Vol.1, Issue 3 $ 4.

99
Colorectal
Cancer:
The Non-Biased
Killer
The Mystery of MS:
No Simple Explanation
Sharon Osbourne's Fight-
Bringing Hope & Support to
Colon Cancer Patients
Special thanks to: Sharon Osbourne,
Sir Elton John, Dr. Edward Phillips,
and Cedars-Sinai Medical Center of
Beverly Hills.
This is personal.
My mother was the cornerstone of our family.
When she was diagnosed with colon cancer,
it was like the whole family got cancer.
She died when she was only 56.
Let my heartbreak be your wake-up call.
Terrence Howard, actor/musician
n
o
s
r
e
h
p
c
a
M
w

e
r
d
n
A

:
o
t
o
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P
Colorectal cancer is the second leading cancer killer in the U.S., but it is largely preventable.
If youre 50 or older, please get screened. Screening fnds precancerous polyps, so they can be removed
before they turn into cancer. And screening fnds colorectal cancer early, when treatment works best. If youre
at increased riskif you have a personal or family history of polyps or colorectal cancer, or you have
infammatory bowel diseaseask your doctor when to start screening.
Screening saves lives.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
1-800-CuC-lNfO {1-800-232-43) www.cdc.govIscteenfotlife
whatdoctorsknow.com
This issue of What Doctors Know marks our
transition from a quarterly to monthly publication.
In making the change, we ran into a minor problem.
Launching in March, meant we wouldnt have been
able to do justice to February an important Heart
Health Awareness month. Rather than ignore
heart month, we combined it into March. So,
technically this issue is a February/March edition.
We have been able to make the transition to monthly
because of the cooperative efforts of prestigious
medical centers and universities across the country
who have the same goal as What Doctors Know: To
inform and educate our readers about health care.
The list is growing daily, but we would like to thank
Mayo Clinic, Cleveland Clinic, Johns Hopkins, Mt. Sinai New York, LSU, Cornell University,
Harvard, Emory University, University of Florida, University of Virginia, UCLA, Baylor, Tulane,
Parkland Hospital, Piedmont Health, Vanderbilt, UC San Francisco, Childrens Hospital of
Dallas, UC San Diego, Loyola, National Jewish Hospital, University of Miami and so many more.
As I indicated, we have combined this issue with Heart Health Awareness Month, Diabetes
Awareness, Multiple Sclerosis Education Awareness Month and National Colon Cancer
Screening Month. As a board certified Gastroenterologist with more than 23 years experience,
I am excited about the opportunity to help inform and educate our readers about the second
most deadly cancer in our country a cancer, that, for the most part is avoidable.
In this issue I have tried to consolidate a user-friendly guide and provide our
readers with a better understanding of colon cancer. Most of all, I want to drive
home the importance of early screening and detection to save lives.
In my 20-plus years and after more than 50,000 colonoscopies, I have told far too many
patients they have colon cancer. I don't think I have ever had a patient who did not
express remorse at having put off a colonoscopy -- especially having just had the procedure
and realizing how easy it would have been to get a screening before it was too late.
If you or a member of your family is age 50 or over and has never had a colonoscopy, do what it takes
to convince them about the importance of this life saving screening. There truly is no more destructive
and life-altering statement a doctor can make telling a patient: "I'm sorry, you have colon cancer."
Finally, I want to offer a special thanks to Sharon Osbourne and the Sharon Osbourne Colon
Cancer Foundation for joining in our efforts to call awareness to Colon Cancer Screening. Mrs.
Osbourne, a colon cancer survivor herself, has been a champion of Colon Cancer Screening
efforts and has donated, time, money and friendship to the cause. I cant thank her enough.
For more information on her foundation, check out the story on page 78.
Steve Porter, MD
Publisher and Chairman
On Call with Dr. Porter
whatdoctorsknow.com
HEADlines
31 Lets Talk About Atrial
Fibrillation & Stroke Risk
34 Todays Teens Will Die
Younger of Heart Disease
36 Asthma & Airway
Inflammation: The Big Picture
38 Are Stress Tests Wrong?
10 Alcohol is a Buzz-Kill for
Developing Teenage Brains
12 Seeing the Benefits of
Crystalens More Clearly
15 Whats New in the World
of Sinus Bugs & Drugs?
18 Does Aspirin Take
Your Breath Away?
22 The Mystery of MS: No
Simple Explanation
24 Mapping a Stroke
26 One for the Memories:
Detecting Alzheimers Disease
28 MS-Get the Facts
40 Heart Health &
Vitamin D
42 The 411 on 911
Chest Pain
44 Cardiologist Tips:
Right Lifestyle Builds
Solid Heart Health
46 Colorectal Cancer: The
Non-Biased Killer
50 Colorectal Cancer
Screening Saves Lives
51 Diabetic Complications
52 Fat Distribution in Black
& White Women May
Predict Heart Disease
IN THE TRUNK
BELOW THE BELT
P10
P34
P46
54 Waist Size Linked to Mortality
Risks in Kidney Disease
56 Early Detection of
Colorectal Cancer
58 Keeping the Change
60 A Real Cause for Concern:
Clostridium difficile-
associated Diarrhea (CDAD)
WHAT DOCTORS KNOW
And you should, too!
whatdoctorsknow.com
Vol. 1 Issue 3
On the Cover
62 Bag the Grocery Guesswork:
Get Healthy with the
Heart-Check Mark
66 Americans Cutting Sugar-
But Its Still Not Enough
68 School Guide Teaches
ABCs of Diabetes
MIND, BODY, AND SOUL
70 Waking Up to Anesthesia
74 Reducing Blood Transfusions
76 MyFoodAdvisor
78 Sharon Osbourne's Fight -Bringing Hope
& Support to Colon Cancer Patients
80 Colon cancer. Genetics or Bad Luck?
TECHNOLOGY &
YOUR HEALTH
01 OnCallWith
Dr.Porter
06 HouseCalls
08 MeetOurDoctors
In Every Issue
P66
P70
Contents
22 TheMysteryofMS:No
SimpleExplanation
46 ColorectalCancer:The
Non-BiasedKiller
78 SharonOsbourne'sFight--
BringingHope&Support
toColonCancerPatients
Vol.1, Issue 3 $ 4.99
Colorectal
Cancer:
The Non-Biased
Killer
The Mystery of MS:
No Simple Explanation
Sharon Osbourne's Fight-
Bringing Hope & Support to
Colon Cancer Patients
Special thanks to: Sharon Osbourne,
Sir Elton John, Dr. Edward Phillips,
and Cedars-Sinai Medical Center of
Beverly Hills.
whatdoctorsknow.com
Published by
What Doctors Know, LLC
Publisher and Chairman
Steve Porter, MD
Editorial Advisory Board
Vicki J. Lyons, MD, Chairman
Timothy J. Sullivan, MD
Editorial and Design Director
Bonnie Jean Myers
Senior Designer
Suki Xiao
Design Associate
Cayden Chan
Executive Director, Marketing
Larry Myers
Production
Kai Xiao, Vice President
IT Manager
Eric Lu
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Products and services are not necessarily endorsed by What Doctors Know,LLC.
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Calling All Doctors. Our readers want to hear from you. What healthcare
issues do you want to address? What do you want to tell patients all
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Drop us a line and let us know about any healthcare topic you want
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Send story ideas to: submit@whatdoctorsknow.com
WHAT DOCTORS KNOW
And you should, too!
Its hard for me to keep track of all of the
things going on in my life. I choose to face
this disease with strength, dignity and lots
of sticky notes.
Fotini, diagnosed in 2007
Multiple sclerosis is a chronic, unpredictable and often disabling disease of the central
nervous system. The progress, severity, and specic symptoms of MS vary from one
person to another, and may include walking, balance and coordination challenges,
fatigue, numbness or issues with memory and concentration.
MS =
lost memories
Join the Movement

