It's a slow and surreptitious process within the lung tissue. At first, few patients notice the subtle changes -- the shallow, uneven breathing; the trapped air; the uncomfortable suffocation. Even when they do, they rationalize: "I'm getting older," they say, or "I need to lose some weight."

Without intervention, the devastation continues -- sometimes a result of cigarette smoke or inhaled toxins, sometimes for no known reason. Over time, the alveoli appear almost moth-eaten, unable to do their jobs. The silhouette of the heart shrinks because of hyperinflated lungs, the diaphragm flattens and the bronchi become floppy and narrow. Other symptoms -- the chronic cough, the mucus, the shortness of breath, the difficulty blowing air out, the inability to do physical activities -- become more pronounced.

Often, more than half of lung functioning is lost before a diagnosis of chronic obstructive pulmonary disease is made. Partly because the condition's patient profile has changed -- it's no longer considered a disease of old men -- and partly because it is fraught with other misconceptions, COPD remains overlooked, even though it is the fourth leading U.S. cause of death.

More than 12 million people are diagnosed with COPD, but at least 12 million more unknowingly have it. "It's absolutely not on anybody's front burner," says Barbara Yawn, MD, a family physician who directs research at Olmstead Medical Center in Rochester, Minn. She also co-chairs the U.S. COPD Coalition, a nonprofit network of organizations dedicated to public education and research. "The primary care physician is focusing on two or three other chronic conditions, and they don't get around to questions of COPD."

Thus, the National Institutes of Health's National Heart, Lung and Blood Institute launched in early 2007 the Learn More, Breathe Better Campaign in an attempt to raise awareness and communicate a key message of early detection. "We are updating attitudes and concepts. We now have more tools to diagnose and treat," says James P. Kiley, PhD, director of the NHLBI's division of lung diseases. "The awareness program is a wake-up call. This disease is on the rise, and we need to get our hands on it. There is a role for primary care physicians, and spirometry is key."

Nonetheless, as Dr. Yawn explains, doctors still ask why they should test for a disease they can't help. "Our first job is to let doctors know this is not hopeless, and if we diagnose earlier we can help patients return to work and to normal activities," she says. "We need to show this is worth identifying. Treating this condition can give doctors, patients and families the same satisfaction and hope that treating other chronic diseases can, especially if we find it earlier when treatments make more difference."

MYTH: Spirometry is cumbersome

"We found that almost 40% of COPD is missed by primary care physicians," says Frederic D. Seifer, MD, clinical associate professor at East Tennessee University Quillen College of Medicine and director of the Erlanger Center for Better Health in Chattanooga. "How can you help these patients without identifying them?"

Two of the biggest reasons COPD gets missed in the primary care setting, Dr. Seifer says, are that most physicians believe it can be diagnosed clinically without spirometry and that it primarily affects men older than 65. "Wrong sex and wrong age," he says, adding that spirometry is essential.

More than 12 million people have chronic obstructive pulmonary disease.

But primary care doctors often recall the expensive, cumbersome, hard-to-calibrate equipment of their medical school days. As a result, barely 20% of their offices have spirometers. "Of 20,000 newly diagnosed COPD patients," says Aaron Milstone, MD, the director of the lung transplant program at Vanderbilt University in Nashville, Tenn., "less than 2% had testing."

Today, spirometers cost less than $1,000. They're small, about the size of a smart phone; they are easy to use; and they are reimbursable. "It's much easier than an EKG," says Stephen Rennard, MD, professor of internal medicine at the University of Nebraska Medical Center in Omaha. "It's like measuring blood pressure."

These newer machines generate a computer report, and Dr. Seifer has been teaching local physicians how to interpret the results. "Physicians are intelligent, and they want to be able to read the reports," he says. "They are less likely to use it if they can't read it."

Additionally, the COPD Foundation sponsors a mobile spirometry unit. "Since Jan. 14, [2007], we've been in 21 cities and tested almost 10,152 [people]" says John Walsh, founder and president, who himself has the alpha-1 form of COPD.

MYTH: Alpha-1 COPD is untreatable

Since she was a child, Melissa Biggs was chronically ill with colds, sore throats and upper respiratory conditions. But it wasn't until the 34-year-old former "Bay Watch" actress had her second bout of pneumonia that she went to an allergy specialist for help.

