waste management activities up 5000 pounds in 2004 Number of facilities Emissions (pounds) Annual Reportable Amount (pounds) Los Angeles County 107 123,991 247,097 Contra Costa County 15 24,365 34,021 Orange County 27 23,111 58,202 San Bernardino County 19 19,341 34,542 San Diego County 16 18,768 39,496 Alameda County 14 12,961 31,918 Kern County 12 12,253 22,239 Solano County 4 7,091 16,219 Riverside County 4 6,691 14,091 Humboldt County 2 6,330 6,950 California Total 274 505,169 595,422 See Full List of Counties The rollback will allow 52 California facilities to stop reporting any details of their use or release of toxic chemicals. These facilities will be allowed to handle 69,426 pounds of toxic chemicals a year without detailed public disclosure. 52 Facilities Will Be Exempt From Detailed Waste Reporting Facility Facilities reporting releases between 500 and 2000 pounds and waste management activities up 5000 pounds in 2004 Number of chemicals Emissions (pounds) Annual Reportable Amount (pounds) Coatings Resource Corp., Huntington Beach 3 3,103 3,103 Westway Feed Products Co, Stockton 1 1,850 1,850 Distinctive Appliances Inc Aka Dacor, City Of Industry 1 1,728 2,592 Solvay Draka Inc., Commerce 1 1,705 1,710 Bardon Enterprises Inc, Santee 2 1,579 1,579 Century Plastics Inc, Compton 1 1,473 1,473 Prc-desoto International Inc., Glendale 1 1,450 1,450 Gillig Corp, Hayward 2 1,381 3,264 American Polystyrene Corp, Torrance 1 1,371 1,371 P.f.i. Inc., Santa Fe Springs 1 1,369 1,629 California Total 52 60,029 69,426 See Full List of Facilities Chemicals for which reporting will be slashed or curtailed are among the most hazardous to human health. The rollback will end annual reporting in California of more than 41,000 pounds of ethylbenzene, 10,000 pounds of styrene, 12,000 pounds of benzene and almost 16,000 pounds of chromium and chromium compounds - all known or suspected carcinogens. It will also eliminate annual reporting for more than 6,200 pounds of chemicals that meet the EPA's criteria for persistent bioaccumulative toxics, or PBTs - chemicals that present the greatest threats to human health and the environment. [EWG 2006]. Although the proposed rollback will reduce the total amount of chemicals used in California that must be reported to the TRI by less than 1 percent, reporting for many individual chemicals will drop sharply. All reporting will end for five different chemicals and reporting will drop by 10 percent or more for 69 chemicals. The TRI is the nation's premiere pollution reporting and citizens' right-to-know program. It is widely recognized as the least controversial environmental program in the country and has been praised by industry and environmentalists as an effective way to increase chemical use efficiency and reduce waste and pollution. The TRI is the only source of chemical-specific information on industrial pollution at the individual facility level. It is an essential source of information for state and local governments and community activists nationwide. Established in 1986, the TRI imposes no mandatory pollution controls on industry, but instead requires the reporting of estimated levels of release and disposal for 650 chemical compounds (less than one percent of chemicals registered for use in the U.S.) by some 23,000 facilities. This simple act of public disclosure is widely credited with spurring voluntary pollution reductions, with total U.S. chemical releases dropping 65 percent since 1989. [Hogue 2005]. In 2006, after the EPA first proposed rolling back the TRI, a report by a dozen state attorneys general, including Bill Lockyer of California, cited striking reductions achieved by industry since the program began: Boeing Company cut its toxic chemical releases by over 82 percent; Monsanto cut its toxic air emissions by over 90 percent; and the Eastman Chemical Co. cut its releases of TRI chemicals by 83 percent. [Spitzer 2006.] In January 2006, the attorneys general wrote to the EPA to protest the planned rollback, saying: "The proposed changes to the rule are not consistent with the purpose of TRI - to provide a maximum amount of information regarding toxic chemical use and releases to Americans - but directly contrary to the statutory purpose." The AGs said the proposed changes "violate the old saying: 'If it ain't broke, don't fix it.' " They said: The changes would significantly reduce the amount of information about releases of toxic chemicals available to the public and as a result would impair efforts by federal, state and local governments, workers, firefighters and citizens to protect Americans and their environment from the harm caused by discharges of toxic chemicals to the air, water and land. In addition to being contrary to the public interest and sound policy, the proposed changes would violate the Emergency Planning and Community Right-to-Know Act, the Pollution Prevention Act, and the Administrative Procedure Act. [Spitzer 2006.]

