Sphincter of Oddi Dysfunction

Sphincter of Oddi Dysfunction

By: Peter B. Cotton, MD, Professor of Medicine, Digestive Disease Center, Medical University of South Carolina, Charleston, SC

The sphincter of Oddi is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through ducts from the liver and pancreas (the Ampulla of Vater) into the first part of the small intestine (duodenum). “Sphincter of Oddi dysfunction (SOD)” describes the situation when the sphincter does not relax at the appropriate time (due to scarring or spasm). The back-up of juices causes episodes of severe abdominal pain. The diagnosis is often considered in patients who present with recurrent attacks of pain after surgical removal of the gall bladder (cholecystectomy), and in some who suffer from recurrent attacks of unexplained pancreatitis. More than half a million cholecystectomies are performed annually in the United States, and 10–20% of these patients present afterwards with continuing or recurrent pains.

About half of these patients will have some impressive objective findings on laboratory studies or imaging (e.g. abnormal liver enzymes on blood testing, or a dilated bile duct on an Ultrasound or CT scan), to suggest definite pathology, such as a stone in the bile duct. These patients are categorized by the Milwaukee classification as SOD Types I and II. MRCP (magnetic resonance cholangio-pancreatography) is nowadays a good non-invasive test for checking on the biliary and pancreatic drainage systems.

When symptoms are severe, and the laboratory and scanning findings are impressive, standard treatment is to perform an endoscopic procedure called endoscopic retrograde cholangiopancreatography (ERCP). This is done under sedation by experts trained in the technique. They pass an instrument (under sedation or anesthesia) down to the duodenum, where the bile duct and pancreatic ducts drain. They inject dye through the Ampulla of Vater into the ducts, and treat what is found, usually by cutting the muscular sphincter (sphincterotomy) to remove any stones or to relieve any scarring or spasm of the sphincter.

Patients with a similar pain problem, but who have little or no abnormalities on blood tests and standard scans (including MRCP), are categorized as SOD type III, with the supposition that episodes of pain are due to intermittent spasm of the sphincter. These patients are very difficult to evaluate and to manage effectively. Indeed some physicians are skeptical of its existence of SOD III, or assume that it is only a small part of a broader problem of a functional digestive disturbance such as irritable bowel syndrome.

A very important problem in this context is that these ERCP procedures carry a significant risk of complications. In particular, ERCP (with or without SOM) can cause an attack of pancreatitis in 5–10% of cases. Whilst most of these result in only a few days in hospital, about 1% of patients suffer a major attack, with weeks or months in hospital. Sphincterotomy also carries a small risk of other severe complications such as bleeding and perforation, and the possibility of delayed stenosis due to scarring.

Because of the risks of ERCP, patients with suspected SOD III are usually advised to try medical treatments first. Some respond to the use of anti-spasmodic drugs and/or anti-depressants that modulate the pain pathways. There have been trials of other medical therapies, such as calcium channel blocking drugs. Despite a few encouraging reports, these modalities have not proven to be effective generally, and are not widely used.

Patients who fail these approaches (at least those with severe symptoms) are usually sent to specialists at tertiary referral centers for further evaluation. This may involve an Endoscopic Ultrasound study to look for minor changes in the pancreas, and MRCP (if not already performed). If nothing else is found, ERCP is recommended to check that there are no subtle structural abnormalities in the papilla, biliary tree or pancreas, and to allow measurement of the actual pressure in the sphincter, by performance of Sphincter of Oddi manometry (SOM). The results of SOM are used to decide whether to perform treatment (at the same ERCP examination), by sphincterotomy of the biliary and/or pancreatic sphincters. SOM is not widely available, and the results are not consistently predictive of the outcome of treatment. In general it appears that biliary sphincterotomy provides benefit in 70% of these patients, at most.
Clinical Study

These uncertainties in how best to diagnose and to treat “suspected sphincter of Oddi dysfunction” (and the risks involved) mandate further scientific investigation. The National Institutes of Health has recently funded an important study called “EPISOD” in 6 major Gastroenterology centers in USA.

Essentially, patients with burdensome pains after cholecystectomy who fulfill the Rome III criteria for sphincter of Oddi dysfunction undergo extensive evaluation for functional and psychiatric disorders. If they consent to the study, they undergo ERCP with SOM, and are randomized to biliary and/or pancreatic sphincterotomy, or to a sham procedure, regardless of the manometry findings. Their clinical course is monitored for up to 4 years. The studies are being conducted at centers located in:
Baltimore, MD
Birmingham, AL
Charleston, SC
Indianapolis, IN
Minneapolis, MN
Seatle, WA

Additional details are available at the NIH website at www.clintrials.gov.
Update: Sphincter of Oddi dysfunction research study needs patients

We have an NIDDK-funded randomized sham-controlled study designed to see which (if any) patients with “Sphincter of Oddi Dysfunction III” respond to sphincter ablation, and which clinical and manometry factors predict the outcome.