at nationalMSsociety.org
MSAW Ad-Fotini_Final.indd 1 1/12/11 2:12 PM
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Q
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of the heart resum
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ark Estes, III, M
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Center, Tufts M
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House Calls
whatdoctorsknow.com
Disclaimer:
The information contained in the magazine is intended to provide broad understanding and knowledge of healthcare topics. This information should
not be considered complete and should not be used in place of a visit, call, consultation or advice from your physician or other healthcare provider. We
recommend you consult your physician or healthcare professional before beginning or altering your personal exercise, diet or supplementation program.
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whatdoctorsknow.com
whatdoctorsknow.com
Meet Our Doctors
Steven Porter, MD
Founder and
publisher of What
Doctors Know, Dr.
Porter is recognized
as one of the top
gastroenterologists
in the country.
He is the medical director of the
endoscopy lab at a leading hospital
in Ogden, Utah and has been
practicing for more than 25 years.
Contact Dr. Porter at (801)387-2550.
Vicki Lyons, MD
Founding member
and chairman of the
editorial advisory
board of What
Doctors Know,
Dr. Lyons is a
board certified and
fellowship trained
allergist and immunologist practicing in
Ogden, Utah. She has been practicing
for 20 years. Contact Dr. Lyons at
(801)387-4850 or www.vicki-lyonsmd.com.
Nadim Bikhazi, MD
Board President of
a healthcare facility
in Northern Utah,
Dr. Bikhazi is and
Otolaryngologist with
specialty training
in the ear, nose and
throat (ENT). Contact Dr. Bikhazi at
(801)475-3000 or www.odgenclinic.com
Brian Wansink, PhD
Director and the
John Dyson Professor
of Marketing of
the Cornell Food
and Brand Lab in
the Department of
Applied Economics and Management
at Cornell University in Ithaca, New
York. Contact Dr. Wansink through the
Cornell Food and Brand Lab website at
www.foodandbrandlab@cornell.edu.
Susan F. Tapert, PhD
Professor of psychiatry
at the University of
California, San Diego
School of Medicine
and acting chief of
psychology at the
VA San Diego Healthcare System.
Jonathan Malka-
Rais, MD
Assistant professor and
board certified allergist
and immunologist at
National Jewish Health
in Denver, Colorado.
James Brewer,
MD, PhD
Neurologist and
associate professor
of radiology and
neurosciences at the
University of California,
San Diego School of Medicine.
N.A. Mark Estes, III, MD
Spokesperson for
the America Heart
Association, Dr. Estes is
professor of medicine,
Tufts University School
of Medicine and
director of the New England Cardiac
Arrhythmia Center at Tufts Medical
Center, in Boston, Massachusetts.
Timothy J.
Sullivan, MD
Contributing editorial
advisory board
member of What
Doctors Know, Dr.
Sullivan spent 25 years
in full-time academic medicine at
Washington University, University
of Texas Southwestern Medical
School, and Emory University. He
currently has a full-time allergy and
immunology practice in Atlanta,
Georgia and is a clinical professor
at the Medical College of Georgia.
Contact Dr. Sullivan at (404)255-2918
or www.trittbreatheandsleep.com.
Phillips Kirk
Labor, MD
Internationally
known for his work in
refractive surgery and
cataract expertise for
more than 20 years.
Dr. Kirk Labor is a board certified
ophthalmologist in the Dallas, Texas
area with affiliations to the American
Academy of Ophthalmology, American
Society of Cataract and Refractive
Surgery, American College of Eye
Surgeons, and Society for Excellence
in Eye Care. Contact Dr. Labor at
(817)410-2030 or www.eyectexas.com.
whatdoctorsknow.com
WHAT DOCTORS KNOW
And you should, too!
Special Thanks To:
Joseph D. Spahn, MD
Associate professor
and board certified
allergist at National
Jewish Health in
Denver, Colorado.
Frank Smart, MD
Internationally
recognized for his
work in heart failure,
transplantation and
mechanical circulatory
support, Dr. Smart
ahs worked as an
academic cardiologist since 1991. He
is Professor of Medicine and chief
of the section of cardiology at the
Louisiana State University School of
Medicine. In addition he is the director
of the Cardiovascular Center of
Excellence at the LSU Health Science
Center in New Orleans, Louisiana.
Scott Hacking, MD
Board certified
interventional
cardiologist, practicing
in Salt Lake City, UT.
Dr. Hacking completed
his cardiology
fellowship at the
University of Rochester, in New York.
Fred A Lopez,
MD, FACP
Currently the Richard
Vial Professor and vice
chair in the Department
of Medicine at
the Louisiana
State University Health Sciences
Center in New Orleans, Dr. Lopez
is a committed educator and a
founding member of the LSUHSC
Academy for the Advancement
of Educational Scholarship.
whatdoctorsknow.com 0
Alcohol is a
Buzz - Kill for
Developing
Teenage
Brains
whatdoctorsknow.com
A
fter more than a decade
of decline, alcohol use
among teenagers is
rising. In fact, it has
become alarmingly
pervasive. According to
various reports, three-fourths of 12th
graders, more than two-thirds of 10th
graders and about two in every five
8th graders have consumed alcohol.
For teens who say they drink, the
average age of first alcohol use is 14.
The rise in consumption appears
to stem primarily from the
notion among teens that
drinking alcohol is less risky
and health-threatening
than using drugs or
other substances. Its
misguided, to say the least.
Every year, approximately
5,000 Americans under the
age of 21 die as a result of
underage drinking, mostly
in traffic crashes and other
accidents. Pre-teens who drink
are also substantially more
likely to engage in violent
behavior or commit suicide.
More often, though, the damage
done is subtler and cumulative. Buzz
or no buzz, alcohol is bad for the
brain, especially in young brains still
developing. In a growing number of
studies, including some conducted
at the University of California, San
Diego School of Medicine, researchers
report that alcohol consumption among
teens, particularly popular binge-
drinking, measurably and significantly
impacts cognitive function.
For example, girls who drink heavily
during adolescence are more likely to
go downhill relative to girls who don't
in terms of their ability to do non-
verbal, spatial tasks, such as piecing
together puzzles, reading a map or
putting together a book shelf. For
boys, we see problems performing tasks
that require concentration, especially
if the task is boring and requires
them to focus for a few minutes.
The effects are most pronounced with
adolescents who drink heavily on a
repeated basis, but there are clear risks
to drinking a lot in just one sitting.
Theres a substance in the brains
white matter called myelin. Its a fatty
material that envelopes the fibers
connecting neurons, a sort of insulating
material that helps guide the electrical
transmissions used to form
effects are magnified. Its not so much
that theyre destroying existing myelin
as the fact that they are slowing down
the process of creating the myelin
needed to build a full, healthy brain.
No one knows yet what the long-
term effects of teen drinking are.
Researchers need to carefully
study young people who have been
examined before they started to
drink, and later to assess the actual
detrimental changes to their brains.
We have begun doing these studies;
we are seeing concerning effects.
Should teens drink? Generally
speaking, absolutely not. There
is evidence that teens who
quit drinking or at least cut
back show improvement
in cognitive function.
Some problems get better
with abstinence. But
others do not. For this
reason, we recommend
that young people who do
drink avoid consumption
to the point of intoxication
or to the point of feeling
hung over the next day.
The hangover will pass, the
brain damage may not.
-Susan F. Tapert, PhD
thoughts. The process of myelination
is a very important part of brain
development and maturation. You want
to maximize it when youre growing up.
Heavy drinking in adolescence does
just the opposite. It appears to disrupt
the brains ability to produce and
lay down myelin. One of our studies
showed that adolescents normally
increase white matter development,
and probably myelin, in some areas of
their brains by 5 to 8 percent between
the ages of 17 and 18. The process
then tapers off so that by ones 20s,
theres little observable change. After
30, theres almost no myelination. In
fact, you begin to lose myelin with age.
Alcoholic adults generally show less
white matter in the brain after chronic
heavy drinking. So, presumably, if
someone started drinking in their 40s,
they start losing white matter they
developed in their teens. For adolescent
drinkers, theres less cushion and the
whatdoctorsknow.com
T
o begin this series on premium lenses,
lets start with a few basic questions. Have
you ever had to hold a newspaper or menu
farther away to see it clearly? Or does
seeing up close and other distances become
more difficult? Did you find you needed
reading glasses when you never needed glasses before?
Starting at around age 40, most of us will experience
difficulty focusing. As we enter our 60s, focusing
becomes more difficult, because this is when were
more likely to develop a cataract in one or both eyes.
A premium lens is an artificial lens that replaces
the natural lens of your eye. Most often used in
cataract surgery, it is an advanced, amazingly simple
way to correct age-related vision problems. More
importantly, these lenses can even enhance vision
and reduce the dependency on reading glasses.
Crystalens is one of the various types of advanced
premium lenses available. Other types, which I will
cover in later articles, include Multi-focal lenses and
Toric lenses. Crystalens and Multi-focal lenses are
designed for patients with age-related presbyopia (loss
of near or intermediate vision). Toric lenses are designed
for patients with astigmatism (an irregularly shaped
cornea). All of the more advanced premium lenses
are designed to improve vision at various distances.
Crystalens: A Natural Fit
Crystalens is the first and only accommodating
intraocular lens (IOL) approved by the FDA
accommodating meaning that the lens moves
naturally within the eye. It is also the only FDA-
Seeing the Benefts of
Crystalens More Clearly
whatdoctorsknow.com
approved presbyopia-correcting IOL for cataract patients
providing a single focal point throughout a continuous
range of vision. It works so effectively because of
its amazing flexibility, working in conjunction with
your eye muscles to greatly improve focus on objects
at different distances near, intermediate and far.
Actually modeled after the human eye, Crystalens is
designed to allow the optic, or central circular part of
the lens you see through, to move back an forth as you
change focus on images around you. Using the eye
muscle, it flexes and accommodates in order to focus on
objects at all distances. This is a tremendous advantage
for the patient because, in the past, cataract surgery
could correct only for the cataract itself. The patient
would still be dependent on eyeglasses after surgery,
but because Crystalens also corrects for presbyopia,
the need for glasses is reduced dramatically. In fact,
some patients hardly if ever need glasses after surgery.
The Crystalens procedure happens during cataract
surgery, which is painless and takes about 15 to 20
minutes or less. It usually begins with eye drops
to numb the eye. Then, a small incision is made
at the edge of the cornea, and the natural lens is
washed away and replaced with the Crystalens
implant. After surgery, patients return to see their
doctor later to assess their results and recovery.
whatdoctorsknow.com
Real Results. Realistic Expectations.
Its important to rememberas I tell all of my
patientsthat a Crystalens implant is not an overnight
fix. No doubt, the benefits of Crystalens are very real
and more than worth having the procedure. However,
each patients vision must improve over time because
the eye has to re-learn how to focus for the best possible
vision. In a way, its similar to a repaired muscle in
your arm or leg. The muscle has to be rehabilitated
to function normally as it did before. The same is
true for the eye after surgery. The eye muscle (called
the ciliary muscle) must be rehabilitated so that it
can adjust to viewing objects at varying distances.
With this in mind, I always give my patients post-
surgery eye exercises to help regain their best vision
as quickly as possible. The length of time this process
takes varies from patient to patient, but most can
return to their normal activities in two or three days.
Another important point is that premium lenses are
considered to be elective, and not a part of the cataract
procedure typically covered by insurance. But for most
people, the enhanced vision that Crystalens provides
is well worth the investment. In fact, based on overall
results, patients with a Crystalens implant see better
at all distances versus those with a standard IOL.
If you suspect you might have cataracts, the first
step is to be evaluated by your doctor. Should you
need surgery, this is when your doctor will discuss
the various premium lens options available, and if
Crystalens is right for you. Ask as many questions
as you want, as this is a doctor-patient decision.
Remember, its not just about improving your vision;
its about the safest, most effective way for your vision
to be the absolute best it can be. -Part one of a series
on Premium Lenses-Phillips Kirk Labor, MD
Crystalens is
a registered
trademark of
Bausch & Lomb
Incorporated
and/or its affiliates.
whatdoctorsknow.com 5
Whats New in
the World of
Sinus Bugs and
Drugs?
whatdoctorsknow.com
I
t is that time of year when seasonal changes,
colds and allergies all add up to misery for
sinus sufferers. This article will bring you
up to speed on the latest buzz in the world
of sinus infections. These are the five most
important and exciting areas of improvement:
1. It is not all about oral antibiotics anymore.
With steadily increasing resistance of many bacteria
to frequently used antibiotics (think of resistant Staph
infections), a major goal has been to minimize the
use of antibiotics. These strong medications tend
to not only kill the bad bacteria but also the good
ones. So any measure to treat sinus infections would
also address a key question: What is the cause of the
sinus blockage? Much like a clogged toilet, unless
drainage is re-established, no amount of antibiotics
will permanently clean the sinuses (think of the
analogy of an outhouse versus a draining toilet).
Adjunctive medication to antibiotics should include
saline rinses, steroids, and even decongestants for a
short period of time to re-establish drainage. Also,
research is focusing on probiotics (beneficial bacterial
cultures) and their help in reconstituting the normal
sinus flora after a period of intensive antibiotics.
2. Biofilms are the new buzz word.
A key concept that has developed in sinus research is
the importance of bacterial biofilms. Imagine these
as complex mucoid structures that act as safe havens
for bacteria to avoid the penetration of antibiotics.
Biofilms tend to accumulate in the sinuses after
prolonged infection and are difficult to remove (like
clearing rubber cement out of cavities). Only surgery,
followed by topical antibiotic irrigation will be able
to clear these resistant bacteria colonies. How do you
know if you have them? Odds are that if you have
resistant infections to multiple oral antibiotics, these
may exist. A CT scan can reveal plugged sinuses
often which may contain bacterial biofilms. Also, the
most difficult to treat bacteria (Staphylococcus and
Pseudomonas) seem to form these biofilm structures.
ENT physicians and otolaryngologists have even
conducted studies using dilute baby shampoo rinses
(do not try this at home!) to remove these films. Much
more needs to be done to understand this concept,
but this a new and interesting field of microbiology.
3. Topical antibiotic and steroid rinses
are important recent advances.
Over the past 10 years, sinus nebulizers have been
developed to irrigate the sinuses locally with antibiotics/
steroids. This involves placing a machine that nebulizes
these medications directly into the nostrils which
decongests and treats infected sinuses. This can be
of particular help to those who suffer from repeated
nasal polyps. The medications used are much stronger
than can be given orally. A major push has been made
to minimize the use of oral antibiotics by using nasal
lavage with salt water (saline). One popular over-the-
counter (OTC) rinsing mechanism is the Netipot
device which reduces post-nasal drip by clearing away
mucus in the nasal cavity. This has been particularly
helpful in patients suffering from seasonal allergies. If
these OTC measures fail, sinus nebulizers using topical
antibiotics or steroids can relieve congested sinuses.
whatdoctorsknow.com
4. The function of the sinus lining is essential.
Most patients who undergo sinus surgery experience
significant benefit (over 85%). For those with persistent
symptoms, the problem may be that the underlying
condition of the sinus lining is not working. Realize
that the sinus lining has delicate cilia on the cells
whose function is to propel mucus out of the sinus
into the nasal cavity. A simple cold can disable cilia
for up to 30 days! This explains why mucus can build
up after colds for so long afterwards. Also allergies
can inhibit the ciliary function, so no matter how
big a sinus opening is made, poor ciliary function
can cause major problems. In patients with cystic
fibrosis, thick mucus that clogs the sinuses causes
permanent ciliary dysfunction. These patients suffer
from repeated sinus infections. Re-activating ciliary
function has been one of the driving forces in recent
sinus research. Maneuvers that help removed thick
tenacious mucus include Mucinex (an over-the-
counter mucous thinning agent) and saline rinses.
5. Recovering from sinus surgery is
much easier than it used to be.
In the past, sinus surgery was tremendously invasive.
Tissue was removed in wanton fashion and many
patients were left with scarred sinus cavities that
continued getting infected. Nowadays, attention has
been directed to minimally invasive sinus surgery.
Minimal, sinus lining-sparing techniques, have evolved
as has dissolvable packing both of which minimize
recovery times. Most sinus surgery requires a down time
of less than 5 days and patients can breathe through
their noses avoiding the completely packed feeling of
yesteryear. Most recently, balloon catheter dilation
(balloon sinuplasty) for blocked sinus outlets has gained
accelerating interest. A balloon is inserted into the
sinus openings which are then enlarged as the balloon
dilates. This procedure results in quick recovery and
excellent post-operative reduction of sinus infections.
Most of the patients do not even require nasal packing
after this procedure. Also, dissolvable steroid stents have
been used with amazing success in polyp sufferers.
6. Treating allergies not only helps the upper airways
(sinuses) but the lower ones as well (asthma).
A relatively new concept in the world of sinus and
asthma is that of the unified airway. To state this
otherwise: what affects the upper airways affects the
lower and vice versa. Treating allergies not only reduces
overall nasal congestion but also reduces inflammation
around the lower respiratory tract (asthma). One
should picture allergies as causing inflammation or
swelling around the sinus openings which increases
nasal congestion and drainage. Efforts are made by
otolaryngologists to reduce allergic inflammation as a
risk factor for repeated sinus infections and infections
of the lower respiratory tract (bronchitis, pneumonia,
etc.). Allergy therapy may include desensitization shots,
sublingual immunotherapy, oral antihistamines, and
topical nasal steroids. One should consult the Cochrane
data base (www.cochrane.org) for more information
about the effectiveness of each of these therapies.
7. Kids with sinus infections need to be fully evaluated.
Many children who have recurring sinus infections get
over their symptoms with antibiotics. Those that do not
improve will need a full evaluation including allergy
testing, CT scan imaging of the sinuses, and evaluation
of their tonsils and adenoids. Also, infants with recurring
infections need to be evaluated for possible gastric reflux
as this is a known risk factor for not only sinusitis, but
also recurring ear infections. Chronic sinusitis is also
one of the first presenting symptoms of kids with mild
variants of cystic fibrosis. Otolaryngologists can ably
evaluate all of these conditions to identify the causes of
persistent infections. Any more than 3 sinus infections
per year would be considered worthy of evaluation.
It is clear that technological advances have allowed
sinus surgeons to improve patient outcomes
from sinus surgery. Challenges still remain in the
arena of antibiotic resistance. With continued
research, technological advances can help sinus
sufferers return to an infection-free lifestyle with
minimal morbidity. -Nadim Bikhazi, MD
whatdoctorsknow.com
Does Aspirin Take
Your Breath Away?
A
spirin and some non-steroidal anti-
inflammatory drugs (NSAID)
can cause acute severe worsening
of asthma. Large surveys have
indicated that between 4% and 11%
of adult asthmatics have experienced
flares of their asthma after taking aspirin or one
of the other non-steroidal anti-inflammatory
drugs. These medications do not cause asthma,
but they can cause dangerous exacerbations.
This susceptibility is often referred to as aspirin
exacerbated respiratory disease (AERD).
The typical reaction includes marked shortness
of breath, intense nasal congestion, and watery
nasal secretions. Sneezing, nasal itching,
redness of the eyes, swelling around the eyes,
rash, flushing of the head and neck, nausea,
and abdominal pain also may occur.
Many asthmatics are not aware that they have
aspirin sensitivity. Approximately 21% of
adult asthmatics experience acute worsening
of their airway functions when given aspirin.
Aspirin sensitivity is present in 30%-40%
among patients with asthma who have chronic
inflammation of the nose and sinuses, and
have nasal polyps. Allergy may be present,
but many AERD patients have no detectable
allergy to environmental antigens. This problem
appears to be slightly more common among
women. Aspirin sensitivity is rare among
children but aspirin challenges of asthmatics 6
to 18 years of age have been positive in 2%.
While there is considerable individual
variation, the problem typically begins with
the development of persistent inflammation
of the nose and sinuses. In one large study in
the United States the onset of rhinosinusitis
occurred at an average of 34 years of age. Two to
three years later the patients developed asthma
and at about that same time the susceptible
individuals developed sensitivity to aspirin and
other non-steroidal anti-inflammatory drugs.
whatdoctorsknow.com
AERD patients then begin to have frequent episodes
of bacterial sinus infections. They have frequent
exacerbations of asthma and often need oral steroids
to control their problems. Nasal polyps (benign
growths of tissue arising in the sinuses or the nasal
membranes) may develop and may cause worse nasal
obstruction, and anosmia (loss of the sense of smell).
Many of the patients who develop polyps require
surgery to reopen the nasal passages. Polyps can
regrow and surgery often is needed multiple times.
Compared to patients without aspirin sensitivity,
AERD patients have more severe impairment of
lung functions, a need for high doses of inhaled
steroids to gain control of their asthma, a higher
frequency of severe episodes of asthma, and higher
rates of hospitalization and intubation for asthma.
The ability of aspirin and other non-steroidal anti-
inflammatory drugs to trigger these reactions appears
to be related to their ability to inhibit an enzyme called
cyclooxygenase-1. Inhibition of this enzyme leads to
the release of inflammatory mediators that then cause
a sudden worsening of asthma and rhinosinusitis.
A diagnosis of aspirin sensitivity, AERD, can be
suspected if there is a reaction immediately after
taking an NSAID. The diagnosis can be confirmed
with a standardized aspirin challenge. This
procedure involves the administration of increasing
doses of aspirin over a period of 3 days and will
result in a reaction in aspirin sensitive patients.
Prevention of Reactions and Treatment
Patients with AERD should be provided a list of
NSAIDs to be avoided. Ibuprofen, indomethacin,
naproxen and several other NSAID drugs nearly
always elicit reactions in aspirin sensitive patients.
There are other non-steroidal anti-inflammatory drugs
that may be tolerated by aspirin sensitive individuals.
Aspirin and other non-steroidal
anti-inflammatory drugs
(NSAID) can cause acute, severe
worsening of asthma, nasal
problems, and sinus problems.
Aspirin sensitivity is present
in approximately 21% of
asthmatic adults, and 30% to
40% of adult asthmatics who
also have chronic inflammation
of the nose and sinuses,
and have nasal polyps.
Knowledge of which anti-
inflammatory drugs should
be avoided and which should
be safe is very important.
Aspirin desensitization can
reduce the severity of the
chronic airway problems
in susceptible patients.
Desensitization also can allow
the use of aspirin and other
NSAID when they are needed
for cardiac, rheumatologic,
chronic pain, or other disorders.
whatdoctorsknow.com 0
Acetaminophen is a very weak inhibitor of the
cyclooxygenase-1 and usually can be used safely
in AERD patients. If there is any question about
the safety of an anti-inflammatory drug, the first
dose ought to be administered in a physician's
office. Allergy and Immunology specialists
and other asthma specialists can provide drug
recommendations and supervise oral challenges.
Desensitization
Early research on aspirin sensitivity indicated that for
a period of 2-5 days after a reaction to an NSAID the
patient can tolerate additional exposures to an NSAID
without a reaction. These observations led to the
development of a protocol for administering increasing
doses of aspirin, treating through a reaction, and
then continuing to give aspirin on a daily basis.
AERD patients who have been desensitized and
continue to take aspirin on a twice-daily basis have
been shown to have a decrease in the severity of
their respiratory tract disease, a decreased frequency
of bacterial sinusitis episodes, a decreased need
for surgery for recurrent polyps, improvement in
the sense of smell, a decreased need for systemic
steroids to control exacerbations, and a decreased
frequency of hospitalization for asthma.
Aspirin desensitization also may be undertaken to
permit the use of aspirin in patients with coronary
artery disease, patients with rheumatologic conditions
that would benefit from NSAID therapy, patients
with chronic pain syndromes, and in patients
with the rare anti-phospholipid syndrome.
Aspirin sensitivity is an important problem that
often is unrecognized until a serious reaction has
occurred. Avoidance of potentially hazardous
medications, and selection of safe alternatives
is essential. Board certified allergists and
immunologists are specialty trained to provide
detailed information about the selection of
medications and can perform aspirin desensitization.
-Vicki Lyons, MD, and Timothy J. Sullivan, MD
When you consider the alternative, eating right and
staying active really dont seem so bad.
Many of the nearly one million deaths each year from
type 2 diabetes, heart disease and stroke could be
prevented with a few lifestyle changesincluding
regular physical activity, healthier food choices and
not smoking. Its not easy. But it is worth it.
Talk to your doctor about your risk for type 2 diabetes
and heart disease. Its your life. Listen to your doctor.
Eat better. Get moving.
Staying healthy isnt easy.
Then again, neither is dying.
For more information, visit CheckUpAmerica.org, or call 1-800-DIABETES.
ADA 295-09 Hard Ad 7x10 V6.indd 1 5/17/09 7:23:51 PM
whatdoctorsknow.com
The Mystery of
Multiple Sclerosis
No Simple Explanation
M
ultiple sclerosis (MS) disrupts
communication between the brain and
other parts of the body. In the worst
cases, it can bring partial or complete
paralysis. Researchers dont yet know
what causes this disease or how to
cure it, but theyve been making progress on both fronts.
Symptoms of MS arise most often between the ages of 20 and 40.
It often begins with blurred or double vision, color distortion, or
even blindness in one eye. It can cause muscle weakness, vision
loss, numbness or tingling, and difficulty with coordination and
balance. MS can bring many other symptoms as well.
In some people, doctors may not be able to readily
identify the cause of these symptoms. Patients may
endure years of uncertainty and multiple diagnoses while
baffling symptoms come and go. The vast majority
of patients are mildly affected, but in the worst cases,
MS can leave a person unable to write, speak or walk.
MS is a disease in which the bodys immune system
whatdoctorsknow.com
The Mystery of
Multiple Sclerosis
inappropriately attacks the brain and spinal cord.
Specifically, the immune system targets the fatty
insulating material around nerves called myelin.
When myelin is damaged, the messages that nerve
cells send and receive can be interrupted.
Researchers estimate that 250,000 to 350,000
people in the United States have been diagnosed
with MS. Scientists dont yet understand what
triggers the immune system to attack myelin in
these people. But researchers do know that whites
are more than twice as likely as others to develop
MS, and women almost twice as likely as men.
Geography seems to play a role in MS. The
disease is much more prevalent in temperate
climates than in tropical regions. Your risk for
MS seems to depend on where you live
before the age of 15. Some studies have found that a
person who moves before the age of 15 tends to adopt
the risk of the new area. People moving after age
15 seem to maintain the risk level of the area where
they grew up. Some researchers believe that vitamin
D, which the body makes when sunlight strikes the
skin, may lower the risk of MS and help explain these
findings, but studies havent yet confirmed this link.
Some microbes, such as the Epstein-Barr virus,
have been suspected of causing MS. But researchers
havent been able to prove for certain that any
microbes raise your chances of getting MS. Cigarette
smoking, however, does appear to raise your risk.
Genes clearly affect how likely you are to develop MS.
Having a sibling with MS raises your risk of getting
MS to about 4% to 5%; having an identical twin
raises your risk to about 25% to 30%. These facts
suggest a strong genetic component to MS. However,
although some studies have linked specific genes
to MS, most of the results havent been definitive.
Researchers are now working on more detailed studies.
Theres no cure yet for MS, but various therapies can
treat it. Researchers are continuing to develop new and
better therapies for MS, with several now in the pipeline.
-Source: NIH News in Health, March 2011,
published by the National Institutes of Health and
the Department of Health and Human Services. For
more information go to www.newsinhealth.nih.gov
Signs and Symptoms of MS
Muscle weakness
Blurred or distorted vision
Numbness of tingling
Coordination problems
Speech disturbances
Vertigo or dizziness
Trouble concentrating
Fatigue
Tremor
whatdoctorsknow.com
V
anderbilt radiologists are
rolling out powerful new
imaging techniques that
provide clearer pictures of
the delicate ebb and flow
of blood through brain
tissue in patients at risk for stroke.
One of the neuroimaging techniques
is called blood oxygenation level-
dependent functional magnetic
resonance imaging, or BOLD fMRI.
It allows radiologists to non-invasively
measure how near tissue is to exhausting
its supply of blood, which is believed to
be a sensitive indicator of stroke risk.
Mapping a Stroke
New imaging techniques prove
valuable tools to assess stroke risk
While BOLD fMRI is a popular
research tool for cognitive
neuroimaging, it is currently
being used clinically at only a
few centers across the country.
At Vanderbilt, Megan Strother, M.D.,
assistant professor of Radiology
and Radiological Sciences and
Neurological Surgery, and colleague
Manus Donahue, Ph.D., are currently
using the technique to assess the stoke
risk of patients with Moyamoya, a
complex disorder causing intracranial
stenosis the narrowing of
arteries leading into the brain.
Patients with Moyamoya are at a
heightened risk for stroke in the first
two years after diagnosis, so the
goal is to image them every three to
six months within that time frame
to help guide treatment decisions.
Surgical intervention options include
arterial bypasses and encephalo-dura-
arterial synanastomosis (EDAS).
The conventional way these patients
would be evaluated is by doing a
cerebral angiogram, Strother said.
Although angiograms provide
great pictures of the blood vessels,
whatdoctorsknow.com 5
angiograms are invasive procedures
which require neuro-interventionalists
to access the artery with a small
catheter through the patients groin,
move the catheter through the patients
aorta to the cervical vessels, and then
image the injected contrast as it flows
through the brain. Angiograms are
high-risk invasive procedures which
can cause complications including
stroke. Additionally, patients are
exposed to radiation and the contrast
can harm patients kidneys.
These risks are eliminated with BOLD
imaging. BOLD is non-invasive and
does not expose patients to contrast or
radiation. Instead of receiving contrast,
patients breathe slightly elevated
levels of carbon dioxide through a
facemask while they lie in the MRI
scanner. The carbon dioxide acts as
a vasodilator, which increases the
amount of oxygenated blood in vessels.
Water surrounding oxygenated and
deoxygenated blood has different
magnetic properties, and therefore
MRI images acquired as the patients
blood vessels dilate allow physicians to
gauge tissue level hemodynamics or
changes in the amount of blood volume
and blood flow. This allows clinicians
to assess better the wide range of
vascular compensation strategies
that may be present, and whether
patients have adequate blood supply
beyond areas of arterial narrowing.
Strother said patients are thrilled
with the ease of the 15-minute
imaging technique, and more than
20 BOLD MRI scans have been
performed over the past
several months. She began
investigating the feasibility
of employing the technique
at the urging of Vanderbilt
neurosurgeons who treat
patients with Moyamoya
and who were discouraged
by insufficient diagnostic
imaging approaches available
for this population.
A key component to
implementing BOLD and
to increasing the number of
patients who can be assessed
with the technique was the
arrival last November
of medical physicist
Donahue from Johns
Hopkins University.
Donahue uses
hemodynamic models to
convert the data generated
by the BOLD technique into
physiologically meaningful
maps of cerebral perfusion and
blood volume reactivity that can
be readily interpreted by clinicians.
Donahue has also added new
noninvasive vessel selective arterial spin
labeling approaches for quantifying
collateral blood flow, or the precise
manner by which tissue receives blood
when a feeding vessel is occluded.
BOLD imaging adds a critical piece
in the puzzle to decide who needs
surgical treatment, by identifying
patients who are at highest risk
for stroke, Strother said.
Over the next few months, BOLD fMRI
and other non-invasive measures of
tissue-level hemodynamics will be added
to MRI scans performed on Vanderbilt
stroke patients. Strother and Donahue
are working with Howard Kirshner,
M.D., director of the Vanderbilt Stroke
Center, on this initiative in hopes that
these imaging techniques will be helpful
in explaining the pathophysiology of
stroke, potentially leading to refinements
in stroke treatment and prevention.
-This information provided courtesy of
Vanderbilt University Medical Center
whatdoctorsknow.com
One for the Memories:
Detecting Alzheimer's Disease
T
he devastating effects of full-blown Alzheimers disease (AD)
are well-known and much-feared. It progressively robs its
victims of their memory and other intellectual abilities.
But some degree of memory loss and diminution of
cognitive function are also part of the natural aging
process. It happens to everybody. The challenge
is differentiating between the first signs of looming AD and
the normal, inevitable annoyances of just getting old.
As a neurologist and Alzheimers disease researcher, I often see patients in
their golden years who have become excessively worried about mild and
intermittent memory dysfunction, who are having senior moments like
misplacing keys or forgetting where they left their car in a large parking lot.
In such cases, the first step is usually to determine and confirm the
existence of a real memory problem. At UC San Diego, we do this by
performing tests that gauge how well a patient forms new memories and
whatdoctorsknow.com
retains that information despite delays
and distractions. The goal is to determine
how impaired memory function is and
whether this impairment appears to
be progressing at a rate beyond that
expected with normal aging. If the
results are worrisome, we may send
the patient for more detailed testing of
memory and other cognitive functions.
Right now, theres no definitive or
predictive test for AD in living patients,
a test based on well-understood,
measurable biomarkers that can both
determine the presence of the disease and
accurately predict its probable course.
Unfortunately, AD is not a
straightforward disease. Hundreds
of millions of dollars have been
spent in recent decades trying to
better understand the biology and
pathology of AD, but it continues
to throw confounding curveballs
that have thwarted many promising
approaches. Despite these challenges,
medical science is getting better at
providing more accurate and predictive tests for AD,
which may allow us, in the future, to intervene at a
time well before significant impairment occurs.
For example, in cases where screening of a patient
suggests mild but abnormal memory loss, we use an
imaging technology called volumetric MRI to assess
the degree of degeneration to structures in the brain
most likely to be affected by AD. In special cases, we
might also sample the cerebrospinal fluid for levels
of a protein that accumulates in AD. These are all
biomarkers that can help in determining which patients
with memory problems will progress to dementia.
Memory screening for individuals concerned about
memory loss is available, but the decision to seek
such information is a very personal decision. No
current treatments directly alter the course of
AD, though it is possible to sometimes slow the
progression of symptoms, such as cognitive problems,
by working to keep the brains vasculature as
healthy as possible through blood pressure control,
smoking cessation, optimal diet and exercise.
Screening provides an objective baseline with which to
evaluate changes, should new concerns crop up. If the
screening detects a potential problem, research suggests
that it will be best to intervene as early as possible,
before significant brain damage accrues. It might also
point to other, perhaps curable, explanations for ones
memory complaints. -James Brewer, MD, PhD
whatdoctorsknow.com
Facts About MS and The National Multiple Sclerosis Society
MS stops people from moving. The National MS
Society exists to make sure it doesnt. We help
each person address the challenges of living with
MS. In 2010 alone, through our national office and
50 state network of chapters, we devoted $159
million to programs and services that assisted more
than a million people. To move us closer to a world
free of MS, the Society also invested $37 million to
support 325 research projects around the world.
The Society partners
with the healthcare
community to promote
quality healthcare.
Information on MS and
the Societys services
are available 24-hours
a day by calling (800
344-4867. We are
people who want to do
something about MS
now. You can join the
movement at www.
nationalMSsociety.org
There are approximately 1,200 positions filled by professional staff
members and over 500,000 positions filled by volunteers. Together they
carry out the Societys daily operations. The Society has some 750,000
general members, including over 370,000 individuals who have MS.
Nationwide income in
2010 was $217 million.
The majority of Society
income comes from private
contributions, 66% of which
is generated through special
events. Approximately 7%
is received from corporate
support, including
pharmaceutical companies
and government grants.
Approximately 73% of
Society income is devoted
to research and service
programs while the
remainder is invested in
support services such as
fund raising and Society
management. It costs
the Society about 15
cents to raise a dollar.
24
/
7
$217 million
whatdoctorsknow.com
Since the founding
by Sylvia Lawry in
March 1946, the
Society has expended
over $721 million to
advance MS research.
During the last 65
years, the Society
has been at the core
of virtually every
major breakthrough
in treating and
understanding
the disease.
Joyce Nelson, the
president and CEO
of the Society, came
up through the ranks
of the organization,
devoting more
than two decades
to the MS cause.
The progress, severity and specific
symptoms of MS in any one person
cannot yet be predicted. Advances in
research and treatment are moving
us closer to a world free of MS. Most
people with MS are diagnosed between
the ages of 20 and 50, with at least two
to three times more women than men
being diagnosed with the disease. MS
affects more that 400,000 people in
the US, and 2.1 million worldwide.
Some prominent American with MS
are: actress Teri Garr, Actress Annette
Funicello, country-music singer Clay
Walker, R&B singer Tamia Washington,
newscaster Neil Cavuto, newscaster
Janice Dean, comedian David Squiggy
Lander, comedian Jonathan Katz, Seattle
Seahawks mascot Ryan Asdourian,
extreme sports activist Wendy Booker,
marathoner Zoe Koplowitz, writer/
director Henriette Mantel, singer Alan
Osmond and his son David, author
Ellen Sue Stern, author Jackie Waldman,
singer Victoria Williams, Triple Crown
horse trainer Kiaran McLaughlin, and
television hos Montel Williams, as well as
the late Congresswoman Barbara Jordan,
cellist Jacqueline du Pr, singer Lena
Horne, and comedian Richard Pryor.
Multiple Sclerosis is an unpredictable, often disabling disease of the central
nervous system. The disease interrupts the flow of information within the
brain, and between the brain and the rest of the body. Every hour in the
United States, someone is newly diagnosed with MS. Symptoms range from
reduced or lost mobility to numbness and tingling to blindness and paralysis.
Some prominent American with ties to MS are: model Alessandra Ambrosio
(father), TV personality Phil Keoghan, actor Martha Madison (mother), actor
Shemar Moore (mother), actor Bill Pullman (friend), model Emme Aronson
(father), actor Michael McKean (friend), and author Jacquelyn Mitchard (friend).
-Source: National Multiple Sclerosis Society. www.nationalmssociety.com
65
years
2.1
years
The US Society is one
of 43 sister Societies
forming the Multiple
Sclerosis International
Federation also
founded by Sylvia
Lawry, who died at
age 86 in 2001.
whatdoctorsknow.com 0
whatdoctorsknow.com
Let's Talk About Atrial
Fibrillation and Stroke Risk
T
heres an alarming gap in knowledge about a common
heart condition, called atrial fibrillation (or AFib). By
closing the gap and arming people with what they need
to know, we could prevent disabling, and even deadly,
strokes. Perhaps, thousands of strokes each year.
Work weve recently done at the American Heart Association/
American Stroke Association to identify gaps in AFib knowledge and
treatment suggests about half of the estimated 2.7 million Americans who
have AFib have not been properly educated about their stroke risk. Physicians
and health care providers commonly provide AFib patients with the
information they need to make informed decisions about individual stroke risk.
whatdoctorsknow.com
The gap? We know that people
who have AFib are at higher
risk of stroke than people who
do not have the condition. Yet,
this information (and resulting
proven prevention) isnt trickling
to the people who need it most.
The solution is as simple, inexpensive
and grassroots as having frank, one-
on-one conversations. Patients need
to be aware of this risk and have
serious conversations with their
health care providers about what they
should be doing to prevent stroke.
Conversation starters
AFib is an irregular heart rhythm that
occurs when the hearts two upper
chambers beat erratically, causing
the chambers to pump blood rapidly,
unevenly and inefficiently. Blood
can pool and clot in the chambers,
increasing the risk of stroke.
The basic message is clear: AFib
is associated with a five-fold
increased risk of stroke. Not only
is it associated with an increased
stroke risk, but also a greater
likelihood that the stroke will lead to
significant disability--even death.
Identifying challenges
In June 2010, the American Heart
Association held an AFib summit,
attended by a wide range of
researchers, clinicians, health care
providers and patients. Our goal
was to sort out AFib knowledge
gaps and make recommendations
about how to address them.
While we identified many areas needing
attention, including a focus on research
that will result in ways to prevent
AFib, one of the most significant
findings was the need for consumer
education. (The summits findings
were published online June 27, 2011,
in the American Heart Association
scientific journal Circulation.)
A survey conducted in July 2011
by Synovate, Inc. for the American
Heart Association, confirmed the
need to talk. One of the findings:
90 percent of patients get AFib
information from their doctors.
Of the 502 adult AFib patients
surveyed, half thought they were at
risk for stroke; 25 percent claimed they
were not at risk; and the remaining
25 percent didnt know. A few other
survey findings: Only two-thirds of
patients surveyed recalled that their
health care provider talked with
them about their elevated stroke risk.
Also troubling is how these patients
perceived the information: Among
the 66 percent who talked with
their doctors, 21 percent said they
were told they have no stroke risk.
Connecting people to information
Lets get the word out now. There
are several proven ways to reduce the
AFib-associated stroke risk. A healthy
lifestyle with maintenance of an ideal
body weight through exercise and
diet can prevent high blood pressure
and diabetes that predispose to AFib.
For individuals with AFib new and
effective medications are available to
thin the blood in order to prevent
the clotting associated with stroke.
The fact is that despite substantial
benefits from taking these
medications, many patients dont
receive or dont take them. There is
a big disconnect in our knowledge
of stroke risk; our knowledge blood
thinning medications can reduce
that risk; and the actual use of the
blood thinning medications.
One of the hurdles could be that blood
thinners have a reputation they dont
deserve. Its true that one popular
blood thinner, called warfarin,
requires monitoring to adjust the
dosing. But newer medications do
not require monitoring. We also
believe physicians and patients tend
to overestimate the risk of bleeding
complications from these medications.
See? We need to talk.
Your life-saving assignment
If you have AFib, make an
appointment with your doctors office.
With todays health care system, you
might have the bulk of your AFib
conversation with your doctors nurse
practitioner or physician assistant.
These people are often charged with
taking more time with patients to
answer questions and educate.
Learn all you can about the condition.
Youll find credible and extensive
AFib information from the American
Heart Association/American Stroke
Association at: www.heart.org/afib.
The solution to closing this gap
is simple communication. We
have to start talking about AFib
and stroke. At a time when the
economy is in turmoil and funding
is scarce, talking doesnt cost a
dime.-N. A. Mark Estes, III, MD
whatdoctorsknow.com
whatdoctorsknow.com
Today's Teens will Die
Younger of Heart Disease
High blood sugar,
obesity, poor diet,
smoking, little exercise
make adolescents
unhealthiest in U.S.
A