CDC Study on Breast Milk in Boston Area

New study from CDC and Boston University shows babies getting unsafe dose of perchlorate New study from CDC and Boston University shows babies getting unsafe dose of perchlorate, underscores need for federal action An Environmental Working Group (EWG) analysis of recently published data from scientists at the Centers for Disease Control (CDC) and Boston University (BU) shows that infants are being exposed to dangerous levels of the rocket fuel component perchlorate. The CDC/BU study, which examined breast milk from 49 Boston area women, found that the average infant in this study is being exposed to more than double the dose of perchlorate that the Environmental Protection Agency (EPA) considers safe; highly exposed babies are ingesting up to 10 times this amount. [1,2] Boston area infants are exposed to unsafe levels of perchlorate in breast milk At the 95th percentile perchlorate dose level in women with lower iodide intake, CDC found a 20% drop in thyroid hormone levels Calculations based on 4kg infant and average daily infant intake of 0.78 liters breast milk. Sources: 1, 3. If this weren't troubling enough, in September of 2006, the CDC published a study showing significant changes in thyroid hormone levels in women who were exposed to far less perchlorate than babies drinking breast milk in this study, and less than the EPA "safe" dose. [3] Since it is also well known that infants are at much greater risk for thyroid hormone disruption than adults, taken together, the findings of these two studies show that the perchlorate levels found in the breast milk of ordinary American women could be threatening the normal development of their exposed infants. [4] Perchlorate, the explosive ingredient in solid rocket fuel, has leaked from military bases and defense and aerospace contractors' plants in at least 22 states, contaminating drinking water for millions of Americans. The chemical has also been found to contaminate dairy milk, produce, and many other foods and plants. [5-12] In a related 2006 study, the CDC found perchlorate in the urine of every one of 2,820 people tested, suggesting that food is a key route of exposure in addition to drinking water. [13] Boston's tap water is not known to be contaminated with perchlorate; the 49 women in this study were likely exposed through food. [14] Infants are at greater risk for thyroid disruption by perchlorate than adults for several reasons. Perchlorate acts by inhibiting the thyroid gland's ability to take up the nutrient iodide, a key building block for thyroid hormone. Unlike adults, infants have minimal stores of thyroid hormones and must rely instead on their own daily production (breast milk does not contain significant quantities of thyroid hormone). Therefore, while adults may be able to use hormone stores to make up for temporary shortages related to chemical insults, infants can only do this to a very small degree. [4] While thyroid hormones regulate metabolism in adults and long-term deficiencies can lead to chronic health problems, the consequences for thyroid disruption in infants are much more serious. Normal thyroid hormone levels are critical for normal brain and organ development, and recent research has shown that infants can suffer permanent neurological deficits from even short-term thyroid hormone insufficiency. [15,16,17] On average, babies drinking breast milk in the Boston study would be exposed to 19 times more perchlorate than the September, 2006 CDC study found would depress thyroid hormone levels by 20 percent in adult women with lower iodide intake (thirty-six percent of women in the U.S. have urinary iodide levels in this "lower" range). [3] To make matters worse, the Boston study found that 47 percent of the babies tested were not getting adequate levels of iodine from breast milk. Since the effects of perchlorate are compounded by insufficient iodide consumption, these babies are at even greater risk for thyroid hormone disruption. [1] Notably, the Boston study also found that even moms who ingested extra iodine by using iodized salt or taking multivitamins containing iodine didn't always have sufficient iodine in their breast milk. [1] This finding is important because it underscores the need for the government to act to reduce perchlorate contamination of food and drinking water, rather than just simply pointing to iodized salt and multivitamins as quick fixes to the perchlorate problem. Earlier research confirmed—health protections still lacking The CDC/BU study confirms earlier research that found high levels of perchlorate in breast milk. [18,19] One study, for example, found perchlorate in every one of 36 samples of breast milk from nursing mothers in 18 states at levels as high as 92 parts per billion (ppb). [18] The Boston study found even higher levels of perchlorate among its 49 women, with a maximum concentration of a startling 411 ppb. The median perchlorate level in CDC/BU study was 9 ppb. [1] The Boston study also measured perchlorate concentrations in the mother's urine, finding a median level of 3.0 ppb. More important than the actual values, however, is the fact that these concentrations are remarkably similar to the levels of perchlorate that the CDC found in its much larger study of perchlorate exposure that tested the urine of more than 2,800 individuals. [13] In that study, the median urinary perchlorate concentration was 3.6 ppb. Since the perchlorate exposures in the two studies are so closely aligned, one can assume that the high levels found in the Boston women's breast milk are, unfortunately, probably typical of the general U.S. population. CDC's large study of urinary perchlorate levels also raises concerns about fetal exposures. CDC found that in the 36 percent of U.S. women with low iodine intake, almost any amount of perchlorate exposure was linked to a significant change in levels of thyroid hormones. [3] For about 1 in 10 of these women, exposure to perchlorate in drinking water at 5 ppb would result in subclinical hypothyroidism; this is a condition that requires treatment if these women become pregnant because it may negatively impact the brain development of their fetus if left untreated. [20] EWG estimates that there are more than 2.2 million women who fall into this latter category. [21] Conclusion Taken together, the weight of the evidence from these studies strongly support the conclusion that perchlorate is a major public health threat that needs to be addressed. Yet, there are still no federal safety standards for perchlorate in drinking water or food. Under pressure from the Pentagon and the defense industry, EPA has delayed setting a drinking water standard for perchlorate. California is in the final stages of adopting a perchlorate drinking water standard of 6 ppb, recommended by state scientists before release of the September, 2006 CDC study. The proposed standard in New Jersey is 5 ppb. Last July, Massachusetts adopted 2 ppb as the nation's first legally enforceable drinking water standard. Senators Boxer, Feinstein, and Lautenberg and Representative Solis from California have introduced legislation in the U.S. Senate and House of Representative that seeks to improve perchlorate monitoring and regulation to better protect public health. Recommendations Breast milk is by far the healthiest food for infants. However, the perchlorate levels found in breast milk in this CDC/BU study are alarming. The doses of pechlorate that infants are getting from ingesting this food are far higher than doses that have been shown to cause significant disruptions of thyroid hormone levels in many adult women. We also know that infants are more vulnerable than adults to the health effects of perchlorate exposure. The level of perchlorate found in breast milk in this study suggests a serious threat to the normal development and health of potentially all American infants. To protect public health: EPA must adopt a maximum contaminant level for perchlorate in drinking water based on the most recent science, including the 2006 CDC study and the Boston study described above. The 2006 CDC study showed convincingly, with statistically valid data from a large human population, that perchlorate levels well below the EPA's "safe" dose cause significant thyroid hormone depression in adult women of childbearing age. With the CDC study showing that even less than 1 ppb perchlorate in water may pose health risks to women, fully protective drinking water standards must be set as low as possible—at no more than 1 ppb—and revised downward as detection and cleanup technology improves. The Food and Drug Administration must also adopt an action level for perchlorate in food that is designed to protect the fetus, infants and children from the adverse effects of these exposures. References: [1] Pearce EN, Leung AM, Blount BC, Bazrafshan HR, He X, Pino S, Valentin-Blasini L, Braverman LE. 2007. Breast milk iodine and perchlorate concentrations in lactating Boston area women. Journal of Clinical Endocrinology and Metabolism epub Feb 2007. [2] Ginsberg G, Rice D. The NAS perchlorate review: questions remain about the perchlorate RfD. Environ Health Perspect. 2005 Sep;113(9):1117-9. Erratum in: Environ Health Perspect. 2005 Nov;113(11):A732. [3] Blount BC, Pirkle JL, Osterloh JD, Valentin-Blasini L, Caldwell LK. 2006a. Urinary perchlorate and thyroid hormone levels in adolescent and adult men and women living in the United States. Environmental Health Perspectives 114:1865-1871. [4] Ginsberg GL, Hattis DB, Zoeller RT, Rice DC. 2007. Evaluation of the U.S. EPA/OSWER preliminary remediation goal for perchlorate in groundwater: focus on exposure to nursing infants. Environmental Health Perspectives 115: 361-69. [5] California Department of Food and Agriculture. 2004. Data cited in: Sharp, R. 2004. Rocket fuel contamination in California milk. Environmental Working Group. Available at http://www.ewg.org/reports/rocketmilk/ [6] Danelski D., Beeman D. 2003. Special Report: Growing concerns: While scientists debate the risks, a study finds the rocket-fuel chemical in inland lettuce. The Press-Enterprise. April 27, 2003 [7] Environmental Working Group. 2003. Suspect Salads: Toxic rocket fuel found in samples of winter lettuce. Available at http://www.ewg.org/reports/suspectsalads/ [8] Environmental Working Group. 2004. Rocket fuel contamination in California milk. Available at http://www.ewg.org/reports/rocketmilk/ [9] Food and Drug Administration. 2004. Exploratory Data on Perchlorate in Food. Available at http://www.cfsan.fda.gov/~dms/clo4data.html [10] Kirk AB, Smith EE, Tian K, Anderson TA, Dasgupta PK. 2003. Perchlorate in milk. Environ Sci Technol. 37(21):4979-81. [11] Kirk AB, Martinelango PK, Tian K, Dutta A, Smith EE, Dasgupta PK. 2005. Perchlorate and Iodide in Dairy and Breast Milk. Environ Sci Technol. 39(7):2011. [12] Sanchez CA, Crump KS, Krieger RI, Khandaker NR, Gibbs JP. 2005. Perchlorate and nitrate in leafy vegetables of North America. Environ Sci Technol. 39(24):9391-7. [13] Blount BC, Valentin-Blasini L, Osterlow JD, Mauldin JP, Pirkle JL. 2006. Perchlorate exposure of the U.S. population, 2001-2002. J Exp Sci Environ Epidem, Online 18 October 2006. [14] Environmental Protection Agency. 2005. Unregulated Contaminant Monitoring Rule data. Updated January 2005. Available at www.epa.gov/safewater/ucmr/data.html [15] Zoeller, T. 2006. Collision of Basic and Applied Approaches to Risk Assessment of Thyroid Toxicants in forthcoming volume. Living in a chemical world: framing the future in light of the past. Annals of the New York Academy of Sciences, 2006: 168-190. [16] Haddow JE, Palomake GE, Allan, WC, Williams JR, Knight GJ, and Gagnon J, et al. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. New England Journal of Medicine 1999: 341: 549-555 [17] Pop VJ, Kuijpens J., van Baar, AL, Verkert, G. et al. 1999. Low maternal free thyroxine concentrations during early pregnancy are associated with impaired psychomotor development in infancy. Clinical Endocrinology 50: 149. [18] Kirk AB, Martinelango PK, Tian K, Dutta A, Smith EE, Dasgupta PK. 2005. Perchlorate and iodide in dairy and breast milk. Environmental Science and Technology 39: 2011-2017. [19] Kirk AB, Dyke JV, Martin CF, Dasgupta K. 2007. Temporal patterns in perchlorate, thiocyanate, and iodide excretion in human milk. Environmental Health Perspectives 115: 182-186. [20] Cooper, D. 2004. Sub-clinical thyroid disease: consensus or conundrum. Clinical Endocrinology 60: 410-412. [21] Environmental Working Group. 2006. Thyroid Threat: Under Proposed Rocket Fuel Standards, Many Women Would Need Treatment To Protect Baby. Available at www.ewg.org.