The study is progressing well with 70 subjects randomized (the largest number ever in a randomized trial in SOD), but we need 214. So, this is a request to consider referring suitable subjects to one of the 7 active sites.

The basic eligibility criteria are: disabling post-cholecystectomy pain, aged 18-65, no prior pancreatitis or previous sphincter treatment, normal anatomy, normal EGD and scans (bile duct <9mm), failed treatment with PPIs and antispasmodics, liver tests and amylase/lipase <2-3X normal, no daily narcotics, not suicidal.

After informed consent and detailed clinical documentation, subjects undergo ERCP with biliary and pancreatic manometry. They are then randomized to sphincterotomy or sham (2:1 sphincterotomy versus sham). regardless of the manometry results. Those patients randomized to the sphincterotomy arm and who have raised pancreatic sphincter pressures are randomized again to biliary or to biliary and pancreatic sphincterotomy. All subjects get a small temporary pancreatic stent. Patients, caregivers, and research coordinators are blinded to the treatment allocation. Success is defined by substantial reduction in pain burden at 1 year (without any repeat intervention).

Details of the protocol and site contacts are available at www.clinicaltrials.gov. Thank you.
Peter B Cotton
Professor of Medicine, Digestive Disease Center, Medical University of South Carolina, Charleston.

Jaw Injuries and Disorders

Jaw Injuries and Disorders


Your jaw is a set of bones that holds your teeth. It consists of two main parts. The upper part is the maxilla. It doesn't move. The moveable lower part is called the mandible. You move it when you talk or chew. The two halves of the mandible meet at your chin. The joint where the mandible meets your skull is the temporomandibular joint.

Jaw problems include
Fractures
Dislocations
Temporomandibular joint dysfunction
Osteonecrosis, which happens when your bones lose their blood supply
Cancers

Treatment of jaw problems depends on the cause.

Alveoplasty

Alveoplasty


What Is It?

An alveoplasty is a type of surgery that smoothes the jawbone. It is also called an alveoloplasty. This procedure is done in areas where teeth have been removed or lost. Alveoplasty can be done alone, but is usually done at the same time that teeth are extracted.

Oral and maxillofacial surgeons usually perform alveoplasties, but some general dentists also do them.


What It's Used For

When a tooth is lost or extracted, it leaves a hole in the jawbone. Even after the gums have healed, there will be high and low points in the bone. This can make it difficult to fit a denture properly. The denture base can rub against the high points. The rubbing may cause sore spots and a bad fit.

Some people who have been missing teeth for many years have lost quite a bit of bone from their jaws. The top of the jawbone becomes very thin. Dentists call this area the ridge. Other people may have a lip of bone that juts out from the rest of the jaw. In these cases, a denture will not fit properly.

Dentists use alveoplasty to smooth lumps in the jawbone or to flatten or taper the jaw's ridge. The amount of bone removal is balanced by the need to maintain bone height. Adequate bone height is necessary to place implants and fit dentures.

Usually, alveoplasty is not done if only one tooth is being extracted. In this case, the area will heal normally on its own. However, if a sharp edge of bone remains after the tooth is removed, alveoplasty can be done to remove it.

Besides smoothing the jawbone, alveoplasty also speeds healing after multiple teeth are extracted. If your dentist removes a tooth, he or she leaves an open socket that fills with a blood clot. Eventually, the gum heals over the socket. An alveoplasty allows the gums to be stitched closed over the hole. This causes quicker healing. It also allows for better control of bleeding because there is no open socket.

Faster healing is important for certain people, such as cancer patients. They may need to have decayed teeth extracted before they receive chemotherapy or radiation therapy to the head or neck. Radiation can dry up the salivary glands and reduce blood flow to the jaw. Both of these problems can increase the risk of further decay.

Once the teeth are removed, radiation therapy cannot begin until the sockets are healed. Alveoplasty will help the area heal faster so therapy is not delayed. In this case, alveoplasty may need to be done even if only a single tooth is removed. In these cases, radiation therapy can usually begin 7 to 10 days after the surgery.
Preparation




Preparation before alveoplasty is different for each person. Some people may be asked to rinse with an antimicrobial mouthwash before surgery. Some also may receive antibiotics or pain medicine before surgery.

In some cases, a dentist will make a model of the jaw. This model will show the surgeon where to remove bone and how much to remove. To make a model, the dentist first takes an impression of the teeth and jaw. This is used to create a cast. The cast is ground down in areas where bone should be removed. Then a plastic model of the cast, called a stent, is made. The stent looks like a denture base, except it is clear. The oral surgeon will use the stent during surgery to make sure the right amount of bone has been removed.
How It's Done




Alveoplasty usually is performed in the office. Sometimes only local anesthesia is used. Some people also may be sedated with medicine given through a vein (intravenous). Others may require general anesthesia in a hospital.