new study that takes a
complete snapshot of
adolescent cardiovascular
health in the United
States reveals a dismal
picture of teens likely
to die of heart disease at a younger
age than adults do today, reports
Northwestern Medicine research.
We are all born with ideal
cardiovascular health, but right
now we are looking at the loss of
that health in youth, said Donald
Lloyd-Jones, MD, chair and
associate professor of preventive
medicine at Northwestern University
Feinberg School of Medicine and a
physician at Northwestern Memorial
Hospital. Their future is bleak.
Lloyd-Jones is the senior investigator
of the study presented Nov. 16 at
the American Heart Association
Scientific Sessions in Orlando.
The effect of this worsening teen
health is already being seen in young
adults. For the first time, there is an
increase in cardiovascular mortality
rates in younger adults ages 35 to 44,
particularly women, Lloyd-Jones said.
The alarming health profiles of 5,547
children and adolescents, ages 12
to 19, reveal many have high blood
sugar levels, are obese or overweight,
have a lousy diet, dont get enough
whatdoctorsknow.com 5
The study used measurements from the AHAs 2020 Strategic
Impact Goals for monitoring cardiovascular health in
adolescents and children. Among the findings:
TERRIBLE DIETS All the 12-to-19-year-olds had terrible diets, which, surprisingly,
were even worse than those of adults, Lloyd-Jones said. None of their diets met
all five criteria for being healthy. Their diets were high in sodium and sugar-
sweetened beverages and didnt include enough
fruits, vegetables, fiber or lean protein. They are
eating too much pizza and not enough whole
foods prepared inside the home, which is
why their sodium is so high and fruit and
vegetable content is so low, Lloyd-
Jones said. HIGH BLOOD SUGAR More
than 30 percent of boys and more
than 40 percent of girls have elevated
blood sugar, putting them at high
risk for developing type 2 diabetes.
OVERWEIGHT OR OBESE Thirty-five percent of
boys and girls are overweight or obese. These are
startling rates of overweight and obesity, and we
know it worsens with age, Lloyd-Jones said. They
are off to a bad start. LOW PHYSICAL ACTIVITY
Approximately 38 percent of girls had an ideal physical
activity level compared to 52 percent of boys.
HIGH CHOLESTEROL Girls cholesterol levels were
worse than boys. Only 65 percent of girls met the ideal
level compared to 73 percent of boys. STILL SMOKING
Almost 25 percent of teens had smoked within the
past month of being surveyed. BLOOD PRESSURE
Most boys and girls (92.9 percent and 93.4 percent,
respectively) had an ideal level of blood pressure.
The problem wont be easy to fix. We are much more sedentary and get less
physical activity in our daily lives, Lloyd-Jones said. We eat more processed food,
and we get less sleep. Its a cultural phenomenon, and the many pressures on
our health are moving in a bad direction. This is a big societal problem we must
address. -This information provided courtesy of Northwestern Memorial Hospital.
50s start to form in adolescence
and young adulthood. These
risk factors really matter.
After four decades of declining
deaths from heart disease, we
are starting to lose the battle
again, Lloyd-Jones added.
The American Heart Association
(AHA) defines ideal cardiovascular
health as having optimum levels of
seven well-established cardiovascular
risk factors, noted lead study author
Christina Shay, who did the research
while she was a postdoctoral
fellow in preventive medicine at
Northwesterns Feinberg School.
Shay now is an assistant professor
of epidemiology at the University of
Oklahoma Health Sciences Center.
What was most alarming about the
findings of this study is that zero
children or adolescents surveyed met
the criteria for ideal cardiovascular
health, Shay said. These data
indicate ideal cardiovascular health
is being lost as early as, if not
earlier than the teenage years.
physical activity and even smoke, the
new study reports. These youth are a
representative sample of 33.1 million
U.S. children and adolescents from
the 2003 to 2008 National Health
and Nutrition Examination Surveys.
Cardiovascular disease is a lifelong
process, Lloyd-Jones said. The
plaques that kill us in our 40s and
whatdoctorsknow.com
A
sthma is a disorder that causes the airways of the
lungs to swell and narrow, leading to wheezing,
shortness of breath, chest tightness, and coughing.
This swelling and narrowing are commonly referred
to as airway inflammation and airway constriction.
Airway
constriction can be measured
using traditional lung function
tests such as spirometry.
However, while measuring
airway constriction is important,
it may not tell the whole story.
Many studies show that even
when lung function tests are
normal, airway inflammation
can be present and may indicate a
potential loss of asthma control.
Understanding airway inflammation
Airway inflammation can often be caused by exposure to allergens
in the air such as seasonal pollens, mold spores, and indoor
allergens (e.g., animals, cockroaches, or dust mites). When the
lungs are inflamed in this way, the cells that line the airways
release large amounts of a chemical called nitric oxide (NO).
This gaseous molecule then appears in the air that is exhaled.
In the early 1990s, researchers
found that high levels of nitric
oxide (NO) in the breath
are a telltale sign of airway
inflammation, and people
with asthma have higher
concentrations of NO in their
breath than those without
asthma. The measure of the
concentration of NO in the
breath is referred to as fractional
exhaled nitric oxide, or FeNO.
Until recently, there has been no easy way to measure
airway inflammation, but now FeNO can be measured
with a simple, noninvasive breath test.
Measuring FeNO
In 2003, the first device used to measure FeNO was cleared
by the US Food and Drug Administration. Then in 2011, the
American Thoracic Society (ATS) published a guideline for
Asthma and Airway
Infammation: The Big Picture
the use of FeNO in asthma management in clinical
practice. They concluded that FeNO is directly related
to airway inflammation and that it can be used to
reliably assess and manage asthma symptoms. In
addition, many studies have shown that regularly
measuring and monitoring airway inflammation using
a FeNO test can help healthcare providers prevent
asthma exacerbations in their patients and better
manage patients asthma on a long-term basis.
Long-term asthma management
The preferred therapies for asthma are inhaled
steroidsthey are highly effective in controlling asthma
symptoms, such as nighttime cough, daytime cough, or
cough with exercise. Although these medicines work well
to control asthma inflammation, they can be associated
with risks, including growth suppression in children.
By regularly monitoring asthma inflammation using
a FeNO test, providers can help control asthma using
the lowest possible inhaled steroid dose. FeNO tests
are inexpensive and used routinely in the offices of
doctors who specialize in asthma. Currently, the only
hand-held FeNO measurement device available in
the United States is NIOX MINO