Some Facts About Sunscreens

Behind the Screen By: Shivani Vora May 14, 2007 - 4:41:20 AM Sunblock has had a few bad years, including class-action lawsuits and new claims that it causes—rather than prevents—cancer. How do you protect yourself this summer? You exercise regularly. You don’t smoke. You always wear your seatbelt. And when you’re in the sun, you never forget your SPF. Bases covered? Not so fast. Researchers at Harvard Medical School recently found that a vitamin D-deficiency—which can result from diligent sunscreen use—is linked to an increased risk of prostate cancer. Meanwhile, a class-action lawsuit is in progress in California against five major sunscreen manufacturers, claiming that their products don’t live up to their label claims of providing protection against UV rays or of being waterproof. Experts, however, warn that this brouhaha isn’t a reason to toss out your sunscreen. “There isn’t an epidemic of vitamin D deficiency,” says Coyle Connolly, a board--certified dermatologist in New Jersey, “but there is an -epidemic of skin cancer from too much sun -exposure.” To maintain adequate levels of vitamin D, says Dr. Connolly, just spend a few minutes in the sun, without sunscreen, over the course of each day. The lawsuits have drawn attention to one dirty secret of sunscreen, however: You have to be a real label hawk to know if your tube is truly “broad spectrum,” meaning that it protects you from both UVA and UVB rays. Any sunscreen with an SPF of 15 will block 94 percent of UVB rays, which penetrate the skin superficially, causing sunburn and skin cancer. UVA rays, on the other hand, cause up to 80 percent of sun-related wrinkles and age spots, and also increase your risk of skin cancer. UVA rays are trickier to fight because they penetrate the atmosphere even on cloudy days, and only four ingredients provide solid protection against them. Two of those ingredients are chemical sunblocks—avobenzone and Mexoryl SX—which work by absorbing and neutralizing UV radiation after it hits your skin, but before it can damage cells. The other two—zinc oxide and titanium dioxide—are physical sunblocks, which form a shield and actually reflect and disperse the radiation before it hits your skin. "Stay away from any sunscreen if it has an SPF of less than 15 or if it does not contain one of these four ingredients,” says Dr. Connolly. Which sunscreen you should grab depends on your needs. Chemical sunblocks are generally more waterproof, but they take 30 minutes to absorb into the skin, while physical sunblocks are effective as soon as you apply them and, because they are made from natural ingredients, can be less irritating. Mexoryl SX has been available in Europe for years, but it was not FDA approved until last year. It provides excellent protection against both short and long UVA rays, whereas the others primarily protect against long UVA rays. No matter which sunscreen you choose, David J. Leffell, MD, professor of dermatology at the Yale University School of Medicine, recommends reapplying it every couple of hours. “Ignore any claims about the longevity of sunscreen,” he warns. Even potions labeled “all day” wear off long before eight hours, he says, and sooner if you’re swimming or sweating. For Your Face Anthelios SX is a daily facial -moisturizer that combines Mexoryl SX and avobenzone to prevent wrinkles, sunspots, and cancer. Chemical sun--screens like these don’t cast a whitish pall over your face like titanium oxide and zinc oxide do. $29, laroche-posay.us.com For Your Lips Men get lip cancer at a much higher rate than women do because lipstick is a physical sunblock. NeoStrata SPF 15 Lip Conditioner ($6.50, neostrata.com) contains titanium dioxide for UVA protection. Most lip products with SPF (including ChapStick) contain oxybenzone for UVA protection, which experts say is not as effective as titanium dioxide, zinc oxide, or avobenzone. For Your Body Jack Black Ultra-Light Spray Sunscreen SPF 25 combines avobenzone for UVA protection with citronella to repel mosquitoes ($18, getjackblack.com). If bug bites aren’t a concern, try UV Expert 20, which combines Mexoryl SX, avobenzone, and titanium dioxide for complete coverage ($39, lancome-usa.com). Recommendations FDA has spent the past 29 years drafting sunscreen standards (FDA 2007), which it urges manufacturers to follow voluntarily. FDA has no public plan for setting a date by which these standards would finally become effective and mandatory. In lieu of enforceable standards, each sunscreen manufacturer decides on test methods, marketing claims, and the level of protection they are willing and able to provide consumers. Health authorities recommend sunscreen, but people are left wondering which of the hundreds of sunscreens on store shelves will best protect their and their families' skin from the sun. Sunscreens are the tip of the iceberg when it comes to ways that the chemical industry and the government are failing to protect public health. An extensive body of scientific literature demonstrates that everyone in the world carries in their body hundreds if not thousands of industrial chemicals at any given moment, the result of exposures to contaminants in air, water, and food, and to ingredients in everyday consumer products. No one understands the health implications of our exposures to complex mixtures of low doses of industrial compounds and pollutants: remarkably, federal health standards do not require companies to test their products for safety before they are sold, including nearly all chemicals in sunscreen and other personal care products, and the federal government approves new chemicals for the market using computer models to predict if they are toxic to humans. These are particularly risky methods given the many studies showing that these pollutants cross the placenta to contaminate babies even before the moment of birth, including a recent study conducted by EWG finding an average of 200 chemicals in umbilical cord blood from 10 newborn babies [read more]. This situation is unacceptable. To protect public health, including the health of the fetus, infant, child and others who are most vulnerable to toxic injury, we recommend: FDA must set mandatory sunscreen safety standards. As mandated by Congress, FDA must complete their safety standards (the "sunscreen monograph"), and establish a date by which these standards will become mandatory. This study confirms the need for mandatory standards — the voluntary system currently in place leaves the public with many sunscreen products that are not as safe and effective as the public needs and expects. FDA must develop UVA standards for sunscreen. While FDA has set guidelines for sunburn (UVB) protection, the agency has not established protocols and requirements for UVA protection. This is a critical gap in public health protection. UVA radiation is deeply penetrating and is linked to skin damage, including premature skin aging, wrinkling, and possibly cancer. FDA is charged with regulating sunscreen and protecting public health, and both of those charges demand that the agency set standards for UVA protection. FDA must approve new, effective and safe sunscreens for use in the U.S. Some sunscreen chemicals have been under review at the Agency for over than a decade. Effective sunscreens not approved in this country are in widespread use elsewhere in the world. FDA sorely needs to streamline and modernize its sunscreen review process to give consumers access to the best products possible. In the larger picture, our system of public health protections allows the vast majority of industrial chemicals to enter commerce with no requirement for premarket safety testing, even for chemicals that will end up in the bodies of Americans from their everyday exposures to ingredients in consumer products. Many state and local organizations and coalitions like the Campaign for Safe Cosmetics are working for important changes that help close the gaps in our system of public health protections. We not only need sunscreens guaranteed to be safe and effective, but we also sorely need policies that would require companies to document the safety of chemicals before they go on the market. And, most importantly, we need policies that would require that chemicals be safe for the fetus, infant, and other vulnerable populations — a simple, commonsense idea completely absent from current federal law. Such advances would dramatically improve our understanding of health impacts from chemical exposures, and would go a long way toward sealing the gaps that leave consumers at risk from a lifetime of exposure to chemicals. U.S. lags behind the world in sunscreen safety and effectiveness. FDA has approved just 17 sunscreen active ingredients for use in the U.S. In Europe 29 have been approved, including some that are more effective than those available here, particularly for blocking UVA. When FDA issued their so-called final monograph for sunscreens (which they subsequently stayed indefinitely at the request of industry), they received multiple petitions urging that they review active ingredients approved for use in Europe. The Agency replied it would "address sunscreen active ingredients that have foreign marketing experience and data at a future time," a hollow promise if their 30-year track record on developing sunscreen standards is any indication. FDA faces pressure from industry, states, and Congress to set UVA standards and approve new UVA sunscreens to protect the public. The industry's trade association petitioned the agency to approve new UVA filters beginning in 2003 (CTFA and CHPA 2003). In a May 2007 letter to FDA's commissioner, six senators urged the agency to finish setting UVA standards for sunscreen (Dodd 2007). They reminded the Commissioner that the agency had missed the Congressisonally mandated deadline of May 2006 for finalizing the draft sunscreen standards, including new UVA standards. "We continue to find this baffling [the lack of UVA standards] since many other countries, including the European Union, have adopted sunscreen standards including UVA to protect their citizens," they wrote. FDA has not reviewed or approved new, effective sunscreens available in other countries.