If the alveoplasty is done along with extractions, the teeth will be removed first.

To start the alveoplasty, the surgeon makes a cut in the gum and peels it back to expose the bone. The surgeon then uses tools and possibly a rotary drill to remove the necessary bone. A file is used to smooth it.

Once the bone has been smoothed, the surgeon squirts water across the area to remove bits of bone. If a stent is required, the surgeon replaces the gum tissue over the bone and sets the stent on top. This helps the surgeon tell whether the correct amount of bone was removed. If the stent does not fit well, more bone will be removed. Then the bone will be reshaped until the stent fits, much like a denture. Then the gum tissue will be replaced and stitched closed. In some cases, a temporary, immediate denture will be inserted at the time of surgery.
Follow-Up




After alveoplasty, the area probably will be sore for about a week. For the first day or two, you may be given narcotic pain medicine. After that, you can use over-the-counter medicine, such as acetaminophen (Tylenol and others) or ibuprofen (Advil, Motrin and others).

You may have some swelling. This should peak after about 24 hours and then taper off. You can use ice on your face to keep the swelling down. You also may notice bruising. Where the bruises appear will depend on the location of the surgery. They may be under your jaw line, on your chin and cheeks, or inside your mouth.

Your surgeon may prescribe antibiotics to prevent infection. An antibacterial rinse may be provided. You also can rinse with a saline (salt water) solution.

Until the stitches dissolve or are removed, you should eat a soft diet. Also avoid using a straw because the suction can encourage bleeding.

After 7 to 10 days, the surgeon will look at your mouth again to see how the area is healing.
Risks




The risks of alveoloplasty include:

Excessive bleeding — This is rare. The area may have some oozing for the first 24 hours after surgery, but then should taper off.
Infection — Because the mouth contains many bacteria, there is always a risk of infection after surgery. This risk is relatively low, however. Your surgeon may prescribe antibiotics to help prevent infection.
The wound opening — The stitches may come loose. This can open the wound and expose the bone. If this occurs, contact your surgeon.
Trauma to the nerve that provides feeling to the lips and chin — This is very rare, but can occur when alveoplasty is done on the lower jaw. If the nerve is bruised, your lip and chin may feel numb long after the local anesthetic wears off. Your lip will not droop. No one else will be able to tell that your nerve is bruised. Nerves heal slowly. In a very small percentage of people, there may be some permanent numbness.
When To Call A Professional




After alveoplasty, contact your surgeon if you have:
Significant bleeding or increased swelling after the first 24 hours
Any indication of an infection, such as fever, chills or inflammation of the area
Loosening of stitches or opening of the wound to expose the bone

About Sever's Disease

About Sever's Disease

Sever's disease, also called calcaneal apophysitis, is a painful bone disorder that results from inflammation (swelling) of the growth plate in the heel. A growth plate, also called an epiphyseal plate, is an area at the end of a developing bone where cartilage cells change over time into bone cells. As this occurs, the growth plates expand and unite, which is how bones grow.

Sever's disease is a common cause of heel pain in growing kids, especially those who are physically active. It usually occurs during the growth spurt of adolescence, the approximately 2-year period in early puberty when kids grow most rapidly. This growth spurt can begin any time between the ages of 8 and 13 for girls and 10 and 15 for boys. Sever's disease rarely occurs in older teens because the back of the heel usually finishes growing by the age of 15, when the growth plate hardens and the growing bones fuse together into mature bone.

Sever's disease is similar to Osgood-Schlatter disease, a condition that affects the bones in the knees.
Causes

During the growth spurt of early puberty, the heel bone (also called the calcaneus) sometimes grows faster than the leg muscles and tendons. This can cause the muscles and tendons to become very tight and overstretched, making the heel less flexible and putting pressure on the growth plate. The Achilles tendon (also called the heel cord) is the strongest tendon that attaches to the growth plate in the heel. Over time, repeated stress (force or pressure) on the already tight Achilles tendon damages the growth plate, causing the swelling, tenderness, and pain of Sever's disease.

Such stress commonly results from physical activities and sports that involve running and jumping, especially those that take place on hard surfaces, such as track, basketball, soccer, and gymnastics. It can even result from standing too long, which puts constant pressure on the heel. Poor-fitting shoes can contribute to the condition by not providing enough support or padding for the feet or by rubbing against the back of the heel.

Although Sever's disease can occur in any child, these conditions increase the chances of it happening:
pronated foot (a foot that rolls in at the ankle when walking), which causes tightness and twisting of the Achilles tendon, thus increasing its pull on the heel's growth plate
flat or high arch, which affects the angle of the heel within the foot, causing tightness and shortening of the Achilles tendon
short leg syndrome (one leg is shorter than the other), which causes the foot on the short leg to bend downward to reach the ground, pulling on the Achilles tendon
overweight or obesity, which puts weight-related pressure on the growth plateSigns and Symptoms

The most obvious sign of Sever's disease is pain or tenderness in one or both heels, usually at the back. The pain also might extend to the sides and bottom of the heel, ending near the arch of the foot.