by Aerocrine.
Controlling asthma
Asthma has no cure, but fortunately, it can be
controlled. Regularly monitoring airway inflammation
alongside measures of lung function can give the
big picture of asthmahelping healthcare providers
and patients begin to control it. -Jonathan
Malka-Rais, MD and Joseph D. Spahn, MD
By the time you notice asthma symptoms, you might already be losing control.
Be in the knowmonitor airway inammation with NIOX MINO

and help stay a

step ahead of asthma.
Rewrite your asthma storyask your healthcare provider about NIOX MINO today!
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NIOX MINO

, NIOX

, and Aerocrine are registered trademarks of Aerocrine AB. 2012 Aerocrine Inc
Important note: NIOX instruments are medical devices regulated in the United States by the US Food and Drug Administration. Complete Labeling for our devices may be found at FDA.gov.
The cleared Labeling is the nal authority for Indications, Directions for Use, Risks, Limitations, Performance, and other information.
Every breath tells a story
I N A S T H M A
whatdoctorsknow.com
Are Stress Tests Wrong?
W
e have all heard stories of friends
and family who have had stress tests
to look for heart disease and got a
clean bill of health only to drop
dead from a heart attack not long
after. Are these stories exaggerations
of those who dislike doctors or does this really happen.
The scary answer is this is a real occurrence, and it happens
all too frequently. The reason is that we currently do not
possess the ability to find a heart attack before it happens.
Heart attacks come from a blood clot in one of the major
arteries of the heart. This clot usually forms on top of
a plaque, a small area filled with cholesterol in the wall
of an artery. Stress tests and other non-invasive tests can
find blockages that take up three-fourths of the artery
diameter, but heart attacks can occur where the diameter
is narrowed only one-fourth to one-half. This means a
large number of future heart attacks can occur with no
warning and no way to reliably detect it beforehand.
Even if doctors do invasive tests like an angiogram which
is an injection of dye in the artery, they can find a
plaque but have no idea if it is getting ready to cause a
heart attack. Today the main focus of cardiologists in
this field is the detection of vulnerable plaque. That is
a cholesterol plaque that for whatever reason is about to
break and cause a clot and heart attack. We know that
stress and cigarettes can cause such a crack, and in addition,
things like viruses and even dental infections can result
whatdoctorsknow.com
a heart attack. We can say what the
overall risk of having a blockage is,
however, and by managing this risk, a
person can reduce their overall heart
attack risk. Lowering LDL or bad
cholesterol and high blood pressure,
as well as quitting cigarette smoking
are established ways to reduce risk. If a
person has diabetes, good sugar control
is also a big factor. Finally knowing
your risk, especially if someone in the
immediate family has had a heart attack
before 60, is a time-tested method to
lower the chance of a heart attack.
In addition to following your doctors
advice on risk factor control, a diet
that is high in anti-oxidants may be
beneficial. If you have high cholesterol
or had a prior heart attack, cholesterol
drugs call statins have also been shown
to make vulnerable plaque more stable.
If you exercise routinely great! If not,
start slow and work up to a healthy
exercise level since sudden extreme
physical exertion can increase risk. It is
always a good idea to talk to your doctor
about risk factors during a routine check
up, and if you have any symptoms of
abnormal breathing or pressure in the
chest or back with exertion, you should
let your doctor know immediately.
Until we have the tools to find heart
attacks before they happen, we will all
have to accept that predicting who will
die from a heart attack is like predicting
next weeks weather by looking out of
the window today. But by reducing
the risk factors we can and carrying an
umbrella, well be as covered as we can
be until then. -Frank Smart, MD
in a plaque crack and heart attack. Other
things that make the blood clotting more
pronounced can increase this risk as well.
Looking for vulnerable plaque is a research
quest at medical schools across the country.
Researchers now measure the temperature
of plaque since it seems that vulnerable
plaque, which is inflamed and primed
for a heart attack, is warmer than stable
plaque. There are also certain chemical and
structural changes that may give a clue as
to the true risk of a future heart attack.
Until there are better detection tools,
we will all have to accept the fact that
doctors cant tell us who is about to have
whatdoctorsknow.com 0
H
opkins research suggests more is not
better and may cause harm
New research by Johns Hopkins scientists
suggests that vitamin D, long known to be
important for bone health and in recent years
also for heart protection, may stop conferring
cardiovascular benefits and could actually cause harm as levels in
the blood rise above the low end of what is considered normal.
Study leader Muhammad Amer, M.D., an assistant professor
in the division of general internal medicine at the Johns
Hopkins University School of Medicine, says his findings
show that increasing levels of vitamin D in the blood are
linked with lower levels of a popular marker for cardiovascular
inflammation c-reactive protein (also known as CRP).
Heart Health and Vitamin D
When it comes to heart health,
how much is too much vitamin D?
whatdoctorsknow.com
Amer and his colleague Rehan Qayyum, M.D.,
M.H.S., examined data from more than 15,000
adult participants in the continuous National Health
and Nutrition Examination Survey, a nationally
representative sample, from 2001 and 2006. They
found an inverse relationship between vitamin
D and CRP in adults without cardiovascular
symptoms but with relatively low vitamin D levels.
Healthier, lower levels of inflammation were
found in people with normal or close to normal
vitamin D levels. But beyond blood levels of 21
nanograms per milliliter of 25-Hydroxyvitamin D
considered the low end of the normal range for
vitamin D any additional increase in vitamin
D was associated with an increase in CRP, a
factor linked to stiffening of the blood vessels and
an increased risk of cardiovascular problems.
The inflammation that was curtailed by vitamin
D does not appear to be curtailed at higher levels
of vitamin D, says Amer, whose newest finding
appears in the Jan. 15 issue of the American
Journal of Cardiology. Clearly vitamin D is
important for your heart health, especially if you
have low blood levels of vitamin D. It reduces
cardiovascular inflammation and atherosclerosis,
and may reduce mortality, but it appears that at
some point it can be too much of a good thing.
Amer says consumers should exercise caution
before taking supplements and physicians should
know the potential risks. Each 100 international
unit of vitamin D ingested daily produces
about a one nanogram per milliliter increase
25-Hydroxyvitamin D levels in the blood. People
taking vitamin D supplements need to be sure the
supplements are necessary, Amer says. Those
pills could have unforeseen consequences to
health even if they are not technically toxic.
Amer and Qayyum, also an assistant
professor in the division of general internal
medicine at Hopkins, say the biological and
molecular mechanisms that account for the
loss of cardiovascular benefits are unclear.
Vitamin D is often called the sunshine vitamin
because its primary source is the sun. It is found
in very few foods, though commercially sold
milk is usually fortified with it. As people spend
more and more time indoors and slather their
bodies with sunscreen, concern is rising that
many are vitamin D-deficient, Amer notes.
As a result, Amer says, many doctors prescribe
vitamin D supplements, and many consumers, after
reading news stories about the vitamins benefits,
dose themselves. Older women often take large doses
to fight and prevent osteoporosis. -This information
provided courtesy of Johns Hopkins Medicine.
whatdoctorsknow.com
The 411 on 911
Chest Pain
What do chest pains mean?
whatdoctorsknow.com
C
hest pain is one of the most
common reasons that
millions of people go to
the emergency room (ER)
each year. Yet, each year,
a substantial number of
people stay at home and suffer from
untreated cardiac conditions. Chest pain
can come on suddenly and at any time.
Could you be having a heart attack?
Can you ignore the pain for now?
Should you go to the ER or call your
primary care physician? Do you call
an ambulance or just drive yourself?
Fortunately, chest pain does not always
signal a heart attack. Often, the pain is
unrelated to any heart problem at all. Even
though the pain may not be related to the
heart, it may still represent serious medical
conditions, which need to be addressed.
A significant number of conditions may
cause chest pain. Sometimes only a physician
or additional testing can tell the difference
between cardiac trouble or other causes.
Chest pain caused by a heart attack or another
heart problem is usually associated with one
or more of the following symptoms:
Pressure, fullness or tightness of the chest.
Many people describe this as a heavy or squeezing
feeling. To some, the sensation may not necessarily
seem like pain but more like pressure. The sensation
is not usually sharp or positional (decreasing or
increasing with various body positions), and doesn't
usually occur when taking a deep breath.
Pain that lasts for more than a minute or two but does
not persist for more than an hour without change.
Shortness of breath, sweating,
dizziness and/or nausea.
Pain that radiates or spreads to the arms, jaw or back.
Heart-related chest pain is often, but not always,
associated with other risk factors like smoking, obesity,
diabetes, sedentary lifestyle, high cholesterol and high
blood pressure. It can also be associated with a family
history involving a first-degree relative with diagnosed
heart attacks or blockages prior to the age of 55.
You may have had prior heart attacks or a
heart condition requiring bypass surgery, an
angiogram or stents. Recurrent heart problems
may mimic the sensations you felt in the past.
Pain that is not related to a heart attack often
presents with the following signs and symptoms:
A burning sensation behind the breastbone,
sometimes associated with a sour taste in
the mouth or regurgitation of food.
Sharp, stabbing pain that lasts for only a few seconds.
Pain that gets better or worse with
changes in body position.
Pain that intensifies with coughing or deep breathing.
Pain that can be recreated by
pushing on the chest wall.
Pain associated with swallowing.
If you experience new or unexplained chest pain or
suspect that you are having a heart attack, you should
seek immediate medical attention. Persistent chest pain
should be evaluated at the hospital. Fleeting, intermittent
chest pain that goes away completely needs to be
discussed promptly with your primary care physician
or cardiologist. When in doubt, a trip to the ER could
save your life or at least bring you peace of mind.
If you experience symptoms related to a heart attack,
do not drive yourself to the hospital unless you have
no other option. If you drive in this condition, it
is dangerous not only for you but also for others
on the road. Call an ambulance instead. Qualified
ambulance personnel can start critical life-saving
treatment immediately. Remember, when in doubt, seek
immediate medical attention. -Scott Hacking, MD
whatdoctorsknow.com
Cardiologist Tips:
Right Lifestyle Builds
Solid Heart Health
M
ake the right lifestyle
choices, and youll build
a solid foundation for
your heart. Phillip J.
Hecht, M.D., FACC,
a cardiologist on the
medical staff and medical director of
cardiovascular services/cardiac rehab, Baylor
Regional Medical Center at Grapevine,
shares his top five tips for peak heart health.
Swap some foods.
Turn to chicken and fish
first, and skip the red
meat. Reach for fruits and
vegetables in place of dairy.
Get walking.
You dont have to join
a health club or buy
any equipment, except
maybe a pair of walking
shoes. Get out there and
do some walking every
day, Dr. Hecht says. He
doesnt make one-size-
fits-all recommendations
but notes that you should
work up a sweat and
feel yourself breathing
faster to get heart-healthy
benefits from your walk.
whatdoctorsknow.com 5
Maintain a healthy weight.
With healthy food choices
and a solid exercise program,
weight loss should follow.
Go to http://www.heart.org/
HEARTORG/GettingHealthy/
NutritionCenter/ to see
healthy recipes.
Check your levels.
See your doctor once a
year to make sure your
blood pressure and
cholesterol levels are
normal. If theyre not, your
doctor can help you get
them under control.
Quit smoking.
All smokers know its bad, even
if they dont want to admit it,
Dr. Hecht says. It takes many
smokers several tries to stop
for good, so keep at it. -This
information provided courtesy
of Baylor Health Care System
whatdoctorsknow.com
Colorectal Cancer:
The Non-Biased Killer
C
olorectal cancer is the
second leading cause
of cancer deaths in the
United States. This
year approximately
160,000 Americans
will be diagnosed with colon
cancer. Of those diagnosed, an
estimated 50,000 will die.
The 50,000 killed by colon cancer is
about the same number of Americans
that will die in an automobile accident.
The difference is that most, if not
all, of colon cancer deaths can be
avoided with a simple screening test.
Fortunately, aggressive Cancer
Screening Awareness campaigns are
having an impact and more and more
people are becoming conscious of the
need to get screened. As a result, we
are seeing an increase in the numbers
for colon cancer screenings for all races
and genders. After all, colon cancer
isnt biased about whom it kills.
In the past 10 years, about 60 percent
of American Caucasians who fit the
criteria for colon cancer screening
have been making that important
appointment and getting the test done.
This number is up about 10 percent
over the previous 10-year period. The
word is getting out to the African
American and Hispanic communities
as well, since we have seen increases
in screenings for these groups.
Unfortunately, the screening numbers
have decreased for Native Americans.
A recent study in the New England
Journal of Medicine show a clear benefit
of a colonoscopy. Just think how much
better it would be if we
could double the number
of people we screen.
Are There Warning
Signs for Colon Cancer?
Colon cancer has few
if any warning signs.
Thats why a screening is
so important. However,
there are some signs that
could by symptomatic
or indications colon
cancer might be present.
Among the warning
signs of colon cancer:
Change in bowels
such as constipation
or diarrhea.
Blood in the stool either
grossly or on guaiac
testing cards provided by
your primary care doctor.
Abdominal pain.
Weight loss
Unfortunately, by the
time these symptoms
appear -- with the exception of
minor traces of blood in the stool
and if cancer is the cause, it means
the disease is fairly advanced. At
this stage, removal of the tumor
probably wont offer total cure
because the disease has most likely
spread into lymph nodes or other
organs. Chemotherapy may prolong
life, but the treatment will not cure
the disease in advanced stages.
What Are The Risk Factors
For Colon Cancer? Am I At
Higher Risk Than Others?
Just as with any other cancer or
disease, there are risk factors and
groups. Keep in mind, colon cancer
is the second leading cancer killer in
this country and it's not particularly
picky about who it affects.
whatdoctorsknow.com
Among the risk factors for colon cancer:
Age. Sporadic colon cancer is thought to occur around
age 65 for the majority of the population.
Genetic predisposition and Lynch Syndrome. People with
Familial Adenomatous Polyposis (FAP), an inherited
condition in which numerous polyps form mainly in the
tissue of the large intestine. While these polyps start
out benign, malignant transformation into colon cancer
occurs when not treated. This group may develop the
potential for colon cancer in their 20s or even earlier.
Screenings should even start in the early teens.
Prior polyps or prior colon cancer. A history
puts you in a high risk group.
A family history of colon cancer or polyps. A family history
of colon polyps means about an 8 percent lifetime risk for
developing colon cancer. A first degree family member such as
mother, father, brother, sister etc., increases the risk to about a
20 percent lifetime risk for the development of colon cancer.
Inflammatory bowel disease. Chronic inflammation in the bowel
secondary to Crohn's disease or ulcerative colitis over prolonged
period of time -- probably at least 7 years -- significantly
increases the risk of colon cancer development. The typical
baseline risk for this group is approximately 4 percent up to a risk
of 16 percent. Treating with anti-inflammatories can decrease
that risk back down to about 8 percent lifetime overall risk.
Race. African Americans are at increased risk of colon
cancer and therefore are recommended to undergo
initial screening at the age of 45 rather than age 50.
Ethnicity. Jewish ancestry is associated with a specific
APC mutation affecting approximately 6% of all Jewish
individuals leading to significant increased risk.
Obesity and decreased activity.
Smoking. This is an interesting risk factor since smoke itself does
not get into the colon. However most of the GI tract associated
with the risk of colon cancer development -- including
esophageal cancer, gastric cancer and colon cancer -- is derived
from the fact that cigarette smoke does get into the saliva,
which is swallowed and contains many of the toxins in cigarette
smoke associated with increased risk of cancer development.
Alcohol usage.
Type 2 diabetes. Even adjusted for other risk factors there is an
increased risk of colon cancer associated with type 2 diabetes
Diet. Particularly associated with increased intake of
red meat, processed meat, and smoked meats. Meats
that have been grilled or fried at high temperatures
develop nitrosamine compounds which are thought
to be factors associated with cancer development.
There are other potential risk factors being
studied with no definitive results.
The only hope to survive colon cancer is early detection. Survival
means getting a screening done early enough to detect the cancer
while it is still contained within the colon wall. Caught in this
stage, the patient has between 75 and 90 per cent probability of
cure with removal and possibly surgical excision of the tumor.
However, if the tumor is caught in the later stages when it
has started to protrude through the colon wall or otherwise
affects local or distant lymph nodes or local or distant other
organs -- the probability of survival drops to eight percent.
whatdoctorsknow.com
Stage IV colon cancer implies distant
metastatic disease (in laymans terms
the cancer is spreading) and the tumor
has spread to the liver. Only about
eight percent of Stage IV patients will
still be alive in five years versus the
90 percent survival rate of patients
diagnosed early while the tumors
are locally confined and successfully
removed surgically or endoscopically.
Stage 0. Carcinoma in situ. A medical
term that means cancer cells have been
found, but they have been detected
before any cells have broken through
the walls of the colon and spread to
other organs. Carcinoma in situ means
the cancer has been detected early and
can usually be successfully removed.
Stage I. This refers to tumor
penetration into as many as three of the
levels of the colonic wall but not the
outer surface of the colon. Survival is
approximately 90 percent with removal
of the polyp and possibly a surgical
excision of the area with reconnection.
Stage II. This refers to when the tumor has penetrated the colon wall but
there is no evidence of the tumor in surrounding lymph nodes. This stage
offers an approximately 75 percent, five year survival rate and may require
adjuvant chemotherapy depending upon the advancement of the cancer.
Stage III. Stage III is categorized in several degrees. The first is
when the tumor has partially penetrated through the colon wall. The
final stages are when a tumor has totally penetrated the wall and has
involved lymph nodes and/or other organs such as the liver.
Stage IV. Stage IV is when the tumor has grown through the wall and affected
regional lymph nodes and organs such as the liver. In Stage IV, the primary
tumor is usually removed and radiation is utilized. Other options include surgical
removal or chemotherapy embolization of the disease in the liver or lung.
Chemotherapy is usually used in stages III and IV of colon cancer along with
drug therapy. Chemotherapy wont usually save the patient, but may prolong life.
What is Colon Cancer Screening?
A colon cancer screening is a procedure to look for colon cancer and may be
performed by a number of different modalities -- each with potential benefits and
drawbacks. However, I think the most reliable procedure is a full colonoscopy
performed by a board certified gastroenterologist. I recommend a colonoscopy
when a patient hits 50. If there are no significant risk factors and no evidence of
polyps, the procedure should be repeated in 10 years. In patients with a family
history of colon cancer, the national recommendation is to start at age 40 and
repeating every five years or sooner if there is evidence of polyps. In patients with
whatdoctorsknow.com
inflammatory bowel disease, the
recommendation is to start screening
with yearly examination after the
patient has had inflammatory bowel
for approximately seven years.
What Are The Types of Colon
Cancer Screening Tests?
Most gastroenterologists prefer the
Colonoscopy as the most effective
cancer screening test. A recent New
England Journal study showed a 50
percent decrease in Stage I colon cancer
among a group of screened individuals.
Another colon cancer screening
technique is called a Virtual
Colonoscopy. Performed under CT,
the Virtual Colonoscopy looks for
tumors larger than one centimeter.
However, the test doesnt eliminate
the need for a colonoscopy, especially
if there is an abnormal finding.
Sigmoidoscopy. This short
scoped procedure is limited to
about one third of the colon.
Seventy years ago this would have been an adequate examination when
approximately 80-90 percent of colon cancer was thought to be limited
to certain parts of the body. Essentially, a sigmoidoscopy is able to find
about one half to one third of all possible colon cancers and polyps.
A fecal occult blood test. This is a test looking for traces of blood in the
stool. The problem I find is this test may not catch bleeding at the time the
polyp is active or the polyp may not have been bleeding when the test was
administered. Since blood can be from several sources, this is a test that can
offer a false read or miss the mark entirely if the polyp isnt active by bleeding.
The newest colon screening test is called DNA Stool Testing. Considered at this
point to be investigational, this is a test looking for abnormal DNA patterns
in the cells that are being shed by polyps or tumors. This may prove to be
effective monitoring high risk patients between colonoscopy procedures.
I cant overemphasize the importance of early screening, early detection,
and early removal for this virtually preventable disease. Colon cancer is a
leading killer and yet, a majority of the deaths could have been avoided by
being proactive and getting a screening. I am often amazed when I inform
a patient they have colon cancer and they respond: This is not a good
time to deal with this. Can I wait 3 or 4 months? Knowing what I know
about colon cancer, the answer is simple. Cancer waits for nobody.
In the spirit of Colonrectal Cancer Screening Awareness Month, my plea is
for everyone to schedule your colonoscopy today. -Steve Porter, MD
For a more indepth look at colon cancer, please see page 80.
whatdoctorsknow.com 50
Name PREPARATION WHAT HAPPENS? FREQUENCY
High-Sensitivity Fecal Occult
Blood Test (FOBT) or Stool Test; or
Fecal Immunochemical Test (FIT)
Note: There are two types of FOBT:
one uses the chemical guaiac to
detect blood. The othera fecal
immunochemical test (FIT) uses
antibodies to detect blood in the
stool. Ask your doctor for a high-
sensitivity FOBT or FIT. The one time
FOBT done by the doctor in the
doctors office is not appropriate as a
screening test for colorectal cancer.
Your doctor may
recommend that you
follow a special diet
before taking the FOBT.
You receive a test kit from your
health care provider. At home,
you use a stick or brush to
obtain a small amount of stool.
You may be asked to do
this for several bowel
movements in a row. You
return the test to the doctor
or a lab, where stool samples
are checked for blood.
This test should be done
every year. (If anything
unusual is found, your
doctor will recommend a
follow-up colonoscopy.)
Flexible Sigmoidoscopy (Flex
Sig) Note: this is sometimes
done in combination with
High-Sensitivity FOBT.
Your doctor will tell you
what foods you can and
cannot eat before the
test. The evening before
the test, you use a strong
laxative and/or enema
to clean out the colon.
During the test, the doctor
puts a short, thin, flexible,
lighted tube into the rectum.
This tube allows the doctor
to check for polyps or cancer
inside the rectum and
lower third of the colon.
This test should be done
every 5 years. When it is
done in combination with
High-Sensitivity FOBT,
the FOBT should be done
every 3 years. (If anything
unusual is found, your
doctor will recommend a
follow-up colonoscopy.)
Colonoscopy
Note: Colonoscopy also is used
as a follow-up test if anything
unusual is found during one
of the other screening tests.
Before this test, your
doctor will tell you what
foods you can and cannot
eat. You use a strong
laxative to clean out the
colon. Some doctors
recommend that you
also use an enema. Make
sure you arrange for a
ride home, as you will
not be allowed to drive.
You will receive medication
during this test, to make you
more comfortable. This test
is similar to flex sig, except
the doctor uses a longer, thin,
flexible, lighted tube to check
for polyps or cancer inside the
rectum and the entire colon.
During the test, the doctor
can find and remove most
polyps and some cancers.
This test should be
done every 10 years. If
polyps or cancers are
found during the test,
you will need more
frequent colonoscopies
in the future.
Colorectal Cancer Screening
Saves Lives
Screening Tests At-a-Glance
The U.S. Preventive Services Task Force (USPSTF) recommends colorectal cancer screening
for men and women aged 5075 using high-sensitivity fecal occult blood testing (FOBT),
sigmoidoscopy, or colonoscopy. The decision to be screened after age 75 should be made
on an individual basis. If you are older than 75, ask your doctor if you should be screened.
The benefits and potential harms of the recommended screening methods vary. Discuss
with your doctor which test is best for you. Getting screened could save your life!
For more information, please call 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/screenforlife
whatdoctorsknow.com 5
The study found that 40 percent of
patients who have diabetes will develop
diabetic kidney disease, which is
very staggering, says Sheldon Shore,
M.D., a nephrologist at Piedmont
Hospital. He adds that he does not find
the increased rates of these diseases
surprising because Americans are
aging and have high rates of obesity.
Diabetes causes kidney disease
because high blood sugar initiates
the process of increasing filtration
in the kidney itself, says Dr. Shore.
It leads to damage of the capillaries,
which in turn causes protein to
leak and it spirals from there.
Unfortunately, I look at diabetes as
a silent killer [when associated with]
kidney disease. A lot of patients have
no symptoms or signs of diabetic
kidney disease, he notes. If we dont
manage their diabetes or their kidney
disease, they can potentially develop
Diabetic