Fake Colgate Toothpaste

Jun 15 - Colgate-Palmolive Co. said on Friday that counterfeit toothpaste falsely labeled as "Colgate" posed a low health risk, and the company said it was picking up the suspected fakes from small independent stores in four U.S. states. Colgate has contacted all of its accounts to ensure they have no fakes, the company added. The counterfeit toothpaste, containing the toxic chemical diethylene glycol, is labeled as being manufactured in South Africa and comes in a 5-ounce tube, a size Colgate does not sell in the United States.

Higher Risk of Stroke in Women

June 21, 2007 — A new study using data from the National Health And Nutrition Examination Survey (NHANES) shows the risk for stroke among US women between the ages of 45 and 54 years is more than double that of men the same age. Independent predictors of stroke risk in this age group included the presence of coronary artery disease and increased waist circumference, suggesting that poor risk-factor control in these women may be to blame for the increased risk. "Women aged 45 to 54 had twice the odds of having experienced stroke compared with men of the same age, and the transition from age 35 to 44 to 45 to 54 marks the steepest rise in stroke prevalence for women," lead author Amytis Towfighi, MD, from the Stroke Center and department of neurology at the University of California, Los Angeles, told Medscape. Their study also showed that from 1999 to 2004, stroke prevalence rates rose in women while they declined in men. The results are published online June 20 in Neurology. Their findings were presented earlier this year at the American Stroke Association International Stroke Conference 2007 and reported by Medscape at that time. Poor Risk-Factor Control? Although the majority of strokes occur in older age groups, those in midlife, between the ages of 35 and 64 years, are still at risk, Dr. Towfighi pointed out. Women under the age of 65 years have risk factors particular to their gender, including risks associated with pregnancy, the use of oral contraceptives and hormone replacement therapy, and a higher prevalence of migraines. "Understanding gender-specific differences in the frequency and predictors of stroke in midlife years is important, which is what prompted us to look into this," Dr. Towfighi said. For this study, they used NHANES data from 1999 to 2004 on 17,061 men and women to look at sex differences in stroke prevalence and identify independent risk predictors among middle-aged individuals. Stroke was identified through the in-home interview portion of the survey, where subjects were asked if they had ever been told by a physician that they'd had a stroke. Of the 17,061 men and women surveyed, 15,309 responded to the question about stroke (90%). Of these, 606, or 4%, reported having experienced a stroke, 51% of whom were men and 49% women. Based on these data, they found that women between 45 and 54 years had significantly higher odds of having had a stroke compared with men of the same age group.

The Cost of Diabetes Treatment

The staggering cost of treating diabetes and the number of diabetes-related programs highlight a need for a national diabetes coordinator to ensure results," Haza said. "We are spending as much on diabetes as we are on the entire Department of Education, but no one is leading the effort." A report by Medco Health Solutions Inc. issued last month found that the growing diabetes epidemic and more aggressive treatment could result in soaring costs to treat the disease over the next three years. An analysis of Medco's 2007 Drug Trend Report found that, by 2009, spending just on medicines to treat diabetes could soar 60 percent to 68 percent from 2006 levels. The sales of diabetes drugs in the United States reached $9.88 billion in 2005, according to data from IMS Health Inc. "Coordinating America's response to diabetes should be mandatory," said Lana Vukovljak, CEO of American Association of Diabetes Educators. "Over the next 30 years, diabetes is expected to claim the lives of 62 million Americans. Surely this health crisis warrants the appointment of a manager charged with aligning budgets and programs for diabetes at the federal level," Vukovljak said in a statement. Uncontrolled diabetes can result in a wide variety of serious health complications, including heart disease, stroke, vision loss, amputation of extremities and kidney disease. "Our findings suggest that there are many missed opportunities for the federal government to enhance its impact on diabetes prevention, detection, treatment and management of complications," Marsha Gold, who led Mathematica's research team, said in a statement.

Symptoms of Ovarian Cancer

In response to reports by patients with ovarian cancer of the symptoms they experienced, Dr. Goff and others have found that certain symptoms are much more frequent in women with ovarian cancer than in women in the general population. These symptoms include bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency. "The symptoms are not specific, and all of us have had 1 or more of these symptoms from time to time," Dr. Goff says. "What's different about the symptoms of ovarian cancer is that they are new symptoms, not symptoms you have had all your life; they occur regularly, either daily or every other day; and they persist more than several weeks." The consensus panel recommended that women who experience these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist, because prompt medical attention might allow diagnosis at the earliest possible stage of ovarian cancer, when prognosis is better. Because there is no effective screening test for ovarian cancer, symptom recognition and regular pelvic examinations are essential for early detection. "We are not 100% sure that identification of symptoms will lead to earlier detection of ovarian cancer, but because there is a potential for that, we need more research to see what effect implementing this statement will have on outcomes," Dr. Goff says. "Even in stage 1, which is associated with a 90% cure rate, women have these symptoms. If women are having these symptoms even in early stages, then with recognition of these symptoms, we may be able to diagnose ovarian cancer in early stages when chance of cure is 70% to 90%, as opposed to the 20% to 30% chance of cure in advanced stages." Although other symptoms are often reported by women with ovarian cancer, such as fatigue, indigestion, back pain, pain with intercourse, constipation, and menstrual irregularities, these symptoms are not as helpful in diagnosing ovarian cancer because they are found in equal frequency in women without ovarian cancer in the general population. A nationwide poll conducted by GCF in May 2007 revealed that women agree that it is important to know the symptoms of ovarian cancer, but 65% did not feel sufficiently informed. There is therefore a great need for information dissemination and education of women and healthcare providers. "By highlighting these symptoms and their potential association with ovarian cancer, more women may seek medical attention, especially if these symptoms persist over a few weeks," Dr. Barakat said. "Since ovarian cancer is much less common than other cancers, such as breast and lung cancer, patient education has lagged behind. Increasing public awareness could potentially lead to more patients being diagnosed with early-stage disease, and potentially lead to fewer deaths from ovarian cancer." Dr. Barakat also highlighted the need for additional research on laboratory screening tests. "One of the most important areas of research in this disease should be the development of novel biomarkers that can detect early ovarian cancer," he says. "Currently, the best test we have is a CA-125 blood test. This tumor marker is only elevated in 50% of patients with early ovarian cancer and has not been shown to be an effective screening tool in this disease." "Our goal is not to scare people, but to arm people with the knowledge that if these symptoms persist, they could be a sign of ovarian cancer or other serious condition," Dr. Goff concludes. "If ovarian cancer is suspected because of these symptoms and a suspicious mass is detected, it is very important for the woman to see a gynecologic oncologist. In that situation, if there is ovarian cancer, women are significantly more likely to have the right surgery and a higher chance of cure, so it could mean the difference between life and death."