A child also may have these related problems:
swelling and redness in the heel
difficulty walking
discomfort or stiffness in the feet upon awaking
discomfort when the heel is squeezed on both sides
an unusual walk, such as walking with a limp or on tiptoes to avoid putting pressure on the heel

Symptoms are usually worse during or after activity and get better with rest.
Diagnosis

A doctor can usually tell that a child has Sever's disease based on the symptoms reported. To confirm the diagnosis, the doctor will probably examine the heels and ask about the child's activity level and participation in sports. The doctor might also use the squeeze test, squeezing the back part of the heel from both sides at the same time to see if doing so causes pain. The doctor might also ask the child to stand on tiptoes to see if that position causes pain.

Although imaging tests such as X-rays generally are not that helpful in diagnosing Sever's disease, some doctors order them to rule out other problems, such as fractures. Sever's disease cannot be seen on an X-ray.
Treatment

The immediate goal of treatment is pain relief. Because symptoms generally worsen with activity, the main treatment for Sever's disease is rest, which helps to relieve pressure on the heel bone, decreasing swelling and reducing pain.

As directed by the doctor, a child should cut down on or avoid all activities that cause pain until all symptoms are gone, especially running barefoot or on hard surfaces because hard impact on the feet can worsen pain and inflammation. The child might be able to do things that do not put pressure on the heel, such as swimming and biking, but check with a doctor first.

The doctor might also recommend that a child with Sever's disease:
perform foot and leg exercises to stretch and strengthen the leg muscles and tendons
elevate and apply ice (wrapped in a towel, not applied directly to the skin) to the injured heel for 20 minutes two or three times per day, even on days when the pain is not that bad, to help reduce swelling
use an elastic wrap or compression stocking that is designed to help decrease pain and swelling
take an over-the-counter medicine to reduce pain and swelling, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin, Nuprin)

Note: Children should not be given aspirin for pain due to the risk of a very serious illness called Reye syndrome.

In very severe cases, the doctor might recommend that the child wear a cast for anywhere from 2 to 12 weeks to immobilize the foot so that it can heal.Recovery and Recurrence

One of the most important things to know about Sever's disease is that, with proper care, the condition usually goes away within 2 weeks to 2 months and does not cause any problems later in life. The sooner Sever's disease is addressed, the quicker recovery is. Most kids can return to physical activity without any trouble once the pain and other symptoms go away.

Although Sever's disease generally heals quickly, it can recur if long-term measures are not taken to protect the heel during a child's growing years. One of the most important is to make sure that kids wear proper shoes. Good quality, well-fitting shoes with shock-absorbent (padded) soles help to reduce pressure on the heel. The doctor may also recommend shoes with open backs, such as sandals or clogs, that do not rub on the back of the heel. Shoes that are heavy or have high heels should be avoided. Other preventive measures include continued stretching exercises and icing of the affected heel after activity.

If the child has a pronated foot, a flat or high arch, or another condition that increases the risk of Sever's disease, the doctor might recommend special shoe inserts, called orthotic devices, such as:
heel pads that cushion the heel as it strikes the ground
heel lifts that reduce strain on the Achilles tendon by raising the heel
arch supports that hold the heel in an ideal position

If a child is overweight or obese, the doctor will probably also recommend weight loss to decrease pressure on the heel.

The risk of recurrence goes away on its own when foot growth is complete and the growth plate has fused to the rest of the heel bone, usually around age 15.

Smokers have slimmer odds of surviving colon cancer

Smokers have slimmer odds of surviving colon cancer


By Amy Norton

NEW YORK (Reuters Health) - Smokers aren't just more likely to develop colon cancer than non-smokers, they might also be at higher risk of dying from the disease, a new study suggests.

The results, reported in the journal Cancer, show that smokers were 30 percent more likely to die of colon cancer during the study and 50 percent more likely to die of any cause than their smoke-free peers.

Former smokers also had worse survival odds than non-smokers, but had a better outlook than current smokers.

"If you needed another reason not to smoke, or to quit smoking, this is as good a reason as any," said lead researcher Amanda Phipps, of the Fred Hutchinson Cancer Research Center in Seattle.

The findings are based on 2,264 people diagnosed with colon cancer sometime between 1998 and 2007. They were interviewed about their pre-cancer smoking and drinking habits, and the researchers followed their rates of death into 2010.

Of 920 non-smokers, 22 percent died of colon cancer during the study. That compared with 30 percent of those who were current smokers around the time of their cancer diagnosis, and 25 percent of former smokers.