"She drew nine vials of blood, did scratch tests," Biggs says. "She said I was severely allergic and diagnosed me as a stoic asthmatic." Weeks later, after further testing, the allergist diagnosed Biggs with an alpha-1 antitrypsin deficiency, the only known genetic cause of COPD.

Almost 40% of COPD is missed by primary care physicians.

Biggs was referred to a critical care specialist. "He said, 'I don't know much, but what I do know [is that] it is rare and it is fatal. I give you two years.'" Biggs, a single mother, says she went into a depression, but she also found out more. "I learned that my doctor was grossly misinformed. It's treatable and it's not rare. It's rarely diagnosed."

The average alpha-1 deficient patient has symptoms for 7.2 years and sees three different doctors before getting a correct diagnosis, says D. Kyle Hogarth, MD, assistant professor of medicine at the University of Chicago Medical Center. He also directs its Alpha-1 Antitrypsin Deficiency Clinical Resource Center.

Alpha-1 antitrypsin is an anti-inflammatory protein that shields the lung's delicate tissues by binding to neutrophil elastase -- a normal lung enzyme that digests bacteria and other foreign substances. Without alpha-1, this digestion goes unchecked, eventually damaging healthy lung tissue. According to a study by the Respiratory & Allergic Disease Foundation, alpha-1 is estimated to affect up to 100,000 Americans, but nearly 95% are undiagnosed or misdiagnosed.

Knowing whom to screen appears to be one of the missing links.

"Our surveillance study found that physicians cannot depend on typical patient profiles to assess whether AAT deficiency screening is necessary," says Dr. Hogarth, the lead author of a study presented at the annual meeting of the American College of Chest Physicians in October 2007. A number of patients who normally would not be screened based on suggested guidelines turned out to be positive for AAT deficiency. "In the real-world setting, this suggests that thousands of patients who have been diagnosed with COPD or severe asthma may actually have alpha-1."

Study findings suggest that all patients with moderate or severe persistent asthma and/or COPD should be tested for AAT deficiency, says Gary Rachelefsky, MD, one of the investigators and a professor of allergy and immunology and director of the Executive Care Center for Asthma, Allergy and Respiratory Diseases at California's UCLA School of Medicine. "It is imperative that clinicians become more vigilant about alpha-1 testing."

MYTH: It's a hopeless condition

It's the "pumpkin pie" talk that helps his COPD patients grasp what they are facing, Dr. Seifer explains.

He draws a circle on the back of the patient's spirometry reading. If the patient has lost one-third of his or her lung function, that's a one-third sized slice of the pie. "This much of your pie is gone. You'll never get it back," he tells them. "We're going to help you quit smoking, because you can't take any more bites out of this pie. For the first time they say they understand their disease."

COPD is the 4th leading cause of death in the U.S.

Understanding is an important part of the treatment equation, as is pulmonary rehabilitation, nutrition and exercise. "This improves quality of life," Nebraska's Dr. Rennard says.

Long-acting bronchodilators and inhaled corticosteroids added to bronchodilators are helping and, in some cases, slowing progression, he said. In the TORCH (TOward a Revolution in COPD Health) study, presented at the American Thoracic Society meeting in May, patients treated with salmeterol/fluticasone propionate had a slower rate of lung function decline over three years compared with patients receiving a placebo. In addition, advances in smoking cessation give primary care physicians new tools.

A previous therapy -- lung volume reduction surgery, originally used in the 1950s -- has re-emerged for patients with upper lobe damage. Surgeons remove the most damaged portion, hoping to restore lung elasticity. And it seems a small umbrella might hold an answer for some patients. Known as the IBV Valve System, these one-way devices are placed inside the lung's upper lobe to redirect airflow to healthier portions of the lung.

"This is just the tip of the iceberg," Dr. Milstone says.

The Global Initiative for Chronic Obstructive Lung Disease, an initiative of NHLBI and the World Health Organization, has developed evidence-based guidelines for COPD management and staging criteria from spirometry. Yet, on average, physicians estimate that only 12% of their patients have COPD. And although 55% of doctors are aware of major COPD guidelines, only 25% use them to guide decision-making.