Complications
40% of Diabetes Patients
Affected By Devastating
Complication
Dr. Randy Martin: One of the
devastating complications
of diabetes is kidney disease.
There is a new study out that
shows there has been a dramatic
increase in its incidence. I met
with kidney specialist Dr. Sheldon
Shore to find out more.
end-stage renal disease, requiring
dialysis or even transplantation.
There are some treatments, such as
ACE inhibitors or angiotensin receptor
blockers, shown to be effective at
controlling diabetic kidney disease, even
putting it in remission, says Dr. Shore.
Dr. Shores message for people who
have diabetes and are worried about
their kidneys? The first step is
making sure you have a primary care
physician and are getting a routine
physical at least on a yearly basis. He
emphasizes that patient education
is key and can help control the
epidemic of obesity in our country.
If you do have diabetes, make sure
you are following a good regimen
of managing your diabetes with
medications and proper diet, says Dr.
Shore. The earlier patients are treated,
the better the chances of slowing down
the disease or putting it into remission.
Dr. Randy Martin: If you have
diabetes, talk to your doctor about
preventing diabetic kidney disease.
As Dr. Shore said, you need to follow
a medication regimen, eat well and
exercise regularly to keep diabetes
under control. Following these
steps and the advice of your doctor
can slow down kidney disease and
even help put it in remission.
HealthWatchMD
with Dr. Randy Martin
Provided courtesy of Piedmont Healthcare
whatdoctorsknow.com 5
Fat Distribution in Black
and White Women May
Predict Heart Disease
A

womans body shape often described as pear, apple or hourglass is usually determined by
the amount of fat in various regions of the body including the bust, waist, arms and hips.
New research from Emory University School of Medicine suggests that these patterns of
fat distribution may help predict arterial stiffness a precursor to cardiovascular disease.
Stiff arteries make the heart work harder to pump blood and are associated with atherosclerosis,
or the buildup of plaques in vessels that can block blood flow and cause a heart attack.
whatdoctorsknow.com 5
measurements in the triceps area could
predict increased arterial stiffness in
black women, while fat in the suprailiac
areas was a predictor in white women.
-Content contributed in part by
Sarah Goodwin, Emory's Center for
Health Discovery and Well Being.
Noting that fat distribution
generally differs between black and
white womens bodies, researchers
enlisted 68 black women and 125
white women, all middle-aged, to
see whether these patterns could
help assess cardiovascular risk.
The study, conducted by Danny Eapen,
MD, a cardiology fellow at Emory,
used data from Emorys Center for
Health Discovery and Well Being.
He presented his findings recently at
the American Heart Associationss
Arteriosclerosis, Thrombosis, and
Vascular Biology 2011 meeting.
Using skin calipers, the researchers
measured subcutaneous fat in seven
sites: the upper chest; midaxillary, or
the side of the torso just under the
armpit; triceps, or the back of the
arm; subscapular, or on the back just
below the shoulder blade; abdominal;
suprailiac, or just above the front
of the hip bone; and the thigh.
Black women have higher rates of
cardiovascular disease than white women
and are more likely to die from it, says
Eapen. Black and white women also
have different patterns of fat distribution,
so we were interested in measuring these
pockets of fat at various regions of the
body to evaluate whether it might be
helpful in predicting cardiovascular risk
between the two groups. Our hope
was to evaluate whether a quick, easy-
to-use clinical tool could aid in further
risk stratifying our female patients.
The study also assessed the
arterial stiffness of the women,
adjusting for heart rate.
As a group, the black women had
greater arterial stiffness than the
white women. They also had more
subcutaneous fat in the armpit, triceps,
shoulder blade and hip bone areas.
In addition, they also found specific
race dependent pockets of fat that could
be related to arterial stiffness fat
whatdoctorsknow.com 5
Waist Size Linked to Mortality
Risks in Kidney Disease
F
or kidney disease patients, a large belt
size can double the risk of dying.
A study led by a Loyola University
Health System researcher found that
the larger a kidney patient's waist
circumference, the greater the chance the
patient would die during the course of the study.
The study by lead researcher Holly Kramer,
MD, MPH, and colleagues was published in
the American Journal of Kidney Diseases.
Waist circumference was more strongly linked
to mortality than another common measure
of obesity, body mass index (BMI).
BMI is a height-to-weight ratio. For example, if
John and Mary are both the same height, but John
weighs 20 pounds more, then John will have a
higher BMI than Mary. But BMI can be misleading
-- a muscular person with little body fat could
whatdoctorsknow.com 55
Dr. Kramer is an associate professor in the Department
of Medicine, Division of Nephrology at Loyola
University Chicago Stritch School of Medicine. Her
co-authors are David Shoham, PhD, and Ramon
Durazo-Arvizu, PhD, of the Department of Preventive
Medicine and Epidemiology at Loyola University
Chicago Stritch School of Medicine; Leslie McClure,
PhD, George Howard, DrPH , Suzanne Judd, PhD,
Paul Muntner, PhD, Monika Safford, MD, and David
Warnock, MD, of the University of Alabama at
Birmingham; and William McClellan, MD, MPH of
Emory University. The study was supported by the
National Institute of Neurological Disorders and Stroke.
Researchers compared kidney disease patients with
large waists to patients who had more normal waist
sizes. After adjusting for BMI and other risk factors,
women with waists equal to or greater than 42.5
inches and men with waists equal to or greater than
48 inches were 2.1 times more likely to die than
those with trimmer waists (less than 31.5 inches
for women and less than 37 inches for men).
Researchers concluded that in adults with kidney
disease, BMI by itself may not be a useful measure
to determine mortality risks associated with fat.
The reason is that BMI reflects several components,
including muscle mass and abdominal fat.
"In contrast," the researchers conclude, "waist
circumference reflects abdominal adiposity [fat]
alone and may be a useful measure to determine
mortality risk associated with obesity in adults with
chronic kidney disease, especially when used in
conjunction with BMI." -This information provided
courtesy of Loyola University Health System.
have a BMI higher than a flabby person with
little muscle mass. Waist circumference, by
contrast, simply measures abdominal fat.
Researchers examined data from 5,805 adults
age 45 and older who had kidney disease and
participated in a study called REGARDS
(Reasons for Geographic and Racial
Differences in Stroke). They were followed for
a median of four years and during that time
686 kidney patients (11.8 percent) died.
The average BMI of the kidney disease patients
who died was 29.2. This was lower than the
average BMI, 30.3, of the patients who survived.
(A BMI between 25 and 29.9 is considered
overweight, while a BMI of 30 and above is obese.)
By contrast, the kidney patients who died had a
larger average waist circumference (40.1 inches)
than the patients who survived (39.1 inches.)
whatdoctorsknow.com 5
R
esults of two studies suggest that a new,
investigational Colorectal cancer screening
test developed in a collaboration between
Mayo Clinic and Exact Sciences Inc. of
Madison, Wis., is highly accurate and
significantly more sensitive than other
noninvasive tests at detecting precancerous tumors
(adenomas) and early-stage cancer. These
findings have important implications
for clinicians and tens of thousands
of Americans. Early detection is a key
driver of better outcomes for colorectal
cancer a disease that affects 1 in
every 17 persons and is the second-
leading cause of U.S. cancer deaths.
The first study, to be published in the
February issue of Gastroenterology,
shows that a new multi-marker
stool DNA test is highly accurate at
detecting precancerous polyps and
early-stage colorectal cancer. This is
the first large-scale, blinded study to
measure the new test's effectiveness.
The second study, to be published in the
March issue of Clinical Gastroenterology
and Hepatology, shows that the stool
DNA test is significantly more accurate
than a new plasma test for identifying
patients with large precancerous
polyps or colorectal cancer, while
delivering fewer false-positive results.
"Our findings in these studies
underscore the great potential of the
stool DNA test as a colorectal cancer
screening tool," says lead author
David Ahlquist, M.D, of Mayo Clinic,
principal investigator of both studies.
"Along with its high accuracy, this test
approach could improve participation
rates due to its patient-friendly features.
The test is noninvasive; requires
no bowel preparation, medication
restriction, or diet change; and can
be performed on mailed-in samples
without the need, expense, or
inconvenience of a health care visit."
The stool DNA test works by finding
signature genetic markers in stool
samples mailed in by patients. A positive
test would be followed by a colonoscopy
to remove the polyps and prevent a
subsequent cancer from forming, Dr. Ahlquist says.
First Study Highlights Stool DNA Test's Accuracy
Titled "Next-Generation Stool DNA Testing for
Detection of Colorectal Neoplasia: Early Clinical
Evaluation," the first article features results from the
first large-scale study to measure the test's accuracy:
Early Detection of
Colorectal Cancer
New Test Offering Greater Accuracy
whatdoctorsknow.com 5
Second Publication Compares Screening Methods
The second article, titled "Stool DNA vs. Plasma
Septin 9 Testing," uses the results of the first study
to compare the sensitivities of the stool DNA test
and a plasma test for methylated Septin 9 (SEPT9)
in identifying patients with large adenomas
or colorectal cancer. Highlights include:
The stool DNA test detected 82 percent of precancerous
polyps compared to only 14 percent detected by SEPT9.
The stool DNA identified 87 percent of cancers at
any stage, compared to 60 percent with SEPT9.
Stool DNA was even more effective at detecting
curable-stage cancer (Stage I, II or III),
detecting such cases 91 percent of the time,
compared to just 50 percent with SEPT9.
The SEPT9's rate of false-positives was nearly four
times that of stool DNA (27 percent vs. 7 percent).
"It was important to
compare tests head-to-
head," Dr. Ahlquist says.
"Our findings are clear
and entirely consistent
with the biology of
the marker release.
Cancerous and pre-
cancer cells are shed into
the stool and detected
by the stool DNA test
long before tumors
progress to invade the
bloodstream for later
detection by the plasma
SEPT9 screening test."
Screening for colorectal
cancer is recommended
for everyone beginning
at age 50, yet 60 percent
of patients are diagnosed
with the disease in its
late stages, primarily
due to poor screening
compliance. Testing
is critical because
survival rates increase
dramatically if colorectal
cancer is detected in
early stages. -This
information provided
courtesy of Mayo Clinic
Across nearly 400 cases, the stool DNA test
detected 87 percent of curable-stage colorectal
cancer. Importantly, detection sensitivity was
not affected by tumor location or stage.
The test detected the majority of large precancerous
polyps at high risk for cancer progression.
Sensitivity was 64 percent for polyps larger than 1
centimeter (cm), 77 percent for those larger than
2 cm and 92 percent for those larger than 4 cm.
"These data illustrate the strength of the multi-marker
stool DNA test to the critical screening targets pre-
cancers and early-stage cancer," says co-investigator
Stephen Thibodeau, Ph.D, a genetics researcher at
Mayo Clinic. "And, importantly, this test appears to
uniquely represent an accurate noninvasive approach
to large polyp detection, which offers the promise
of actually preventing cancers from developing."
whatdoctorsknow.com 5
Keeping the Change
I didnt believe this the first
time I heard this. But Im
quickly becoming a convert.
A short time ago I had lunch with
a person who had won the Worlds
Biggest Loser competition one year.
We had just finished giving speeches
at a big conference, and the adrenalin
rush from having finished had left us
both stress-famished. Our lunch
together was a ton of fun, but kept
noticing this person kept saying things
like, Notice how Im not putting
dressing on my salad, notice how
Ive taken the turkey off my sandwich
and Im not eating the bread, notice
how Ive asked for a refill of water.
After about the fourth or fifth
time he mentioned food I began
to realize he wasnt really talking
to me. He was talking to himself.
He was reminding or reinforcing
changes that werent second nature
to him. Wow . . . what willpower.
This friends strategy to Keep the
Change was a mindful eating strategy.
Being mindful works for some people,
but for others of us, it would end
up seeming like a full-time job.
When a person finishes a goal, its
easy to backslide because the race is
finished. Losing 10 or 30 pounds is
a reward unto itself. You did it; you
won the race, and you want to stop.
But if this is what it takes to lose
weight and keep the change, its
easy to see why 95% of all diets fail.
Losing
weight is easy.
Its keeping
weight off
that is hard.