FDA Site for Tweens - Reducing Obesity

Spot the Block Using the Nutrition Facts Label to Make Healthy Food Choices -- A Program for Tweens http://www.cfsan.fda.gov:80/~dms/spotov.html

New, Continuous 7-Day Blood Sugar Tracking

FDA Approves Continuous 7-Day Glucose Monitoring System The U.S. Food and Drug Administration today approved a device that measures glucose levels continuously for up to seven days in people with diabetes. While a standard fingerstick test records a person’s glucose level as a snapshot in time, the STS-7 Continuous Glucose Monitoring System (STS-7 System) measures glucose levels every five minutes throughout a seven-day period. This additional information can be used to detect trends and track patterns in glucose levels throughout the week that wouldn’t be captured by fingerstick measurements alone. However, diabetics must still rely on the fingerstick test to decide whether additional insulin is needed. “The STS-7 System supplements standard fingerstick meters and test strips, providing diabetics ages 18 and older with a way to see trends and track patterns,” said Daniel Schultz, M.D., director of FDA’s Center for Devices and Radiological Health. “It can help detect when glucose levels drop during the overnight hours, show when glucose levels rise between meals and suggest how exercise and diet might affect glucose levels.” The STS-7 System, manufactured by DexCom Inc. of San Diego, Calif., uses a disposable sensor placed just below the skin in the abdomen to measure the level of glucose in the fluid found in the body’s tissues (interstitial fluid). Sensor placement causes minimal discomfort and can easily be done by patients themselves. The sensor must be replaced weekly. An alarm can be programmed to sound if a patient’s glucose level reaches pre-set lows or pre-set highs. Diabetes is caused by the body’s inability to produce or use insulin, a hormone that unlocks the cells of the body, allowing glucose (sugar) to enter and fuel them. An estimated 20.8 million people in the United States—7 percent of the population—have diabetes. Most have type 2 diabetes, a condition in which the body does not properly use insulin. An estimated 5 percent to 10 percent of people with this chronic disease have type 1 diabetes, which results from the body's failure to produce insulin. People with type 1 diabetes must take insulin every day. Diabetes can lead to wide fluctuations in blood sugar levels. Over time, abnormally high levels of glucose can damage the small and large blood vessels, leading to diabetic blindness, kidney disease, amputations of limbs, stroke, and heart disease. While there is no known cure, studies have shown that patients who regularly monitor and regulate their blood glucose levels have lower incidences of complications associated with the disease. FDA’s approval of the STS-7 System was based on results of a study conducted by DexCom of 72 patients with diabetes at five clinical sites in the United States. The study demonstrated that the STS-7 System was safe and effective for detecting trends and tracking patterns in glucose levels in adults. A three-day version of the device, the STS Continuous Glucose Monitoring System, was approved in March 2006.

Calcium to Prevent Osteoporosis - Take More!

The totality of the evidence indicates that high calcium intake is important both for prevention and management of osteoporosis, and recent negative trials do not refute the much larger body of positive studies. The challenge is not to haggle over exactly how much is enough but, as the Surgeon General's report on osteoporosis put it, to recognize that current intake is far below optimal values. It is imperative to take action to augment calcium intake, both in the general population and particularly in persons being treated for osteoporosis. For many patients, calcium supplements are the most appropriate choice to ensure adequate intake. A number of different calcium compounds are used in supplements; the 2 main forms are calcium carbonate and calcium citrate. Although absorption of calcium citrate is similar to calcium carbonate, a calcium carbonate supplement contains 40% calcium vs the 21% found in calcium citrate.[52] Because formulations may contain different amounts of calcium, the number of tablets needed to obtain a recommended dose may vary. Figure 6 depicts the amount of calcium found in common compounds. Patients often erroneously believe that they are obtaining sufficient calcium through their diet. However, it is known that the median calcium intake in postmenopausal women in North America is substantially below existing recommendations.[11] Because milk and milk products provide the majority of dietary calcium in the United States, if a person is lactose-intolerant, a vegan (consuming no animal products), or avoids dairy products for other reasons, it may be especially challenging to obtain adequate amounts of calcium solely through diet.[50] In addition to being aware of the amount of dietary calcium they are ingesting, it is important that patients understand that absorption from foods can be affected by a number of factors, many of which have already been well described. These include age, vitamin D, pregnancy, and plant substances in the diet. Oxalates (found in chocolate and spinach) and phytate (found in whole grains) are among dietary substances that impair absorption. Therefore, 8 cups of spinach are needed to obtain the same amount of calcium obtained from an 8-ounce serving of milk or 1 cup of yogurt, which contain calcium in an easily absorbable form.[51] Vitamin D. Although vitamin D status has been discussed as a potential confounder of results in calcium studies, the importance of vitamin D in its own right must also be emphasized. It has long been recognized that vitamin D is important for calcium absorption, and recent studies have demonstrated that absorption efficiency increases with improving vitamin D status up to serum 25(OH)D levels of about 80 nmol/L (32 ng/mL).[43,44] Postmenopausal women, as reported in many studies, tend to have average serum 25(OH)D values ranging from 50 to 55 nmol/L (20 to 22 ng/mL)[43,45] and are therefore absorbing the calcium they ingest with reduced efficiency. Protein. As with vitamin D, protein plays an important role in its own right. Although North Americans are considered to consume generous amounts of protein it is also true that many fragile elderly individuals have low protein intake. If these same individuals are our osteoporosis patients, then they will probably not respond well to pharmacotherapy until their nutritional status is repaired. If deficient in calcium, vitamin D, and protein, many will be unresponsive to monotherapy, whether nutritional or pharmacologic. This is seen most obviously in patients with hip fracture, whose outcomes have been shown to improve dramatically with protein supplementation.[46] Exercise. Bones are designed to bear loads and to resist mechanical forces. Maintenance of adequate bone mass requires continued mechanical loading. Nutrition alone may slow the progress of disuse bone loss, but it will not block its full, ultimate expression. Optimal exercise regimens are uncertain, but impact loading appears to be more osteotrophic than, for example, weight lifting or swimming. In general, patients with osteoporosis need to maintain as vigorous an exercise program as is compatible with their bone fragility status. Good online sources of information for patients about calcium and or bone health include the National Institutes of Health, Office of Dietary Supplements;[51] American Osteoporosis Foundation;[54] and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.[53]