"We are in a Columbus-like era for the treatment of COPD. We are going forward with great impact," Dr. Milstone says. "We now need to focus on primary care physicians and internists, to let our colleagues know the future is really quite bright, that we have great optimism."

A parasite that is the leading cause of heart failure in Latin American countries appears to be far more common here than previously thought. Public health officials and physicians are now struggling to devise strategies for detecting, treating and preventing transmission, according to a series of papers published over the past year and symposiums at recent infectious disease meetings.

"This is really a neglected disease, but Chagas is more and more on the radar screen in the U.S.," said Caryn Bern, MD, MPH, medical epidemiologist at the Centers for Disease Control and Prevention's division of parasitic diseases.

Chagas disease, caused by the Trypanosoma cruzi parasite and carried by the triatomine or "kissing bug," has always been here in a very limited way. Many mammals are infected. The first indigenous human case was noted more than a half century ago in the Oct. 15, 1955, Journal of the American Medical Association, but its incidence in humans has been considered rare.

Widespread testing of the blood supply as of January 2007 triggered by cases of transmission through transplanted organs and transfused blood -- in some cases causing death -- has enabled the detection of many more infections. Most are in people who have spent significant time in Latin America or, because this parasite can be transmitted to a fetus, are children of immigrants from endemic regions. A handful of cases, though, seem to have been contracted on this side of the border.

Data from the American Red Cross presented at the American Society of Tropical Medicine and Hygiene meeting in Philadelphia in November 2007 show that one in 30,000 donors tested positive for the parasite. This number is much higher in some regions of the country with large numbers of Latin American immigrants.

Not everyone who tests positive on the initial screen will actually carry it, but at least 317 people in 30 states were confirmed as infected last year by AABB, an association which represents organizations that collect about 65% of the U.S. blood supply. Experts say more than 100,000 people may have Chagas without knowing it.

More than 100,000 people may have Chagas without knowing it.

"We're just seeing the tip of the iceberg," said Patricia Dorn, PhD, associate professor of biological sciences at Loyola University New Orleans. She was the lead author on a paper in the April 2007 Emerging Infectious Diseases that documented the first locally acquired case of Chagas in Louisiana.

In order to facilitate treatment, JAMA published a review of data by leading experts in this field. In addition, the first U.S. clinic devoted to it, the Center of Excellence for the Diagnosis and Treatment of Chagas Disease at Olive View-UCLA Medical Center in Los Angeles, opened last month.

"We want to treat these patients, and we want to follow them long term because this has not been looked at before in the U.S.," said Sheba Meymandi, MD, center director and associate professor of medicine at UCLA.

But with all this activity comes a growing awareness of the complexity of dealing with Chagas.

Experts urge physicians to test those who may be infected, but determining who that may be is difficult. Dr. Meymandi is running a trial to evaluate the effectiveness of screening all Latin American patients with heart conduction abnormalities and unexplained cardiomyopathy. She is also testing close relatives of those known to carry the parasite.

Until the results are available, the categories of those who potentially carry this -- including those who have spent significant time in Latin America -- are too broad to allow targeted testing. This infection is also, for the most part, asymptomatic for decades until heart or gastrointestinal trouble appears.

Not all infants born to mothers infected with Chagas will acquire the disease.

"The most important thing for physicians is to keep Chagas disease on the differential," said Dr. Bern.

There's also not yet an easy way to detect this parasite. Two different tests, at minimum, are needed, and even those whose results are negative may still be infected.

"There is not one single test that is considered the gold standard, and we may be missing some people," Dr. Bern said.

And then there's the question of what to do with a positive result. Drug treatment is most effective in those who are newly infected and those who are younger than 18.

Limited evidence suggests that treating those who are older can have some benefit, and one of the more contentious debates is whether adults should be given these medications. They can be hard to take, and they're not always effective.

Moreover, the majority of those infected will never develop the major heart or gastrointestinal problems that drug treatment seeks to prevent. The estimated 20% to 30% of patients who do can be monitored and managed symptomatically.

"The bottom line is that there are no properly structured, double-blinded trials that demonstrate that giving a full course of the drug to those with long-standing infection is beneficial," said Louis V. Kirchhoff, MD, MPH, professor in the division of infectious diseases at the University of Iowa. Dr. Kirchhoff has been studying Chagas disease for more than 20 years.