whatdoctorsknow.com 5
The problem is that keeping 10-30
pounds off isnt easy to celebrate.
Theres no reward, or change, or
progress to see. Without the motivation
to keep the change, how do you do it?
There are two different options.
One is to find a support group for
maintaining weight loss - the TOPS
program (Take Off Pounds Sensibly)
is one of my favorites. A second
option is to adjust your goal.
The solution for the rest of us is a
Mindless Eating strategy. That is,
making no more than three easy changes
in your life so you can mindlessly
eat less without being aware of it.
Three easy changes. Thats
it. Mindlessly easy.
Five months ago, Jennifer Huget
started her Me-minus-10 program.
My Food and Brand Lab at Cornell
University has been working with
Jennifer to find 3 easy changes that she
could make each month. We analyzed
photographs of her kitchen, dining
room, cupboards, and refrigerators.
We went over daily patterns of her
and her family, and we asked how
she would respond to different eating
scenarios. Based on this we used our
Mindless Method to suggest three easy,
daily changes she should consider.
After 3 months, Jennifer had lost 12
pounds. Now comes the difficult part.
At the end of each month we reviewed
her progress and suggested three more
changes for her to make. Generally,
these changes are research-based (many
of them reported in my book, Mindless
Eating) that have proven to help people
eat at least 11% less food. After 3
months, Jennifer had lost 12 pounds.
In one of our recent studies -- with the
National Mindless Eating Challenge
-- we found that a person who did a
change for 25 or more days lost twice
as successful in losing weight than
someone who did it for 20 days.
With Jennifer, we helped her adjust
her goal. Instead of having the goal to
Lose 10 pounds, she changed it to
Get my family to eat healthier (without
them knowing it). She kept focusing
on making three small changes that
would benefit her family, but also
help keep her on track. For instance,
she put a piece of fruit next to her
husbands car keys every morning. She
put 20% of any dinner entre into the
refrigerator before serving the rest for
dinner. She made sure there were little
baggies of cut up fruit or vegetables
on the middle refrigerator shelf.
Anything daily change that keeps you
just a little bit disciplined ends up keeping
you a lot disciplined. The key to keeping
the change, is in making a related change.
For more info visit MindlessEating.
org. -Brian Wansink, PhD
whatdoctorsknow.com 0
T
he extensive use of
antibiotics is not without
adverse consequences.
One of the most serious
complications is a
gastrointestinal infection
caused by a bacteria known as
Clostrium difficile. This diarrheal
illness associated with antibiotic use was
first well-characterized in the hospital
setting in the late 1970s. Recent data
demonstrate that these infections are
not only increasing in incidence and
severity, but are also more difficult to
treat. In addition, an increasing number
of these infections are diagnosed in
healthy people who have neither been
in the hospital nor taken antibiotics.
What are the risk factors for
developing Clostridium difficile-
associated diarrhea?
Antibiotic use is the most commonly
recognized risk factor. Any antibiotic
can cause this infection but the most
commonly implicated are clindamycin,
certain penicillins, cephalosporins,
and more recently fluoroqinolones like
levofloxacin. Other risk factors reported
include hospitalization or living in an
extended care facility, being age 65 or
older, severe debilitation or underlying
illness, and use of certain cancer drugs.
Taking a class of drugs known as
proton pump inhibitors to suppress
stomach acids also puts you at risk.
How does it occur?
Disruption of the normal bacterial
population in the gut with subsequent
colonization by the C. difficile bacteria
occurs first. This bacteria produces
toxins which can cause a range of
symptoms including watery diarrhea,
nausea, decreased appetite, fever, weight
loss and abdominal pain. The infection
A Real Cause for Concern:
Clostridium dificile-
associated Diarrhea (CDAD)
can become very severe with the
development of shock and even death.
How is it diagnosed?
This infection should always be
suspected when diarrhea develops
around the time of antibiotic use.
Stool analysis for detection of the
toxin or the organism is used to
confirm the diagnosis. Nucleic acid-
based testing schemes employing
PCR are being increasingly used.
Visualization of the colon with
sigmoidoscopy and colonoscopy may
also be used in certain circumstances.
whatdoctorsknow.com
How is this infection treated?
Patients with minimal symptoms may
only need to stop the antibiotic that
caused the infection. Most patients
with symptoms will need to be treated
with certain antibiotics for 10 to 14
days. The antibiotic should be orally
administered so that it can be delivered
to the infected area of the gut. The
drugs typically used are metronidazole
and vancomycin. Milder infections are
treated with oral metronidazole while
more serious infections are treated
with oral vancomycin. Fidaxomicin
is a new drug that was recently
approved by the FDA for treatment of
CDAD that does not respond to more
conservative medical management.
In addition, fluids and electrolytes
should be administered to replace losses
incurred with diarrhea. Agents which
slow down the motility of the gut are
generally avoided. There is no consensus
regarding the value of probiotic therapy
for this infection; studies to date have
been inconclusive. Probiotic therapy
consists of repopulating the gut with
bacteria that do not produce disease.
Probiotics can be administered as
yogurt drinks or capsules. Surgery to
remove the gut may be needed when
severe disease does not respond to more
conservative medical management.
How often does CDAD recur?
Despite resolution of CDAD-associated
symptoms with oral antibiotics like
metronidazole and vancomycin, about
one-quarter
of patients
will develop
recurrent
disease. These
recurrences
usually occur
within 3 weeks
of the completion
of antibiotic therapy
and may reflect a new
infection or relapse from the
original infection, perhaps due
to an impairment in this patients
immune system. Treatment of the
first recurrence is very similar to
the initial CDAD infection but
subsequent recurrences can occur
and often require expert consultation
with infectious disease experts.
Is there a vaccine to prevent
infection with C. difficile?
There is currently no vaccine available
to prevent this highly contagious
infection. Because C. difficile is
spread in stool, the best prevention
methods are hand cleaning, use
of gloves, restricting antibiotic
use, isolation of patients who are
hospitalized, and sterilization of
the hospital environment including
medical equipment. Handwashing
with soap and water is preferred to
alcohol-based hand sanitizers because
the latter may not kill spores
associated with this bacteria.
-Fred A. Lopez, MD, FACP
whatdoctorsknow.com
G
rocery shopping can be daunting,
especially when trying to eat healthy, but
the trusted American Heart Association
Heart-Check mark is making things much
easier. Now, even more kinds of heart-
healthy foods can be identified by the
Heart-Check mark on product packaging including
fish, nuts and other foods higher in the better fats.
The Heart-Check mark has the strongest aided brand
awareness and trust among leading on-package
nutrition icons. Since its creation in 1995, the Heart-
Check Food Certification Program has helped
Red-and-white icon helps
shoppers easily find even more
options for heart-healthy foods
consumers eat healthier and lead by example for
friends and family. Identifying heart-healthy foods is
a solid first step in building a heart-healthy lifestyle.
The American Heart Association announced in
September that foods higher in monounsaturated and
polyunsaturated fats also known as the better fats
would be included in the Heart-Check program.
The association also announced that in order to be
certified, some product categories must be lower in
sodium and added sugar, and higher in dietary fiber.
Those changes will be incorporated by 2014 to allow
food manufacturers time to reformulate their products.
whatdoctorsknow.com
Bag the
grocery
guesswork:
Get healthy
with the
Heart-Check
mark
Its time to renew that New Years resolution
which included getting healthier. Be sure to stock
your kitchen with American Heart Association
certified products. Visit heartcheckmark.org
and click the Certified Products tab for a
full list of delicious, heart-healthy foods that
will help develop a sensible eating plan.
Find healthy food options, recipes for dinner
tonight, grocery list builder and more, visit heart.
org/nutrition. Start living, and eating, with heart-
health in mind. -This information provided
courtesy of: The American Heart Association
The American Heart Association/American Stroke Association
receives funding mostly from individuals. Foundations
and corporations donate as well, and fund specific
programs and events. Strict policies are enforced to prevent
these relationships from influencing the associations
science content. Financial information for the American
Heart Association, including a list of contributions from
pharmaceutical companies and device manufacturers,
is available at www.heart.org/corporatefunding.
whatdoctorsknow.com
About the Heart-Check mark
The American Heart Association
established the Heart-Check
mark in 1995 to give consumers
an easy, reliable system for
identifying heart-healthy foods
as a first step in building a
sensible eating plan. Nearly 900
products that bear the Heart-
Check mark have been screened
and verified by the association
to meet criteria for heart-healthy
foods. To learn more about the
Heart-Check mark, and to see a
complete list of certified products
and participating companies
and the nutritional criteria, visit
www.heartcheckmark.org.
About the American Heart
Association The American Heart
Association is devoted to saving
people from heart disease and stroke
Americas No. 1 and No. 4 killers.
We team with millions of volunteers
to fund innovative research, fight
for stronger public health policies,
and provide lifesaving tools and
information to prevent and treat
these diseases. The Dallas-based
association is the nations oldest
and largest voluntary organization
dedicated to fighting heart disease
and stroke. To learn more or to
get involved, call 1-800-AHA-
USA1, visit heart.org or call any of
our offices around the country.
Are you
the picture
of health?
Colorectal cancer is the 2nd leading cancer killer.
But it doesnt have to be.
Katie Couric, Co-Founder
EIFs National Colorectal Cancer Research Alliance
Photo by Andrew Eccles
Colorectal cancer and precancerous polyps dont always cause symptoms. So you can look healthy
and feel fine and not know there may be a problem.

Screening helps find polyps so they can be
removed before they turn into colorectal cancer. This is one cancer you can prevent!

Screening
can also find colorectal cancer early, when treatment often leads to a cure.

If youre 50 or older,
make sure you really are the picture of health. Get screened for colorectal cancer.
1-800-CDC-I NFO ( 1-800-232-4636) www. cdc. gov/ screenf or l i f e
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
whatdoctorsknow.com
Americans
Cutting Sugar -
But It's Still Not
Enough
whatdoctorsknow.com
The study, published in the American
Journal of Clinical Nutrition in July
2011, found that the consumption
of added sugars, such as those found
in sodas, sports drinks, juices and
sweetened dairy products, decreased
among all age groups over a decade.
The largest decrease came in the
consumption of sodas, traditionally
the largest contributor to added
sugar consumption, according to
Jean Welsh, MPH, PhD, RN, study
author and post-doctoral fellow
in pediatric nutrition at Emory
University School of Medicine.
While we were hopeful this would
be the case, we were surprised
when our research showed such a
substantial reduction in the amount
of added sugar Americans are
consuming, said Welsh. Were
hopeful this trend will continue.
So, why the change? One of Welshs
partners in the study, Miriam Vos,
MD, MSPH, an assistant professor
of pediatrics in the Emory University
School of Medicine, and a physician
on staff at Childrens Healthcare
of Atlanta, attributes much of
the shift to public education.
Over the past decade, there has been
a lot of public health awareness about
obesity and nutrition, and I think
people are starting to get the message
about sugar, says Vos. Were not
trying to send a message that sugar is
inherently bad. Its more that the large
amounts of sugar we consume are
having negative effects on our health,
including increasing our risk of obesity,
diabetes and cardiovascular disease.
The study interpreted data of 40,000
peoples diets collected by the Centers
for Disease Control and Prevention
(CDC) over 10 years. From the
surveys, researchers were able to
calculate how much added sugar
that is sugar that is not originally
part of a food that Americans
are consuming. In 1999-2000, the
typical persons daily diet included
approximately 100 grams of added
sugar, a number that had dropped
to 77 grams by 2007 and 2008.
While the study shows that the
amount of added sugar Americans
are consuming is lower, it doesnt
mean the amount is low enough.
The American Heart Association
recommends that we get about five
percent of our calories from added
sugars, says Vos. In 1999 to 2000,
people were consuming about 18
percent of their calories from added
sugars. Over 10 years, that amount
decreased to 14.5 percent of our
daily calories, which is much better.
But, clearly, 14.5 percent is still three
times more than what is considered
a healthy amount. Were on the right
track, but we still have room for
improvement. -This information
provided courtesy of Emory Health
Now Blog, Woodruff Health Sciences
Center, Emory University.
In Americas battle against obesity, there
is some good news. According to a study
conducted by Emory researchers, Americans
consumed nearly a quarter less added sugars
in 2008 than they did 10 years earlier.
whatdoctorsknow.com
S
chool-age children with diabetes face unique challenges. They
may be vulnerable to serious swings in their blood glucose
levels at any time. A newly updated booklet, Helping the
Student with Diabetes Succeed: A Guide for School Personnel,
can help. The guide offers suggestions for parents, teachers,
principals and others to ensure the safety of these kids.
School Guide Teaches
ABCs of Diabetes
Diabetes is one of the most common
long-term diseases in school-age
children. It affects about 200,000
young people nationwide. Most
students with diabetes must
carefully monitor and control
their blood glucose throughout
the day. A severe drop in glucose
levels can be life-threatening.
The guide urges parents to notify
school officials that a child has
diabetes. Parents are encouraged
to partner with the childs health
care team to develop a diabetes
medical management plan. The
guide recommends that parents
give permission for medical
information to be shared by the
school and health care team.
Unfortunately, the need to
manage diabetes doesnt go away
at school, says Dr. Griffin P.
Rodgers, director of NIHs National
Institute of Diabetes and Digestive
and Kidney Diseases. The guide,
quite literally, can be a lifesaver.
To view, download or order a free
copy of the guide, go to www.
YourDiabetesInfo.org/schoolguide, or
call the National Diabetes Education
Program at 1-888-693-6337.
-Source: NIH News in Health,
March 2011, published by the
National Institutes of Health and the
Department of Health and Human
Services. For more information
go to www.newsinhealth.nih.gov
whatdoctorsknow.com
:

f
s
t
l
t

1/11
NowYou Can Help Every
Student withDiabetes Succeed!
U
p
d
a
te
d
E
d
itio
n
Available Now from the National Diabetes Education Program
An Essential Addition to Your School
Health Resource Shelf
With Helping the Student with Diabetes Succeed: A Guide
for School Personnel, you can help ensure a safe learning
environment and equal access to educational opportunities
for all students with diabetes. Now you can put this
updated edition of the guide from the National Diabetes
Education Program to work in your community.
Designed to Empower School Personnel,
Parents, and Students
Developed with and supported by leading diabetes,
pediatric medicine, health professional, and education
groups, the guide empowers school personnel to help
meet students routine and emergency diabetes care needs
throughout the school day.
The Right Tool at the Right Time
Along with its user-friendly tools and comprehensive
diabetes resource list, the guide provides school personnel,
health care providers, parents, and students a team
approach for working together to carry out the students
diabetes care plan.
Youll find these
important tools:
Diabetes Primer and
Glossary with updated
diabetes information
rom A to Z
Action Steps for
key school personnel,
parents, and students
o that everyone knows
whats expected of
hem
Sample medical management and emergency
action care plans for health care providers and school
nurses to adapt for meeting students needs
Copier-ready handouts for all school personnel
Review of school responsibilities under federal
aws including Section 504 of the Rehabilitation Act,
he Americans with Disabilities Act, IDEA, and
FERPA
Complete online version with no copyright restrictions available at http://ndep.nih.gov/media/Youth_NDEPSchoolGuide.pdf
Feel free to download a copy and create a link to the school guide on your own website.
For additional NDEP resources, visit www.betterdiabetescare.nih.gov and www.diabetesatwork.org.
Order your free copy today! Call 1-888-693-NDEP (6337) or fill in the information below and fax this flyer to
the National Diabetes Information Clearinghouse (NDIC) at 703-738-4929 or mail it to: NDIC, 1 Information Way, Bethesda, MD,
20892-3560.
To order multiple copies: Call NDIC at 18008608747 (Visa and MasterCard accepted) or fill in the information below and mail
the flyer along with your check or money order payable to NDIC to: NDIC, 1 Information Way, Bethesda, MD, 20892-3560.
Name
Organization:
Address:
City/State/Zip:
Phone number: E-mail:
Number of copies ordered: Amount Enclosed: $
F
irs
t
C
o
p
y
is