When Phipps and her colleagues accounted for other factors -- like patients' age, education and whether they'd gotten routine colon cancer screening -- current smokers were still 30 percent more likely than non-smokers to die of the disease.

Former smokers were 14 percent more likely to die of colon cancer.

The findings, according to Phipps, once again underscore the importance of kicking the smoking habit, and preferably never picking it up. Whether quitting after a diagnosis helps extend colon cancer patients' lives is unclear.

Still, Phipps said, since smoking is related to a range of health problems, including heart and lung disease, "there is always a reason to quit."

In the U.S., it's estimated that 1 in 20 adults will develop colon cancer in their lifetime. Studies have suggested that together, current and former smokers have a 20-percent greater risk of developing the cancer than lifelong non-smokers.

SOURCE: http://bit.ly/jH5dIn Cancer, online April 14, 2011.

Growth hormone treatment tied to diabetes in kids

Growth hormone treatment tied to diabetes in kids


By Kerry Grens

NEW YORK (Reuters Health) - Type 2 diabetes is eight and a half times more common among children in the United States treated with growth hormone than among kids who are not on the hormone treatment, a new study shows.

The researchers, based at the pharmaceutical company Eli Lilly, found that of more than 11,000 kids who took growth hormone, 11 were diagnosed with type 2 diabetes after treatment started, while none of them had type 2 diabetes before treatment.

An additional 26 kids had an impaired ability to process blood sugar, which is often a precursor to type 2 diabetes.

The children in the study received growth hormone for a variety of conditions, including a deficiency of the hormone, very short stature, or genetic disorders such as Prader-Willi syndrome or Turner syndrome.

All the patients at some point in their treatment took Humatrope, a growth hormone marketed by Eli Lilly.

The company has been monitoring children on the growth hormone to detect any unexpected side effects of the drug.

The study, which is published in the Journal of Clinical Endocrinology and Metabolism, did not compare the children who took growth hormone to children with similar health conditions who did not take the hormone; rather, the researchers compared them to a large group of kids in the general population.

According to the National Institutes of Health, about 8 out of every 100,000 kids aged 10 to 19 are diagnosed with type 2 diabetes each year. For comparison, the rate seen in the kids on growth hormone represents 100 out of every 100,000.

Dr. Christopher Child, the lead author of the study and a researcher at Lilly Research Center in England, told Reuters Health in an email that he was not surprised to see a larger proportion of diabetes cases among children who took growth hormone.

A previous study in 2000 found a similarly increased rate of diabetes, and the company had noted several diabetes cases in reports of potential side effects.

Growth hormone is known to interfere with the activity of insulin, the hormone that regulates blood sugar. It's unclear whether the growth hormone treatment itself is responsible for the higher diabetes risk seen in the kids, however.

Child and his colleagues found that 10 of the 11 children with diabetes also had risk factors for the disease. These included obesity, radiation treatment from leukemia, and some of the growth conditions themselves that prompted the hormone treatment.

"Thus, the increased diabetes incidence compared to the general population may well reflect, at least in part, the known increased risk of diabetes in some of the patient groups for whom (growth hormone) treatment is currently indicated," Child said.

In seven of the 11 diabetic children, their hyperglycemia - the high blood sugar involved in diabetes - resolved over time. In four of those seven children, it resolved after they stopped taking growth hormone.

Child said his company will continue to monitor the health of children long term following their treatment with growth hormone, including for signs of diabetes.

"We recommend closer surveillance of (growth hormone)-treated patients with pre-existing type 2 diabetes risk factors before, during and after treatment, to assess glucose metabolism and to encourage those lifestyle measures that have been shown to be effective for prevention of diabetes, such as diet and exercise," Child said.

SOURCE: http://bit.ly/mOY4w2 The Journal of Clinical Endocrinology and Metabolism, online April 13, 2011.

Potential Roles of the Placebo Effect in Health Care

Potential Roles of the Placebo Effect in Health Care

A special issue of Philosophical Transactions of the Royal Society B, a publication of the UK's national academy of science, recently examined the science and theory behind the placebo effect in addition to its future role in health care.

The placebo effect is a beneficial health outcome resulting from a person's anticipation that an intervention—pill, procedure, or injection, for example—will help them. A clinician's style in interacting with patients also may bring about a positive response that is independent of any specific treatment.

Themes discussed in the issue included:
Previous research has found that empathy and social learning, emotion and motivation, and spirituality and the healing ritual may be important factors for understanding the placebo effect. Information about these factors as well as other well-studied placebo mechanisms will help to build further research about the biology of placebo and how the body uses it to heal itself.
A focus on translational ("bench-to-bedside") research, particularly for placebo studies, is to develop strategies for using placebo response interventions in clinical settings. Because much of placebo research has been done on humans, there is potential for using some of this scientific evidence in the field of patient care. Although recommending and prescribing placebo treatments remains controversial, the researchers explore the current scientific literature to better understand how, when, and why placebo treatments might be used in health care.
Conditioning and expectancy are two of the most accepted theories in placebo response research. For example, a doctor's visit in which both the process of being treated (conditioning) as well as the physician's verbal suggestions that a treatment may be beneficial (expectancy) may promote a placebo response. The researchers suggest that by examining placebo research from the perspective of these different learning and verbal mechanisms, studies can be designed to investigate the effect of the placebo response on medical care.