All About Sleeping Better

Insomnia: Once you and your doctor have ruled out any medical problems that may be causing your insomnia, you might try self-care methods. "Good sleep hygiene" refers to practices you can follow to help ensure adequate, quality sleep. For good sleep hygiene, try to do the following: Stick to a regular bedtime schedule. Get out of bed at the same time each morning, even if it's a weekend or holiday. Avoid napping during the day. Avoid stressful activities and vigorous exercise for two hours before going to bed. Before going to bed, try relaxation techniques, such as deep breathing, yoga, or meditation. Make sure your bedroom is dark, quiet, and cool. Use earplugs or eye shades if needed. Leave the bedroom if you can't sleep. Go into another room and read or do something relaxing and quiet. Exercise regularly. Avoid substances that contain caffeine (such as coffee, tea, soft drinks, or diet pills). Avoid alcohol and nicotine before bed. Snoring: If your snoring is light, try these self-care techniques: Sleep on your side. Avoid alcohol, and don't smoke. Avoid sleeping pills and other sedatives. Also, seek treatment for any allergies or nasal obstructions you may have. Sleep apnea: Weight loss can improve but may not adequately treat sleep apnea. Avoiding alcohol and sleeping pills can also help. You may want to talk to your doctor about a technique called continuous positive airway pressure (CPAP). With CPAP, each night you wear a mask that increases the air pressure inside your throat. This prevents your airway from becoming too narrow and may allow you to sleep without interruption. Except in very carefully selected cases, surgery does not adequately treat anything more than the mildest degrees of sleep apnea (though it may be more effective for troublesome snoring). A dental brace that holds your lower jaw forward during sleep is an increasingly available option for snoring and mild to moderate sleep apnea. Pregnancy and sleep: Pregnant women who experience insomnia during pregnancy may find relief by taking afternoon naps, drinking warm milk, or taking a warm (not hot) bath before bedtime. Exercise during the day should help too. Expectant mothers may find it more comfortable to sleep on their side, with pillows supporting their head, abdomen, and topside knee. Women who are pregnant should not take sleeping pills or herbal sleeping remedies without talking with their doctor first. Narcolepsy: Often, naps help relieve narcolepsy but cannot be relied on exclusively. Your doctor may prescribe stimulants (such as Ritalin or dextroamphetamine) to make you more alert. Antidepressants may be used to treat cataplexy (drop attacks) or sleep paralysis, if present. Restless leg syndrome: Cutting your caffeine intake may help. Other self-help measures may include a warm bath or relaxation exercises before bed. Hot or cold packs on your legs may provide relief. Several effective medications are available. Restless leg syndrome is a very treatable condition. Nightmares/night terrors: If your child has a nightmare or night terror, the best medicine is comfort. If the dreams reoccur frequently, talk with your child's doctor about the problem. Age: The lighter sleep patterns of older adults can sometimes lead to sleep problems. However, studies show that older adults who exercise and keep active sleep better than those who don't. Elderly people who don't sleep well at night may find afternoon naps helpful. However, excessive naps will disrupt sleep at night. Getting adequate light during the day, particularly in the morning, is important. Lifestyle: You'll sleep better if you have good sleep hygiene and avoid caffeine, alcohol, nicotine, and heavy meals before bed. Regular exercise can improve sleep, as long as the exercise is performed at least two hours before bedtime. Medication: If you think prescription or over-the-counter medication may be causing your sleep problems, talk with your doctor. You may need to have your medication dose adjusted or may need to take a different kind of medication. Depression and anxiety: If depression or anxiety is keeping you up for more than a few nights, talk to your doctor about treatment. Heart failure and lung problems: If you experience breathlessness when you lie down to sleep or awaken in the night feeling breathless, you should see your doctor. You could have problems with your heart or lungs.

Hearing Loss and Aides

Technological advances in hearing aids and HATS have expanded the range of options available to improve the success of a device use. Today's hearing aids differ significantly from their analog predecessors because the application of digital signal processing has permitted many adaptive and/or automatic features. In the past decade, hearing instrument technology has developed to the point that digital hearing aids now constitute nearly 90% of all hearing aid sales in the U.S.[21] This growth has permitted decreases in the cost of digital technology so that digital hearing aids now span the range from entry-level prices to high-end pricing, thus allowing all users the option of digital technology. Included in the benefits of digital hearing aids are improved sound quality; multiple listening programs for different listening environments; advanced noise reduction strategies; acoustic feedback reduction; compatibility with remote control options; and flexibility in manipulation of the frequency, compression, and gain ( Table 1 ). These developments allow the audiologist considerable flexibility in choosing appropriate technology for the varied needs of older adults. Such features as automatic function of the telecoil (a hearing aid component for use with the telephone or for coupling to HATS) and multiple programs ensure that even those with limited manual dexterity or cognitive impairments can wear a device that optimizes performance across a broad range of listening environments. It is no longer necessary to find the switch or remember to return to a listening program when the conversation has ended for effective telephone use. Difficulty understanding speech amid noise is a common complaint for hearing aid users. Directional microphone technology has advanced to optimize the directional responsiveness of the hearing aid microphone in order to reduce the level of noise when the noise source is from an angle that is behind or beside the hearing aid user. Automatic directional systems are intended to accurately switch between directional and omnidirectional modes, and this option is available even in the lower-priced entry-level digital devices.

New Cardiopulmonary Resuscitation Guidlines (CPR)

CPR consisting of chest compression plus mouth-to-mouth ventilation is a major element in the chain of survival for people with cardiac arrest. However, although bystander CPR improves the likelihood of survival, it is attempted in less than one third of patients who collapse, partly due to the reluctance of bystanders to undertake mouth-to-mouth ventilation. In CPR guidelines, according to the current authors, cardiac-only resuscitation by bystanders is recommended in dispatch-assisted resuscitation or if a rescuer is unwilling or unable to do mouth-to-mouth ventilation, but this technique is not generally known or taught to the public. One study has shown that cardiac-only resuscitation results in better survival without neurologic impairment.

Saline Nasal Irrigations for Chronic "Sinus" Symptoms

Nasal irrigation previously has been demonstrated to be an effective, safe, and well-tolerated means to treat frequent or chronic rhinosinusitis. The current authors reported results from a randomized controlled trial of 6 months of therapy with 2% saline nasal irrigation vs usual care in the December 2002 issue of the Journal of Family Practice. The authors found that the use of saline was associated with fewer sinus symptoms, improved sinus-related quality of life, and reduced use of antibiotics and nasal sprays. A follow-up study to this trial demonstrated that participants in the original randomized trial continued to use nasal irrigation as a successful modality to treat rhinosinusitis. Given the apparent clinical success of nasal irrigation for frequent or chronic rhinosinusitis, the authors sought to examine qualitative data regarding the everyday benefits and drawbacks of irrigation from study participants. Their results are summarized in the "Study Highlights." Study Highlights Participants from the researchers' primary study were invited to participate in structured 30-minute interviews to explore their experience with nasal irrigation for rhinosinusitis. Patients included in the original study had either 2 episodes of acute sinusitis or 1 episode of chronic sinusitis in the past year. In addition, participants reported a moderate-to-severe overall daily quality-of-life burden associated with rhinosinusitis. Participants randomized to receive nasal irrigation had an educational session that included lessons on rhinosinusitis and individual coaching on the practice of nasal irrigation. 28 of the original 35 subjects who received nasal irrigation agreed to participate in the interviews for the current study. Their clinical data were similar to the original cohort as a whole. 4 main content themes emerged from these interviews: Patients felt empowered in being able to access, monitor, and adjust treatment with nasal irrigation on their own. They were pleased to be less reliant on clinician visits and antibiotics. Patients were enthusiastic regarding the efficacy of nasal irrigation in reducing sinus symptoms and improving their quality of life. Many subjects reported improvement within the first or second use of nasal irrigation. Patients cited fear of having water in the nasal cavity, initial unpleasant sensation of water in the nasal cavity, having to learn how to perform nasal irrigation effectively, the time to perform nasal irrigation, and occasional mild adverse effects as potential barriers to the use of nasal irrigation. Adverse effects included saline drainage and nasal burning, but these events were not strong enough to stop the practice of nasal irrigation. Patients noted that the initial education session, particularly individual coaching on the practice of nasal irrigation, was effective in overcoming many of the barriers to the use of nasal irrigation. In addition, their experience at home with adjusting the schedule, salinity, and temperature of nasal irrigation allowed for effective and well-tolerated treatment. Pearls for Practice Nasal irrigation with saline solution has been demonstrated to improve symptoms of rhinosinusitis, sinus-related quality of life, and the use of other medications for rhinosinusitis. This treatment appears effective over the long term. The current study demonstrates that patients with frequent or chronic rhinosinusitis may have some initial trepidation regarding the use of saline nasal irrigation, but some coaching on how to use irrigation along with self-adjustment of therapy allowed patients to overcome potential barriers to treatment. Patients find the use of nasal irrigation empowering and effective.