A randomized clinical trial that may answer this question of drug treatment for long-term infections is under way, but there is also the challenge of getting patients access to treatment. The drugs are not approved by the Food and Drug Administration, even though they have been used in Latin America for decades. They are only available in the United States from the CDC, which provides them at no charge.

Despite these challenges, experts hope that all this testing will not only protect the blood and organ supply, but also ensure that more babies who contract the parasite congenitally will be treated.

Not all infants born to mothers who are infected will acquire Chagas. But some will -- and treatment is most effective in this group soon after birth.

Researchers have found an explanation for runners who struggle to increase their pace, cyclists who cant pedal any faster and swimmers who cant speed up their strokes. Scientists from the University of Exeter and Kansas State University have discovered the dramatic changes that occur in our muscles when we push ourselves during exercise.

We all have a sustainable level of exercise intensity, known as the critical power. This level can increase as we get fitter, but will always involve us working at around 75-80% of our maximal capacity. Reported in the American Journal of Physiology: Regulatory, Integrative and Comparative Physiology, this research shows why, when we go beyond this level, we have to slow down or stop altogether. This is the first time that researchers have looked at processes taking place inside the muscles when we exceed the critical power.

The study showed that when we exceed our critical power, the normally-stable pH level in our muscles, is quickly pushed to levels typical of exhaustion. Moreover, the level of phosphocreatine in the muscles, a high-energy compound which serves as an energy reserve, is quickly depleted when exercise intensity exceeds the critical power.

Professor Andy Jones of the University of Exeter, lead author on the paper, said: The concept of critical power is well known by sportspeople, but until now we have not known why our bodies react so dramatically when we exceed it. We were astonished by the speed and scale of change in the muscles.

The research team used a magnetic resonance scanner to assess changes in metabolites in the leg muscles of six male volunteers who exercised just below and just above the critical power.

The research offers a physical explanation for the experiences of exercisers of all levels of ability. Professor Jones concludes: The results indicate that the critical power represents the highest exercise intensity that is sustainable aerobically. This means that it is likely to be an important intensity for maximising training gains. Exercising above the critical power cannot be sustained for long because it is linked to changes in the muscle which lead to fatigue.


Posted by: Evelyn    Source

New research from Johns Hopkins specialists suggests that obese kidney disease patients face not only the usual long odds of a tissue match and organ rejection, but also are significantly less likely than normal-weight people to receive a kidney transplant at all.

The Johns Hopkins study results, would be published online this Wednesday in the Journal of the American Society of Nephrology, reveal that morbidly obese patients (those who on average weigh 100 pounds more than their ideal weight) are on the transplant waiting list for a median of five years - two years more than the median wait time for a patient of normal weight.

Because patients tend to get sicker the longer they wait on dialysis, obese patients are 44 percent less likely than normal-weight patients to ever receive a kidney transplant, the scientists report. Each year, 8 percent of the patients on the list die waiting for a kidney.

Johns Hopkins transplant surgeon Dorry Segev, M.D., who led the study, suggests that obese patients might be turned down, sometimes multiple times, because of the added cost and poorer outcome linked to transplants in overweight patients.

Being overweight should not be a disqualifying and discriminating factor against these patients, Segev says.

He adds that at Johns Hopkins, the rate at which overweight, severely obese, and morbidly obese patients are listed and receive transplants is much higher than the national average. As a result, the waiting times for obese patients are not significantly different.

Patients understandably think that being placed on the transplant waiting list is an implicit promise of fair, unbiased therapy under a transparent allocation scheme, Segev says. Unfortunately, the system that has been established nationally may not be living up to that promise.

The studys findings may be explained, he says, by economic pressures as well as medical ones. He notes that Medicare - the principal insurer for kidney transplants - pays a set amount for the operation regardless of a patients overall health, difficulty of the operation, length of stay, postoperative care and complications, all of which may increase substantially with obese patients. Transplant centers, therefore, may be under pressure to avoid operating on these individuals.

In addition, Segev says, centers with lower surgical survival rates overall risk losing Medicare funding.