F
R
E
E
!
Each
additional
copy is $3.
Limit 6
copies per
customer.
The National Diabetes Education Program is a joint
program of the National Institutes of Health and the
Centers for Disease Control and Prevention.
whatdoctorsknow.com 0
W
hen you face surgery, you might have many
concerns. One common worry is about going
under anesthesia. Will you lose consciousness?
How will you feel afterward? Is it safe?
Every day about 60,000 people nationwide
have surgery under general anesthesia. Its
a combination of drugs thats made surgery more bearable for
patients and doctors alike. General anesthesia dampens pain, knocks
you unconscious and keeps you from moving during the operation.
Prior to general anesthesia, the best ideas for killing pain during
surgery were biting on a stick or taking a swig of whiskey, says Dr.
Emery Brown, an anesthesiologist at Massachusetts General Hospital
in Boston. Things improved more than 150 years ago, when a dentist
in Massachusetts publicly demonstrated that the anesthetic drug ether
could block pain during surgery. Within just a few months, anesthesia
was being used in Australia, Europe and then around the world.
General anesthesia changed medicine practically
overnight, says Brown. Life-saving procedures like open-
heart surgery, brain surgery or organ transplantation
would be impossible without general anesthesia.
General anesthesia affects your entire body. Other types of
anesthesia affect specific regions. Local anesthesiasuch as a
shot of novocaine from the dentistnumbs only a small part
of your body for a short period of time. Regional anesthesia
Waking Up to
Anesthesia
Learn More Before You Go Under
numbs a larger areasuch as everything below the
waistfor a few hours. Most people are awake during
operations with local or regional anesthesia. But general
anesthesia is used for major surgery and when its
important that you be unconscious during a procedure.
General anesthesia has 3 main stages: going under
(induction), staying under (maintenance) and recovery
(emergence). NIH-funded scientists are working
to improve the safety and effectiveness of all 3.
The drugs that help you go under are either breathed
in as a gas or delivered directly into your bloodstream.
Most of these drugs act quickly and disappear rapidly
from your system, so they need to be given throughout
the surgery. A specially trained anesthesiologist or
nurse anesthetist gives you the proper doses and
whatdoctorsknow.com
continuously monitors your vital signssuch as heart
rate, body temperature, blood pressure and breathing.
When patients are going under, they experience
a series of deficits, says Dr. Howard Nash, a
scientist at NIHs National Institute of Mental
Health. The first is an inability to remember
things. A patient may be able to repeat words you
say, but cant recall them after waking up.
Next, patients lose the ability to respond. They wont
squeeze your fingers or give their name when asked,
Nash says. Finally they go into deep sedation.
Although doctors often say that youll be asleep
during surgery, research has shown that going under
anesthesia is nothing like sleep. Even in the deepest
stages of sleep, with prodding and poking we can wake
you up, says Brown. But thats not the case with
general anesthesia. General anesthesia looks more like
a comaa reversible coma. You lose awareness and
the ability to feel pain, form memories and move.
Once youve become unconscious, the anesthesiologist
uses monitors and medications to keep you that way. In
rare cases, though, something can go wrong. About once
in every 1,000 to 2,000 surgeries, patients may gain some
awareness when they should be unconscious. They may hear
the doctors talking and remember it afterward. Worse yet,
they may feel pain but be unable to move or tell the doctors.
Its a real problem, although its quite rare, says
Dr. Alex Evers, an anesthesiologist at Washington
University in St. Louis. Anesthesia awareness can lead
whatdoctorsknow.com
to post-traumatic stress disorder, a severe anxiety
disorder that can arise after a terrifying ordeal.
Scientists have developed strategies to identify
and prevent anesthesia awareness. Small studies
suggested that brain monitors might help. But in
2008, Evers and his colleagues reported the results
of the largest study to compare different techniques.
Brain monitoring did no better than standard
monitoring in preventing anesthesia awareness.
Addiction to alcohol or drugs increases the risk for
anesthesia awareness, but doctors cant accurately
predict who will be affected. A research team in
Canada identified variations in a gene that may allow
animals to form memories while under anesthesia.
Ongoing studies are exploring whether this gene
plays a role in anesthesia awareness in people.
Other researchers are searching for genes
that may affect how anesthetic drugs are
processed, or metabolized, by the body. Genetic
differences might affect the proper dosage or
the selection of drugs for each patient.
Nash and his colleagues have found that studies of the
common fruit fly may offer clues to how genes affect
anesthesia. When certain repeating segmentscalled
copy number variationsare snipped from the flys
genome, it affects the insects response to anesthesia.
Copy number variations are known to affect human
responses to other drugs. Nash suspects that these gene
segments may also affect how patients react to anesthesia.
As researchers learn more, I expect genetic screening
will become more common in the clinic, says Nash.
After surgery, when anesthesia
wears off, you may feel some
pain and discomfort. How
quickly you recover will
depend on the medications
you received and other factors
like your age. About 40% of
elderly patients and up to one-
third of children have lingering
confusion and thinking
problems for several days
after surgery and anesthesia.
Right now, the best cure
for these side effects is time.
Brown and his colleagues
are working to develop
drugs to help patients more
quickly emerge and recover
from general anesthesia.
Anesthesia is generally
considered quite safe for
most patients. Anesthetics
have gotten much safer over
the years in terms of the things were most worried
about, like the patient dying or having dangerously
low blood pressure, Evers says. By some estimates,
the death rate from general anesthesia is about 1 in
250,000 patients. Side effects have become less common
and are usually not as serious as they once were.
Dont delay important surgery because of fear of
anesthesia. If you have concerns, talk with your
doctor. It might help to meet in advance with the
person who will give you anesthesia. Ask what kind
of anesthesia you will have. Ask about possible
risks and side effects. Knowing more might help
you feel less concerned about going under.
WHEN YOU GO UNDER
General anesthesia has five major effects on your
body. Researchers are working to develop drugs
that target each of these characteristics:
Lack of Consciousness. Keeps you from
being aware of your surroundings.
Analgesia. Blocks your ability to feel pain.
Amnesia. Prevents formation of memories.
Loss of Movement. Relaxes your muscles
and keeps you still during surgery.
Stable Body Functions. Stabilizes your
heart rate, blood pressure, temperature,
breathing and kidney function.
-Source: NIH News in Health, April 2011,
published by the National Institutes of Health and
the Department of Health and Human Services. For
more information go to www.newsinhealth.nih.gov
Did you know that 2 out of 3 people with diabetes
die from heart disease or stroke?
Call 1-800-DIABETES (1-800-342-2383) or visit www.diabetes.org/MakeTheLink
Ask about the link between diabetes and heart disease and learn how
the ABCs of diabetes can help you lower your risk:
A: Lower your A1C, a test that measures average
blood sugar over the past 3 months, to less than 7
B: Keep your Blood pressure below 130/80
C: Get your bad Cholesterol (LDL) below 100
An educational partnership of the
NAD-0111 7x10 8/23/02 10:28 AM Page 1
whatdoctorsknow.com
REDUCING BLOOD
TRANSFUSIONS
Proving Beneficial to Patients & Hospitals
A

Loyola University
Hospital study has
demonstrated how the
hospital has improved
patient safety and cut
costs by reducing the
number of blood transfusions.
In 2009, the average amount of blood
products transfused per patient at
Loyola was 10 percent lower than it was
in 2008, saving $453,355. The average
amount of blood products transfused
dropped from 2.03 units per patient in
2008 to 1.82 units per patient in 2009.
Results were reported at the annual
meeting of the College of American
Pathologists in September.
We are giving the right blood
component, in the right amounts, to
the right patient at the right time, with
the goal of improving patient care,
said Phillip J. DeChristopher, MD,
PhD, medical director of Transfusion
Medicine, Blood Bank and Apheresis.
Blood transfusions save lives, but
they also carry risks. Studies during
the last 10 years have found that
transfusions make patients more
susceptible to infections and increase
the risk of poor outcomes such as
longer hospital stays, cancer recurrences
and multi-organ system failures. The
more you transfuse, the higher you
put patients at risk for unintended
consequences, DeChristopher said.
Transfusions of red blood cells,
platelets, plasma and other blood
products were approved decades
ago without randomized controlled
clinical trials to establish optimal uses.
Consequently, doctors sometimes
order more transfusions than
necessary, DeChristopher said. He
noted, for example that the amount
of plasma transfused per patient in
the United States is two to three
times higher than the amounts
transfused in Canada and Europe.
Loyola launched a new initiative for
blood utilization as part of its Blood
Management Program. The program
implemented blood-use protocols that
included evidence-based indications,
educational programs for doctors and
nurses and oversight of the Blood
Utilization Review Committee.
The initiative resulted in some
patients receiving less blood or no
blood at all -- without compromising
patient care. For example, instead of
successively administering two units
of blood, a doctor might now instead
order one unit and then reassess later
to see if a second unit is needed.
We don't want to expose patients
to blood products unless we
have to, DeChristopher said.
whatdoctorsknow.com 5
While patient safety is the primary
goal, blood management also can
result in significant cost savings.
The study documented only the
amount saved in purchasing blood.
It did not include the larger savings
involved in storing, compatibility
testing, transfusing blood and treating
adverse effects. The savings we
documented are just the tip of the
iceberg, DeChristopher said.
Blood management also can help
relieve chronic shortages in the blood
supply, especially during summers and
holiday seasons when donations drop.
Blood products are a vital community
resource, and we need to be good
stewards, DeChristopher said.
The less blood we use, the more
patients benefit, and the less strain
we put on the blood supply. -This
information provided courtesy of
Loyola University Hospital.
whatdoctorsknow.com
The American Diabetes Association Offers Free
Online Resource for Recipes and Meal Planning
My Food Advisor:
Recipes for Healthy Living
whatdoctorsknow.com
L
ooking for healthy recipes
to lose weight, manage
your diabetes or prevent
the development of type
2 diabetes? The American
Diabetes Association
announced the launch of a new online
nutrition resource, MyFoodAdvisor
: Recipes for Healthy Living. This
new online resource will feature
a new set of recipes, a meal plan,
and other healthy tips each month,
accessible only to those who register
(www.diabetes.org/RFHL). Those
who register will receive a monthly
e-newsletter to notify them when new
content is available, and to link them
back to the Recipes for Healthy Living
microsite. The best part- its free.
Healthy eating recommendations can
sometimes be overwhelming. What
Can I Eat? is one of the most common
questions asked by those who have
diabetes. Patients need a good place to
turn to when deciding what to prepare
for themselves or their families,
said Elizabeth Mayer-Davis, former
President, Health Care & Education,
American Diabetes Association.
MyFoodAdvisor: Recipes for Healthy
Living helps assist in food and
nutrition-related decisions, as they are a
key component of diabetes management
and type 2 diabetes prevention.
Meal planning helps improve blood
glucose, blood pressure and cholesterol
numbers. Research shows that
losing weight can prevent diabetes
complications, such as blindness,
kidney disease, heart attack and stroke.
Additionally, by losing 7 percent of your
body weight (15 pounds if you weigh
200 pounds) through diet and 150
minutes of physical activity per week,
you can reduce your risk for developing
type 2 diabetes by 58 percent.
Explore Recipes, Meal Plans, and More
MyFoodAdvisor: Recipes for Healthy
Living provides consumers with
information they need to make healthy
eating decisions through a platform
containing recipes, one-day meal
plans, cooking tips and food videos.
Interactive videos provide consumers
with cooking demonstrations of
diabetes-friendly recipes, showing
members how to use and prepare
fresh, healthy foods. The videos
and recipe tips make meal planning
easier. They provide practical advice
for creating meals and snacks for any
time of the day, said Mayer-Davis.
For more information, or to
register for MyFoodAdvisor:
Recipes for Healthy Living, visit
www.diabetes.org/RFHL -This
information provided courtesy of The
American Diabetes Association.
whatdoctorsknow.com
C
edars-Sinai Medical Center announced
the establishment of the Sharon
Osbourne Colon Cancer Program at the
Samuel Oschin Comprehensive Cancer
Institute. Following her personal and well
publicized struggles with colon cancer,
Osbourne realized a need to provide support for the
nationally recognized Cedars-Sinai Medical Center
Colon Center, which is devoted to saving lives through
advanced research, early detection, prevention and
state-of-the-art treatment options for colon cancer.
The Sharon Osbourne Colon Cancer Program
will fund three vital initiatives, including:
1) sponsored care and direct financial
assistance to people in need;
2) specialized care and treatments for colon
cancer patients at Cedars-Sinai; and
3) elevated awareness and education for
patients, families and the community.
Colon cancer is a particularly insidious disease that
strikes both men and women. If caught in time, the
treatments can be highly effective but they are not
fun for anyone and can be out of reach financially for
too many. When I saw people taking the public bus
after a chemotherapy treatment, I knew I had to get
involved. Osbourne said. I am passionate about
making it my personal mission to do what I can to
make sure that all colon cancer patients are empowered
with the same resources and receive the same level of
Sharon Osbourne Colon Cancer
Program Established at the
Samuel Oschin Comprehensive
Cancer Institute at
Cedars-sinai Medical Center
treatment I received. This Program is the embodiment
of a dream of mine and partnering with Cedars-Sinai
allows me to touch the lives of so many others.
Sharon Osbourne recently became a household name
after starring with her husband, Ozzy, and two of their
three teenage children in the Emmy Award-winning hit
reality series, The Osbournes on MTV. In the midst
of the shows success, Osbourne was diagnosed with
colon cancer in July of 2002. She was treated at Cedars-
Sinai Medical Center by a team of doctors, including
her surgeon, Edward Phillips, MD, FACS, director of
the Center for Minimally Invasive Surgery. Now fully
recovered and with the cancer in remission, Osbourne has
collaborated with Dr. Phillips and Cedars-Sinai to make
her dream of helping others with colon cancer a reality.
Sharons strength, conviction and determination
throughout her ordeal have inspired numerous people
and have brought colon cancer awareness directly into
our community, remarked Dr. Phillips. Sharon boldly
allowed the public into her private world and in the
process, inspired us with her candor and positive outlook
during a tumultuous time in her life. With the funding
from this Program, we will have the opportunity to
offer others with colon cancer the support they need.
For more information, or to make a donation to the
Sharon Osbourne Colon Cancer Program at the Samuel
Oschin Comprehensive Cancer Institute at Cedars-
Sinai Medical Center, please visit www.cshs.edu.
Sharon Osbourne's Fight
-Bringing Hope & Support to
Colon Cancer Patients
whatdoctorsknow.com