DHEA In Older Men

Because blood levels of dehydroepiandrosterone (DHEA) and testosterone decline with age, some people believe that DHEA and testosterone supplementation can reverse the effects of aging. This hypothesis was examined in a double-blind, placebo-controlled, randomized trial that included 87 men and 57 women aged 60 or older. Baseline levels of DHEA-S (the sulfated form of DHEA) in both sexes, and baseline levels of bioavailable testosterone in men, were required to be below the 15th percentile for normal young adults. Men received a DHEA tablet (75 mg) daily, a transdermal testosterone patch (5 mg daily), or double placebo; women received a DHEA tablet (50 mg) or placebo. After about 2 years of follow-up, no differences were noted between the active-drug and placebo groups in physical performance (i.e., aerobic capacity and muscle strength) or in quality of life as measured on a validated questionnaire. In the active-drug groups, small increases in bone density were noted only at the femoral neck in men and at the distal radius in women. These changes were much smaller than those typically seen with bisphosphonate drugs. No significant adverse events occurred. Comment In this well-done randomized trial, supplementation with DHEA or low-dose testosterone conferred no obvious benefits to older adults. Based on these and previous results, the authors and an editorialist conclude that DHEA and testosterone should not be used as anti-aging supplements. The editorialist also believes that DHEA should be treated as a regulated drug and not as a dietary supplement. — Allan S. Brett, MD

Quinine Drugs Removed from Market

FDA Removes Unapproved Quinine Drugs From Market Yael Waknine Medscape Medical News 2006. © 2006 Medscape December 13, 2006 — The US Food and Drug Administration (FDA) has ordered the removal of unapproved drug products containing quinine, citing serious safety concerns and deaths associated with their use. The action is part of a larger effort to remove all unsafe, unapproved drugs from the market.Since 1969, the FDA received 665 reports of serious adverse events (including 93 fatalities) associated with quinine use, according to an alert sent yesterday from MedWatch, the FDA's safety information and adverse event reporting program. Serious adverse events have included cardiac arrhythmias, thrombocytopenia, and severe hypersensitivity reactions; potentially serious interactions with other drugs can also occur.The FDA notes that only one quinine product (Qualaquin, made by Mutual Pharmaceutical Company, Inc) is currently approved by the FDA. Although indicated only for the treatment of uncomplicated Plasmodium falciparum malaria, the drug is often prescribed to treat leg cramps and similar conditions despite drug label warnings advising that the risks associated with its use in this setting outweigh potential benefits.Unapproved quinine drug products are marketed without these drug label warnings, which increases the risk for their misuse and potential consumption of doses that have not been reviewed or approved by the FDA. Because of its narrow therapeutic index, quinine must be used carefully; dose modifications and/or close monitoring may be required for patients with hepatic or renal impairment. Under the FDA order, all manufacturing of these products must cease within 60 days. However, some previously shipped merchandise may remain on pharmacy shelves for a short time. Consumers have been advised to contact their healthcare provider with any questions or concerns regarding their use of unapproved quinine products.Adverse events potentially related to quinine therapy should be reported to the FDA's MedWatch reporting program by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.