The scientists analyzed data from 132,353 men and women with kidney disease who were on the United Network for Organ Sharing (UNOS) deceased donor kidney transplantation list from 1995 to 2006 in the United States.

Patients weight was rated using the body mass index (BMI) scale - weight in kilograms divided by height in meters squared. A normal BMI is 18.5. Overweight is 25 (25 to 30), obese is 30 to 35 severely obese is 35 to 40 and morbidly obese is 40 to 60.

Of the group analyzed, 48,349 were of normal weight, 45,411 were overweight, 25,509 were obese, 9,479 were severely obese and 3,605 were morbidly obese.

After adjusting for additional health factors that might affect a persons eligibility for transplantation (such as blood type, age, type of kidney disease, diabetes and heart disease), the scientists observed that the likelihood of receiving a transplant, when in comparison to patients with a normal weight, decreases by 4 percent for overweight patients, 7 percent for obese patients, 28 percent for severely obese patients and 44 percent for morbidly obese patients.

Segev says the number of overweight patients joining the UNOS waiting list has gone up markedly in the last decade as the rate of obesity has grown in the U.S. population. From 1995 to 2005, the number of severely obese patients added to the list increased by 310 percent, and the number of morbidly obese patients added to the list increased by 247 percent. In contrast, the number of people of normal weight added to the list increased by only 33 percent.

The transplant community needs to develop appropriate guidelines stipulating which patients are appropriate for transplantation and to do our best to treat them equally, says Segev. Similarly, both outcomes evaluation and reimbursement need to reflect the varying difficulty of care for these patients in order to remove the disincentives of taking on challenging cases.

A study by Johns Hopkins surgeon Anne Lidor, M.D., is currently examining whether overweight transplants patients should be recommended for gastric bypass surgery at the time theyre first listed.

This would improve survival while the patient is waiting for a kidney and also improve survival after receiving the kidney, which should eliminate any potential bias for receiving a kidney in a timely fashion, says Segev.


Posted by: Evelyn    Source

Strategies for decreasing a childs risk for obesity often focus on improving eating habits and maintaining a high level of physical activity. While this is one way to address the issue, another way to reduce the risk of childhood obesity could simply come down to positive parenting, as per a Temple University study reported in the recent issue of Child Abuse & Neglect.

This is the first study to show the association between neglect in childhood and childhood obesity. Prior studies looked at maltreatment in childhood and how it affected these individuals in adulthood, said Dr. Robert Whitaker, the studys lead author and a pediatrician and professor of public health at Temple University.

Examples of neglect include a parent not showing enough affection to the child due to preoccupation with his/her own problems, not taking a child to the doctor when he/she needed it, and leaving a child at home without the proper supervision.

Data was obtained from the Fragile Families and Child Wellbeing Study, a birth cohort study of 4,898 children born between 1998 and 2000 in 20 large U.S. cities. At age 3, 2,412 of these children had their height and weight measured, and mothers answered items on the Parent-Child Conflict Tactics Scales about three types of child maltreatment in the previous year: neglect (such as not providing proper supervision for the child), corporal punishment (such as spanking the child on the bottom with a bare hand) and psychological aggression (such as threatening to spank the child but not actually doing it).

Eighteen percent of the children were obese, and the prevalence of any episode of neglect, corporal punishment or psychological aggression was 11 percent, 84 percent and 93 percent, respectively.

The odds of obesity were 50 percent greater in children who had experienced neglect, after controlling for the income and number of children in the household, the mothers race/ethnicity, education, marital status, body mass index, prenatal smoking and age, and the childrens sex and birth weight. Neither the frequency of corporal punishment nor psychological aggression was linked to an increased risk of obesity.

Corporal punishment and psychological aggression are common discipline techniques resulting from a childs misbehavior, and the child may come to anticipate them as consequences of their misbehavior, Whitaker said.

In contrast, the child may not understand the cause of the neglect and the child might mistakenly feel at fault, he added.

These experiences of neglect could translate into a great deal of stress for the child, which might, in turn, influence mood, anxiety, diet and activity. As we know, adults eat in response to stress; the same could be true for children, Whitaker said.

You cant make a childs life stress free, but parents can strive to be more of a buffer against stress, rather than one of the causes of stress, he said.


Posted by: Diana    Source