I want to start by thanking everyone here tonight

for honoring me with the "Spirit of Hope" award.
Spirit is the most appropriate word for what I found
after I was diagnosed with cancer. I was a woman
who had everything: an adoring husband, healthy
children, I was a successful business woman, an
Emmy award winning producer of my own TV show; life
was perfect, nothing could touch me or so I thought. But
to be truthful, I was an arrogant, self-absorbed woman
who thought I knew everything. And then cancer came
and kicked me in the ass! Believe it or not, it changed my
life for the better. It made me muster up my spirit and my
hope to better myself, both physically and mentally.
I really think that I can look at myself now and
say I'm a much nicer person than I was before my
diagnosis. I took my life for granted, I took people
for granted, I didn't truly appreciate the gift of
life or what it meant to have your health. Why
did it take me being faced with the prospect of
maybe losing my life before I embraced my life?
It was quite ironic that when I was diagnosed, I
happened to have a film crew living with me at the
time. After a lot of thought, I realized that maybe we
could put a positive spin on this and document my
treatment so people would see that going through
chemo is not that bad. I also wanted to show kids that
when they are faced with the situation that they may
lose their parent, it doesn't always have to be fatal.
At the end of the day, I chose to go public with my
cancer because I was so ignorant about the WORD
"cancer" and I wanted to try to educate people about this
Sharon Osbourne Accepts
the"Spirit of Hope Award
disease. I honestly had no idea that women could even
get colon cancer and I thought of myself as an educated
woman. Well, in this case, I wasn't, so I wanted other
men and women to know how prevalent this disease
is and if I could find my spirit to fight, anyone can.
Cancer does not only affect the patient it affects the
entire family. Early on in my treatment I could see what
this disease was doing to my loved ones. My husband
had a mental breakdown, my son chose to turn to
drugs, and my daughters were so terrified they chose
to isolate themselves. Each time I would have a set back
in my treatment, I would see the fear in my children's
eyes and that would make me fight even harder.
The thought of chemo had always terrified me, I
honestly thought it was the worst thing that any
person would ever have to endure. But it turned out
to be an enlightening experience. Im not going to talk
about the medical side effects; all of us in the room
know what they are. But it gave me the opportunity
to meet so many incredible people: men and women
who dedicate their lives to healing the sick; other
patients who were going through the same treatment
as myself, how strong they were and seeing their
spirit shining through; and strangers from all over
the world, who wrote to me giving me their support,
that's when I realized how amazing people can be.
I think it's important that people are educated about
cancer. That way fear won't overwhelm hope. And as
long as hope survives, we'll survive. Thank you again
for this wonderful award. Sharon Osbourne
In 2004, Sharon Osbourne was given the
"Spirit of Hope" award by the Women's Guild, a
philanthropic support group to Cedars-Sinai.
Before you read any
further, be warned. What
you are about to read
is in-depth, scientific,
specific and detailed
information about
cancer. If you prefer
your reading to be less
technical stop now. For
those of you who want
the nitty gritty read on.
whatdoctorsknow.com 0
T
here is a common expression: "the acorn
never falls far from the oak " In plain speak,
this means as your ancestors went, you will
follow. We use this principal in medicine
everyday. Among the first things we want
to know about you is your family history.
If your grandparents lived into their nineties and were
in good health, we expect the same from you. This is
because with most disease there is a significant genetic
component. If your family history is littered with
prostate cancer, breast cancer, heart disease, hypertension
and type 2 diabetes, we assume you are at high risk
for these problems. If none of your grandparents
lived past 60, we don't think you're condemned to
die by 60, but making it to 90 might be a stretch.
There are lifestyle variables such as smoking,
excessive alcohol consumption, sedentary lifestyle
and obesity due to excessive caloric intake, affecting
different outcomes. Still, if you have a family history
of these illnesses, the odds are against you.
Colon cancer is an exception to the rule. Approximately
1 in 4 patients who develop colon cancer have either
an inherited tendency or a genetic predisposition
for the development of the disease. However,
this represents a minority of those affected.
The breakdown for colon cancer development is as
follows: Out of 100 patients who will be diagnosed,
75 will have sporadic colon cancer. This means
there is no family history. Twenty of the 100 will
have a family history of colon cancer in one or more
family members and they will have an inherited
predisposition. Five of the 100 will be members of
families genetically linked to colon cancer disorders.
There are two major pathways for colon cancer. The
first pathway is a series of mutations in gene expression
within the colon cells resulting in colon cancer. This
subset comprises 100% of FAP patients and about 80%
of sporadic and inherited colon cancer. The mechanism
leading to cancer expression in these individuals is a
problem called APC (adenomatous polyposis coli gene).
In the FAP syndrome this gene is congenitally absent
and the probability of colon cancer development over
a lifetime is 100%, with most patients undergoing
cancer development by the time they are in their mid-
Colon cancer.
Genetics or Bad Luck?
whatdoctorsknow.com
20s. This group of patients is easily identified because of pronounced
family colon cancer history at a young age along with the presence of
hundreds or thousands of colon polyps on sigmoidoscopy or colonoscopy
at a very young age. Eighty percent of sporadic colon cancer sufferers
will acquire abnormality of the APC gene over the course of a lifetime.
Usually, this genetic mutation occurs in the patients 40s and requiring
about 20 years for complete transformation to colon cancer -- usually by
age 65. This will lead to cancer in about 80 percent of affected individuals.
The APC gene mutation results in cellular overgrowth cancer. From
this point, mutation of a second tumor-suppressing gene called
K-ras, results in conversion from simple cellular overproduction to
a condition known as aneuploidy. This causes disorganized division
within the cells, marking the transition from overgrowth of tissue
to adenomatous polyp, which is the precursor for colon cancer.
Beyond this, another mutation is necessary in a gene known as the DCC
gene (deleted in colorectal cancer). This is another mutation, or turn off, of
a suppressor gene required for the actual transformation from adenomatous
polyp to colon cancer only after the final step, deactivation of the p53 gene.
These mutations must occur in the proper sequence to result in cancer.
Why do we get colon cancer?
"When a mommy and daddy love each other very much and get married, something
magical happens in the mommy's tummy, and 9 months later a tiny baby is born."
What actually happens is this. With fertilization, there is
a joining of genetic material from both parents.
Immediately after fertilization, the result is a zygote and it begins a rapid
series of cellular divisions eventually leading to an adult human body
containing about 14 trillion cells in a highly specialized matrix. Early
in the development process, all cells are basically stem cells. This means
they are pluripotent (can become any type of tissue), because every cell
within the human body contains all of the genetic code for the human
body to be completely reproduced -- totaling about 25,000 genes. We
see most genes turn off with further and further cell specialization.
Cells specialize through a process known as differentiation.
Differentiation leads to specialization of cell types divided
into three subsets of cellular specialization early on.
The initial three cell specialties are:
1. Ectoderm which gives rise to the skin, eyes, hair and central
nervous system, as well as peripheral nerves.
2. Mesoderm, which gives rise to muscles bones and cartilage.
3. Endoderm, which gives rise to the internal organs.
This is an oversimplification, but this is not an article on embryology,
but rather gene expression and its role in cancer development.
The early pluripotent stem cells bear a striking resemblance
to the traits identified with cancer. These include:
1. Rapid cellular growth and division.
2. Angiogenesis or growth of blood vessels into the newly developing
tissue to carry oxygen and nutrition to the developing cells.
3. Invasiveness, which implies the ability to migrate through other tissues.
As we go from pluripotent cells of the embryo, to the completely specialized
cells of the adult, we go through a pattern of gene turnoff. Shut down of the
primitive genes and focus on genes necessary for the specialized cell function.
FAP
100%
APC Gene missing at birth.
Cancer can start by mid 20s
LYNCH
100%
MMR Leads to MSI
whatdoctorsknow.com
The development of cancer involves a process known as dedifferentiation.
This is a process in which there is a regression to a more primitive cell
type through mutations affecting genes turned off during specialization
that are reactivated. This will result in repeat expression of primitive
or primordial traits, which leads to the aggressive pluripotent cell type
behavior responsible ultimately for the development of cancer.
The biochemistry of gene shutdown
Gene shutdown usually comes from a process in biochemistry known as hyper
methylation. This involves the addition of the methyl group to the 5 prime
carbons of cytosine nucleotides in the DNA chain. Methyl groups are thought
to serve as signaling sites, but with excessive methylation of the gene, it will no
longer be read or produced by the cell. In the case of differentiation, this is the
mechanism for gene turnoff. In the case of colon cancer development, it involves
the turnoff of suppressor genes, including the APC gene, the K-ras-gene and p53.
Gene activation is restarting of genes turned off during specialization, by
methylation described above, but in the presence of free radical hydroxy
groups, which are part of the free radical cascade. These free radical hydroxy
groups will cause a process called hydroxylation in which the hydroxy group
becomes attached to the methyl group as an unintended consequence leading
to activation of the gene once again. This enables re-starting of the gene
formerly shutdown to express primitive traits and the type of pluripotent
cell activity of division and invasiveness attributed to cancer cells.
Cells with a high metabolic rate tend to have a rapid turnover. This is because of
the hydroxylation in the presence of hydroxy free radicals, leading to corruption
of the genetic code, which leads to activation of the p53 gene, causing apoptosis
or cell death. For this reason, we see frequent mutations in cells with a high
turnover rate that are also induced by errors in the copying of the cell genetic
code. It is thought that it takes about 1000 cycles of cell division to result in
mutation, which is why we see cancer expression at a very young age in patients
with congenital APC mutation, leading to familial polyposis and in a more rare
subset of cancer patients born without K-ras gene, a condition called Li-Fraumeni
syndrome. These patients have very high rates of cancer development at a very
young age. This makes sense, since rapidly developing cells turning over every
3 days will have about 10 years before significant mutations begin developing.
The sequence of mutations leading to most cases of familial
polyposis related colon cancer as well as most cases of
sporadic and inherited colon cancer includes:
First. The loss of the APC gene function either acquired
or congenital leads to rapid cell overgrowth.
Second. Either congenital or acquired loss of the K-ras
gene leads to disorganized division in the nucleus. The
growth now becomes an adenoma (pre-cancer).
Third. Loss of the DCC gene is further loss of control of the cell life cycle.
Fourth. Permanent loss of the function of the p53
gene. Conversion from adenoma to cancer.
The second pathway to cancer development affects the patients with Lynch
syndrome and the 20 percent of the sporadic colon cancer patients. These
patients will develop colon cancer because of gene regulation failure,
however the failure comes from a slightly different process. This failure
is from a defect in the genetic mismatch repair system "MMR ". This is
an error within the cell affecting the fidelity of the DNA copying during
cell division. Failure of the MMR system can result in what is termed
microsatellite instability or "MSI ". This causes either shortening or
lengthening of the code and leads to improper gene expression, resulting in
failure to recognize the gene properly and subsequent cancer development.
ALL Colon Cancer
Inherited 30%
LYNCH 4%
FAP 1%
SPORADIC 75%
75%
1%
4%
30%
Sporadic Cancers(75% of all Cancers)
APC Gene lost around age 40.
MMR repair gene defect leads
to Microsatelite instability.
Leads to cancer in the 40s
25%
75%
whatdoctorsknow.com
Of those patients with Lynch syndrome, about 80 percent
will develop colon cancer in their mid 40s. This genetic
defect is also the culprit in approximately 20 percent of
the populations sporadically occurring colon cancer.
The sequence of mutations leading to development of
colon cancer in patients with Lynch syndrome includes:
First. Abnormality of MMR, the mismatch
repair system which allows for:
Second. Microsatellite instability resulting in
abnormal gene expression and copying, then:
Third. Failure of p53 gene to kill off the abnormal, resulting
cells with chromosomal defects (this remains controversial).
The Expected age of colon cancer development
based on pathway to development.
1. Sporadic colon cancer and acquired APC mutation usually presents
with polyp around age 50 with cancer shortly after age 60.
2. Lynch syndrome typically with polyps starting around
mid-20s with colon cancer by the mid 40s.
3. FAP 100% certainty of colon cancer development by the mid 20s.
It is possible that both the failure of the MMR system and the APC
gene loss are actually separate pathways mediated by the same final
common pathway, which is p53 gene turn off, since anywhere along
the way the p53 gene can activate the cell kill switch to stop the
developing problem. For this reason, it may not be that important
how we get to the point of the p53 failure, but that the failure
occurs. The major clinical importance of how we get there has more
to do with treatment strategies. Let it suffice to say, no matter how
we arrive at the permanent turn off of p53, it is the point of no
return. In fact, this is the final common pathway in approximately
50 percent of all human malignancies, not just colon cancer.
The role of the p53 gene in healing, similar to cancer development
The human body is a fairly steady system. Without injury or
infection, the production of cells within the body is driven
primarily by the rate of cell turnover in the given organ system.
We are born with the same number of brain cells we will have for
the rest of our lives. We may have enlargement of muscles cells,
but for the most part, they do not die rapidly or turnover. The
same is true of our bones and other connective tissue. Much of
our cell turnover comes in the skin, the hair, the lining of the
digestive system and glandular tissue such as the breast or prostate.
And finally, production of blood and immune system cells.
We see an interruption of this body stability in an injury or
infection. When this happens, an aggressive assault is triggered by
the immune system to repair the affected area tissue and to allow
rapid cellular development growth and repair. Your immune system
is composed of a number of different types of inflammatory cells
circulating throughout the blood stream. These cells are responsible
for looking for any abnormality within our bodies and attacking
that abnormality. These cells include neutrophils, lymphocytes,
and monocytes. They produce a number of chemical mediators
such as lymphokines and cytokines, allowing for the following:
1. Movement of cells through blood vessel walls and across tissue planes.
2. Growth of new blood vessels into the affected area.
3. Turn off of cell suppressor gene p53 to allow rapid growth of
new cells to replace injured, damaged, or destroyed cells.
STEM CELL
Methylations
turns Off
primitive
need genes
Hydration from
free Radical
overload.
Re-activates
aggressive genes
Turn off APC
by Hyper-
methylation
overgrowth of
normal cells
Normal
cell rapidly
producing
Turn off K-RAs
Primitive
genes allow
clonal growth
invasiveness
spread.
Specializes Cell.
Stable cells do only
assigned work.
Normal
suppressor genes
(k-ras,APC,P53)
cell kills itself
by triggering
cell death.
Aneuploidy.
Abnormal
chromosomes
in various stages
of development.
Adenomateous
polyps.
Damage cell
becoming
more
primitive.
whatdoctorsknow.com
If this sounds familiar remember, these are the same
traits seen in stem cells prior to differentiation and
in cells after mutations allowing dedifferentiation
of stable differentiated cells to become cancer.
Interestingly, it is the p53 gene that is modulated at
the time of injury or infection, allowing the alteration
of the cell life cycle with rapid cloning of individual
cells for the repair process. This is probably achieved
through a process called hyper methylation, which
refers to the addition of methyl groups to the 5 prime
carbons on cytosine molecules within the sequence
of the p53 gene genetic code, which has a silencing
effect. This silencing of p53 permits the aberration of
the cell lifecycle and even of cell death development.
The difference between cancer and healing is
simply reversible versus irreversible P53 turn off.
With resolution of the infection or inflammation, or
with treatment with anti-inflammatory medications
such as aspirin, we can see normalization of the
p53 gene function resulting in a return to normal
cell cycle, the stoppage of rapid growth cells,
and a return to normal life cycle of the cells.
Yes, you did read that aspirin has the ability to reverse
inflammation, and at the same time restart the p53
gene. This raises the question of whether aspirin can
be used to treat cancer. We know it cant, but we also
do know there is a role for aspirin in the prevention of
cancer. Its use is already recommended for patients over
50 for prevention of stroke and heart attack. But study
after study has shown a correlation between regular
aspirin usage and the decrease of polyp development for
the type necessary for colon cancer development. There
is no current recommendation for the use of aspirin
for colon cancer prevention because current wisdom
suggests the risk of ulcer development with aspirin could
outweigh the potential benefit. Another way to look at
it is if aspirin is already recommended for adults over
50 for other purposes, the benefits could be derived,
even in the absence of a specific recommendation.
How aspirin can reduce cancer risk
A good example of the inflammatory response effects
on colon cancer development may be seen with a
brief review of ulcerative colitis. Ulcerative colitis is
a type of autoimmune inflammatory bowel disease.
This condition results from a mistake in the immune
recognition system, "the body recognizes the lining of
the colon cells as being foreign, or transplanted and tries
to destroy the colon cells through the immune pathway.
This is an example of the friendly fire mechanism
whatdoctorsknow.com 5
or self-destruction of the body through immune
recognition errors characterized by an enormous
amount of human pathophysiology, a recurring theme
in medicine. "This results in a chronic inflammatory
state and raises the lifetime cancer risk from about
4 percent to around 16 percent. It is now becoming
accepted that treatment of ulcerative colitis with low
dose derivatives of aspirin will reduce the risk of colon
cancer and chronic colitis patient's from 16 percent back
down to a more manageable 8 percent lifetime risk.
Role of inflammation in cancer
It is worth mentioning the contribution to cancer
development and proliferation provided by the
body's immune system to cancer development. We
have already seen how inflammation causes changes
resulting in cellular reactions similar to cancer onset.
It should be noted, the body has a significant immune
response to cancer cells, which can actually result in
reversal of a tumor and even complete stoppage of
cancer development. It is not yet clear whether the
defect is in the immune system, which allows some
types cancer to develop while stopping others.
Possible future treatment through p53 activation
Much attention is being given to the p53 gene, both in
its normal function, its healing and fighting infection
ability and its ability to restore the body to its normal
state and finally, its final and complete suppression
that results in the development of cancer in so many
situations. We will update any new changes in colon
cancer treatment, not only during colon cancer screening
month, but any time new information becomes available.
Where do we go from here?
I would summarize by saying progression from normal
cells to cancer cells involves activation of primitive growth,
promoting genes in combination with the turnoff of
tumor suppressing genes. It is the combination of these
two factors that leads to most colon cancer development.
We are now standing at the threshold of what I think
will be a great age of discovery and hope. The first
chemotherapeutic agents were derived from mustard
gas in the chemical warfare labs of World War I. The
principal was to kill cells that developed rapidly, giving
these poisons at a dosage that would hopefully kill the
cancer cells without killing the human host. We are
still using chemical warfare with 5-FU and leucovorin
as the primary mainstays in the war on colon cancer.
That is changing with a better understanding of the
genetic abnormalities involved and the development
of more targeted therapies, including monoclonal
antibody therapies. I do not pretend to know where this
will lead, but I think that we are on the right path.
This is small consolation to those already
afflicted with colorectal cancer, but it holds out
great hope that eventually we may see an end
to the war on cancer. -Steve Porter, MD
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