Based on the evaluation of placebo research found in this issue, the researchers concluded that more rigorously designed studies are needed in order to better understand the complexities of the placebo effect and how it can be adapted for a clinical setting.
References
Meissner K, Kohls N, Colloca L. Introduction to placebo effects in medicine: mechanisms and clinical implications. Philosophical Transactions of the Royal Society B. 2011;366:1783–1789. [Epub ahead of print]
Colloca L, Miller FG. How placebo responses are formed: a learning perspective. Philosophical Transactions of the Royal Society B. 2011;366:1859–1869. [Epub ahead of print]
Colloca L, Miller FG. Harnessing the placebo effect: the need for translational research. Philosophical Transactions of the Royal Society B. 2011;366:1922–1930. [Epub ahead of print]

Standard Heart Drugs Won't Ease Pulmonary Hypertension Patients with pulmonary arterial hypertension don't benefit from aspirin or simvastatin, study finds

Standard Heart Drugs Won't Ease Pulmonary Hypertension
Patients with pulmonary arterial hypertension don't benefit from aspirin or simvastatin, study finds

By Mary Elizabeth Dallas

WEDNESDAY, May 18 (HealthDay News) -- Although commonly used to treat heart disease, aspirin and simvastatin offer no benefit to patients suffering from pulmonary arterial hypertension, or PAH, a progressive disease characterized by increased blood pressure in the arteries of the lungs, according to new research.

In a study funded by the U.S. National Institutes of Health, researchers divided 65 patients into four groups: one receiving aspirin; one taking simvastatin; one receiving both drugs; and one in which patients received a placebo (or dummy pill).

"Surprisingly, we found no evidence that aspirin or simvastatin had beneficial clinical effects in this population," said Dr. Steven Kawut, study lead author and associate professor of medicine and epidemiology at the University of Pennsylvania School of Medicine.

After taking the assigned medication for six months, patients were asked to see how far they could walk in six minutes. The distance tended to be shorter in the simvastatin group, and no difference was seen between the aspirin and placebo patients.

Following these early results, the U.S. National Heart, Lung, and Blood Institute discontinued the study based on a recommendation from the Data and Safety Monitoring Board.

"The results of this study do not support the routine treatment of PAH with these medications," Kawut said in an American Thoracic Society news release.

The findings are scheduled to be presented Wednesday at the American Thoracic Society international conference in Denver.

PAH, which is incurable, causes shortness of breath, dizziness and fatigue, and can lead to heart failure and death.

The researchers concluded that both aspirin and simvastatin may be prescribed for usual clinical indications in patients with PAH, but should not be administered specifically to treat PAH.

"The findings show the importance of subjecting traditional cardiovascular therapies and drugs which appear effective in the laboratory to placebo-controlled [randomized clinical trials] in humans before recommending their use," Kawut said.

Research presented at meetings is considered preliminary until published in a peer-reviewed journal.

SOURCE: American Thoracic Society, news release, May 18, 2011

Tonsil Removal Might Cure Bedwetting in Some Kids With Sleep Apnea Study shows additional benefit of the surgery for certain children

Tonsil Removal Might Cure Bedwetting in Some Kids With Sleep Apnea
Study shows additional benefit of the surgery for certain children

(HealthDay News) -- Half of children with sleep apnea who also wet the bed might stop their bedwetting if their tonsils or adenoids are removed, new research suggests.

Obstructive sleep apnea (OSA) is marked by interruptions in breathing while asleep; it is common among children with enlarged tonsils or adenoids. Exactly how sleep apnea results in bedwetting is not fully understood, but hormonal changes may play a role.

However, half of the 417 children in this latest study who had sleep apnea and were bedwetters stopped wetting the bed after they had their tonsils or adenoids removed. Children in the study were aged 5 to 18, and were followed for just under one year after their surgery, on average.

Those who did not stop wetting the bed after the surgery were more likely to be born prematurely, be male, be obese or have a family history of bedwetting, the investigators noted. Premature birth was the greatest predictor of continued bedwetting after surgery.

"If they haven't seen an ear, nose and throat specialist, see one to see if the child who wets the bed has OSA that can be cured by tonsil or adenoid removal," said study author Dr. Yegappan Lakshmanan, chief of pediatric urology at Children's Hospital of Michigan, in Detroit.

The findings were to be presented Monday at the annual meeting of the American Urological Association (AUA), in Washington, D.C. Research presented at medical meetings should be viewed as preliminary until it has been published in a peer-reviewed medical journal.