New Research on Care/Prevention of Chronic Diseases

Introduction Chronic disease prevention and management were hot topics receiving daily attention at the 2006 American Academy of Family Physicians (AAFP) Scientific Assembly. A comprehensive evidence-based lifestyle management plan for cardiovascular disease prevention was offered by Steven Masley, MD, FAAFP.[1] Alvin Lin, MD, FAAFP, and Kay M. Nelsen, MD, discussed how "good is not good enough" in our current approach to chronic disease care and offered new, more rigorous targets for physicians and patients alike.[2] Evidence-Based Lifestyle Changes for Cardiovascular Disease Guidelines for patients and physicians from the American Heart Association (AHA), the American Diabetic Association (ADA) and other organizations advocate lifestyle change including diet, exercise, smoking cessation, and other behaviors to improve cardiovascular (CV) risk. The number of research studies which pinpoint and specify the rationale for making changes, and the risk reduction associated with each lifestyle change, has grown significantly. This body of literature empowers physicians to better counsel patients on prevention of adverse CV events, particularly stroke and myocardial infarction. Dr. Masley reviewed the mechanism for plaque formation and rupture as the basis for a paradigm switch from coronary procedures such as angioplasty to diet change. Despite data supporting prevention, the United States spent $200 billion on CV therapies in 1998 with only 6% expended on preventive strategies for patients.[3] Yet interventional cardiology was associated with a failure rate of 40%, preventing only 1 of 30-40 deaths, and improving only 1 of 30-40 CV events.[3] The procedures also carried the risks for loss of cognitive function, death, and stroke.[4] Indications for revascularization procedures should only be angina and restoration exercise capacity. Among risk factors identified for CV disease, the top 5 are: Cholesterol; Diabetes mellitus (DM); Smoking; Hypertension; and Obesity. Ethnic differences exist for each risk factor[5]; for example, obesity and hypercholesterolemia have a higher prevalence among blacks and Hispanics compared with Asians. Dr. Masley suggested that exercise treadmill testing is useful for predicting CV risk because exercise capacity is a powerful predictor of mortality.[6,7] Class I evidence for stress testing indicated for evaluation of includes: Known CV disease; Suspected angina; Diabetics embarking on an exercise program; and An occupation that affects public health. Measures of cardiac fitness include the 1-minute heart rate recovery and the blood pressure (BP) response. Plaque assessment using carotid intimal media thickness is another tool that can help track responses to lifestyle change or medication.[8] The following 10 lifestyle steps were described by Dr. Masley to reduce adverse CV events: Step 1: Reduce low-density lipoprotein (LDL) cholesterol using a combination of dietary measures such as adding soy and garlic,[9] switching from saturated and hydrogenated fats to unsaturated fats, increasing plant sources of omega-3 fats,[10] and increasing monounsaturated nut intake of walnuts, almonds, and pecans[11,12] before medications are considered. Step 2: Improve total cholesterol/high-density lipoprotein cholesterol (TC/HDL) and triglyceride/HDL cholesterol (TG/HDL) ratios to reverse the metabolic syndrome epidemic. Increasing HDL levels may be achieved with prolonged regular aerobic exercise of no less than 30-45 minutes daily[13] and moderate alcohol intake of 1-2 drinks daily.[14,15] A modest increase may be seen with garlic,[16] onion (3% to 5% improvement), and soy (up to 5% improvement)[17] intake. The type of carbohydrate eaten affects insulin levels and TC/HDL ratios, and glycemic load is more important than glycemic index.[18] Hence, a high-fiber intake of grains, beans, vegetables, and fruits has a beneficial effect, while consumption of fluffy whole wheat breads and potatoes can raise postprandial blood sugar levels. Step 3: Increase intake of beneficial foods. Follow diets, such as the Mediterranean or Japanese diet, high in vegetables and fruits, fiber, olive oil, and soy[19,20]; the emphasis should be on adding healthy -- rather than eliminating unhealthy -- foods. More specifically, soy isoflavones (from, for example, edamame beans) are associated with possible reduction of clot formation[21,22] and improved endothelial function.[23,24] Dark cocoa reduces clotting and is a potent antioxidant, thereby suppressing LDL oxidation and, possibly, lowering plaque formation.[25] Step 4: Change type of fat intake to nuts and olive and canola oils, but remain mindful of calories associated with high nut consumption. One handful of walnuts has 280 calories, but if eaten before a meal can help to induce satiety and reduce overall caloric intake.[26] Saturated fats should be avoided because of: Increased clot formation; Weight gain; and Increased LDL cholesterol. Trans fats in margarines and processed foods should be avoided and lean proteins (chicken and turkey) should be selected over red meats. Step 5: Reduce LDL oxidation by: Eating at least 5 servings of fruits and vegetables daily, especially the most colorful produce (like blueberries, pomegranates, and red and black beans)[27]; and Adding garlic[28] and spices,[29] particularly capsaicin and curcumin from chili and turmeric, respectively. Step 6: Decrease clotting and CV events using: Omega-3 fats; Garlic; Moderate alcohol; and A baby aspirin for primary and/or secondary prevention of CV and cerebrovascular events, if there are no contraindications. Fish and seafood (which should be eaten 2-3 times weekly) are excellent sources of omega-3 fats; Dr. Masley's first-choice recommendations are: Salmon; Trout; Sardines; Mussels; and Oysters, followed by: Shellfish; Mahi mahi; and Halibut. His choices reflect lower mercury levels of less than 2 ppm; intake of big-mouthed fish, such as yellow-tail tuna, increases exposure to higher mercury content. Flax, soy products, nuts, green leafy vegetables, canola oil, and fish oil supplements also contain omega-3 fats. The dosing of omega-3 depends on its indication: 300 mg daily for health maintenance; 3-4 g daily for hypertriglyceridemia; 2-4 g for anti-inflammatory purposes or for disc herniation; and 1-2 g for arrhythmias. Fish oil supplements should be selected on the basis of independent testing for heavy metals, low levels of lipid peroxides (they should not taste fishy or rancid), and dosed to minimize risk for bleeding and drug interactions. Step 7: Enhanced arterial function and BP is best achieved by 30-60 minutes of moderate activity for 6 days a week burning at least 2000 kcal weekly, and strength training 2-3 times weekly working at least 8-12 body parts and targeting blood pressure (BP) at 110/70 mm Hg (below pre-hypertensive levels).[30] Salt intake should be limited to less than 2400 mg daily, while calcium and magnesium should be maintained at 100 mg and 500 mg daily respectively. Step 8: Judicious use of supplements is advised because of variability in evidence for efficacy and the lack of standardized manufacturing guidelines. Dr. Masley recommended adequate intake of: Folic acid 400 mcg daily (diet plus supplement); Vitamin B6 -- 10-25 mg daily; Vitamin B12 -- 10-1000 mcg; and Phytosterols from plant foods. Evidence for using coenzyme Q10, hawthorne, and acetyl-L-carnitine is inconclusive and these are not currently recommended for cardiac health. Step 9: Stress management should directly address adequate sleep (at least 7 hours daily) and restful and relaxing activities such as meditation, yoga, and deep prayer. Step 10: Success at making lifestyle changes is linked to: Physician attention to patient beliefs; Limitations and goals; and Venues for offering intensive and effective lifestyle change in practice, including the group medical visit model specifically focused on CV targets, regular chart review, and documentation of patient progress. Management of Chronic Disease: When Is Good Not Good Enough? Drs. Lin and Nelsen discussed how chronic diseases are a major cause of disability in the United States, reviewing the major causes of death and morbidity[2]: Childhood obesity; Arthritis; Adult DM; Hypertension; and Hypercholesterolemia. They presented data that provide physicians with specific and more rigorous goals and endpoints for the control of DM, cholesterol, and BP. As Dr. Nelsen explained, global focus of organizations such as the World Health Organization, United Nations, and the World Bank continues to be on infectious rather than chronic diseases. Despite the change in chronic disease management from acute hospital admission to ambulatory care delivery, the use of information systems and team-based healthcare, the goals of continuity of care, service integration, and patient education provided through patient-centered care are far from being reached worldwide. The burden of chronic diseases continues to rise with 29 million deaths worldwide in 2002 from[31]: CV disease; Cancer; Chronic respiratory disease; and DM. According to an important trial, "a combination of personal and non-personal health interventions could lower the global incidence of CV events by as much as 50%.[32]" Government action to reduce salt content of processed foods is an example of a non-personal health intervention. Case in Point: Diabetes Mellitus Twenty-one million Americans were diagnosed with DM in 2005 and 10 million over 60 years have DM currently. Only 1 out of 5 Healthy People 2000 goals were met for the US population namely, a small 3% reduction in amputations from DM.[33,34] The goals related to DM that have not been met are reduction of: Disease incidence; Renal disease; and Blindness. Only one half of diabetics are taking proper medications.[35] Health disparities in DM management persist, and although 90% of patients with DM see physicians, they are not well monitored for: Hemoglobin A1c (HbA1c) levels; Self glucose testing; Annual urinary albumin screening; and Foot care. Health education occurs for less than 50%.[36] Data from a meta-analysis propose HbA1c goals as low as possible, suggesting that there is no threshold that is too low.[37] In one study, for every 1% drop in HbA1c there was a 21% decrease in all-cause mortality and adverse endpoints. Another study demonstrated a 28% increased risk for death for every 1% increase in HbA1c value, regardless of BP, cholesterol level, body mass index, and smoking status.[38] The Lower the Better Even in those without DM, lower HbA1c is associated with reduced CV and all-cause mortality. LDL cholesterol goals for DM have been well articulated by the AHA and the American College of Cardiologists with atheromatous regression and reduced CV mortality demonstrated at lower levels when LDL is lowered to 60 mg/dL.[39] Like HbA1c and LDL cholesterol in DM, BP control is now guided by the "lower is better" principle. Regardless of comorbidities including DM, lower levels of BP are associated with better outcomes of mortality and CV events. The risk for CV morbidity and mortality begins at a BP of 115/75 mm Hg, and for every increase in blood pressure of 20 mm Hg systolic or 10 mm Hg diastolic, the risk for CV events increases 2-fold.[40] Conversely, every 2-mm Hg drop in systolic BP translates into a 10% drop in stroke incidence and a 7% drop in CV events. Some data are slightly more hopeful, including a study showing that diabetes processes of care (such as eye and foot exams, measurement of microalbuminuria, diabetic education, and vaccinations) and intermediate outcomes (for example, HbA1c and LDL cholesterol) have improved nationally in the United States in the past decade.[41] This same trial, however, showed that: 2 in 5 persons with diabetes still have poor LDL cholesterol control; 1 in 3 persons still has poor BP control; and 1 in 5 persons still has poor glycemic control. Summary Drs. Lin and Nelsen concluded that physicians need to be more aggressive with all lifestyle strategies that lead to reduced HbA1c, LDL cholesterol, and BP in both diabetic and nondiabetic patients. For diabetic patients, target HbA1c should be as low as possible. For LDL cholesterol, diabetics should aim for levels below 70 mg/dL. Patients with hypertension should be controlled to levels at or below 115/75 mm Hg.