There are many other causes of bedwetting, Lakshmanan said. "About 5 to 7 million children are bedwetters, and the causes fall into three main groups: bladder issues, sleep-related problems and the kidneys," he explained. "The children in this study wet the bed due to sleep-related problems."

So why weren't they all cured? "Bedwetting is multifactorial even within these groups, and eventually we should be able to pinpoint the cause for every single child," Lakshmanan said.

"There are several potential causes of bedwetting, and sleep apnea is clearly one of them," said Dr. Lane S. Palmer, chief of pediatric urology at the Cohen Children's Medical Center in New Hyde Park, N.Y.

"There are secondary positive effects of this tonsil- or adenoid-removing surgery, but I don't know that I would jump to have my child's tonsils or adenoids out as a primary treatment for bedwetting," he said. "Children with sleep apnea and bedwetting should see an otolaryngologist first."

"This study really underscores the fact that children who have other issues with sleep should be looked at for bedwetting because anything that depresses sleep at night can lead to bedwetting," said AUA spokesman Dr. Anthony Atala, a urologist at Wake Forest University in Winston-Salem, N.C.

"If a child has bedwetting, pay close attention to their sleep patterns, and observe them while they are asleep and you can see whether they are breathing at a regular pace, and if not, seek additional help," Atala said.

Children with sleep apnea can be difficult to rouse, which may cause the bedwetting, said Dr. Dennis Kitsko, an otolaryngologist at the Children's Hospital of Pittsburgh. "But not every child with sleep apnea will wet the bed, and not every bedwetter will have sleep apnea."

Still, "snoring in children is abnormal," said Dr. Linda Dahl, an ear, nose and throat doctor at Lenox Hill Hospital in New York City. "Children snore because their tonsils and adenoids are enlarged, and they end up getting other behaviors that go along with sleep apnea, including bedwetting," she explained.

"There are many ancillary benefits that you may not attribute to removing large tonsil and adenoids, such as putting an end to bedwetting," Dahl added.

SOURCES: Yegappan Lakshmanan, M.D., chief, pediatric urology, Children's Hospital of Michigan, Detroit; Lane S. Palmer, M.D., chief, pediatric urology, Cohen Children's Medical Center, New Hyde Park, N.Y.; Anthony Atala, M.D., urologist, Wake Forest University Medical Center, Winston-Salem, N.C.; Dennis Kitsko, M.D., otolaryngologist, Children's Hospital of Pittsburgh; Linda Dahl, M.D., ear, nose and throat specialist, Lenox Hill Hospital, New York City; May 16, 2011, presentation, American Urological Association annual meeting, Washington, D.C.

Pills, Surgery Both Effective for Chronic Reflux: Study Each approach seems to ease condition, each has pluses and minuses, experts say

Pills, Surgery Both Effective for Chronic Reflux: Study
Each approach seems to ease condition, each has pluses and minuses, experts say


TUESDAY, May 17 (HealthDay News) -- Both surgery and popular medications such as Nexium, Prevacid or Prilosec can successfully treat the discomfort of chronic reflux, according to new research.

Millions of Americans experience what's known formally as chronic gastroesophageal reflux disease, or GERD. The condition is caused by acidic stomach contents washing up into the esophagus. GERD can have a debilitating effect on sleep, work and general quality of life.

However, "we have made very dramatic improvement in our treatment of GERD, that's the good news," said lead researcher Dr. Jean-Paul Galmiche, a professor of gastroenterology in the College of Medicine at Nantes University in France. Treatments include laparoscopic surgical fixes and the use of proton pump inhibitor (PPI) drugs such as Nexium (esomeprazole), Prilosec (omeprazole) and Prevacid (lansoprazole).

The new study -- which was funded by Nexium's maker, AstraZeneca -- found "dramatic improvement in the results of surgery and excellent results also with medical therapy," he stated. There was no real difference between the medical and surgical approaches in terms of their overall ability to ease GERD, "which was not expected," Galmiche said.

Each treatment option did have its merits and demerits, however. For example, with surgery there is less regurgitation than with the medications, Galmiche said, but on the other hand, "you have more bloating and flatulence after surgery."

This means that the choice of one treatment over the other is really up to the patient, he said. If you don't want to take pills for the rest of your life you may opt for surgery, or if you fear surgical complications you can opt for PPIs. "You can choose your preferred treatment," Galmiche said.

The report was published in the May 18 issue of the Journal of the American Medical Association.

The study included 554 people with GERD who had already responded well to Nexium in a three-month try-out period prior to their entry into the study. These participants were selected because, according to one outside expert, people with reflux who do not respond to a PPI probably have another condition other than GERD.

"Those are [also] the people who tend to not do as well on surgery, because a lot of them have non-acid reflux or another cause of their symptoms," explained Dr. Amar R. Deshpande, an assistant professor of gastroenterology at the University of Miami Miller School of Medicine.

Of the 554 people selected into the trial, 372 completed five years of follow-up, including 192 randomly assigned to treatment with Nexium and 180 assigned to laparoscopic antireflux surgery.

Although the study used Nexium as its PPI, Galmiche pointed out that there is no reason why other drugs in this class wouldn't work as well.

People taking Nexium were allowed to increase their dose as needed, the investigators noted.

Five years after initiating treatment, the researchers found that GERD was in remission for 85 percent of the patients who had undergone surgery and 92 percent of the patients who were taking Nexium.

Those taking Nexium had similar levels of heartburn and acid regurgitation from the start to the end of the study. However, these symptoms lessened among those who had surgery, the researchers noted.

For example, at five years, 13 percent of those taking Nexium had acid regurgitation compared with 2 percent of those who underwent surgery. Yet there was no significant difference between the groups in the severity of heartburn, abdominal pain or diarrhea, the investigators found.

In terms of complications, 11 percent of the surgery patients had difficulty swallowing, compared with 5 percent of those taking Nexium. Among those having surgery, more suffered bloating than those taking Nexium (40 percent versus 28 percent) and the same held for rates of (excess) flatulence (57 percent versus 40 percent), the researchers found.

In addition, about 29 percent of those who had surgery and 24 percent of those on Nexium experienced some serious adverse event.

Overall, however, "this large, multicenter randomized trial demonstrated that with modern forms of antireflux therapy, either by drug-induced acid suppression or after laparoscopic antireflux surgery, most patients remain in remission for at least five years," the study authors concluded.

Commenting on the study, Deshpande said that "if you did well on Nexium and if you continued it or went to surgery, both afforded you a nine out of 10 chance of staying in symptom remission over the next five years."

As he sees it, GERD therapy typically becomes a personal choice. "If you are taking one pill once a day, most people tend to want to do that [rather] than undergo surgery," he said. However, it is those who do well on a PPI that typically also do well after surgery, he noted.

People who might opt for surgery are those who don't want to take pills or are afraid of the side effects of PPIs, Deshpande said.

SOURCES: Jean-Paul Galmiche, M.D., professor, gastroenterology, College of Medicine, Nantes University, France; Amar R. Deshpande, M.D., assistant professor, gastroenterology, University of Miami Miller School of Medicine; May 18, 2011, Journal of the American Medical Association

Many Women Can Have Cervical Cancer Test Every 3 Years: Study Can forgo yearly Pap smear if they also test negative on HPV test, research suggests

Many Women Can Have Cervical Cancer Test Every 3 Years: Study
Can forgo yearly Pap smear if they also test negative on HPV test, research suggests


WEDNESDAY, May 18 (HealthDay News) -- Women 30 and older who have good results from each of the two cervical cancer tests available today can safely wait three years for their next screening instead of just one year, according to new research.

The finding is not likely be controversial, said Dr. Charles Capen, chief of gynecology/oncology at Scott & White Healthcare in Temple, Texas, given that most current guidelines already recommend that women 30 and over who are otherwise healthy be screened with both a Pap smear and a test for a virus linked to cervical cancer every three years as long as the initial tests are both negative.

Unlike some cancers, cervical cancer is usually slow-growing, and it is curable if detected early, according to the U.S. National Cancer Institute.

"This [new research] confirms the latest guidelines," agreed Dr. Therese Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston. "That is fabulous as it can give clinicians and women everywhere a lot of reassurance."

Hopefully, it will also spur more doctors to actually follow these guidelines, added Bevers, as recent research has revealed that most doctors are giving the Pap test more often than recommended -- i.e., once a year.

The study findings will be presented at the annual meeting of the American Society of Clinical Oncology being held in June in Chicago. The results were released early Wednesday during a teleconference.

Cervical cancer risk can be assessed by two different tests: the traditional Pap smear, which searches for abnormalities in cervical cells, and a newer test that can detect DNA of the virus that causes most cases of cervical cancer: human papillomavirus, or HPV. That screening is referred to as the HPV test.

The new study involved more than 330,000 women enrolled in a large northern California health plan who were undergoing both types of tests between 2003 and 2005 and who were followed for five years after being tested.

The estimated five-year risk for developing cervical cancer was 7.5 per 100,000 women in those who had normal Pap smears, versus a much lower 3.8 per 100,000 for women who were negative on the HPV test.

When the two tests were performed together with both yielding negative results, the estimated risk was 3.2 per 100,000 women, meaning that the HPV test alone is almost as good as the two combined.

"A single negative HPV test [predicted] an extremely low cancer risk for women [which] was not appreciably lowered by having a normal Pap test," said lead author Hormuzd Katki, principal investigator in the Division of Cancer Epidemiology and Genetics at the U.S. National Cancer Institute.

That means that women who test negative on the HPV test alone might be able to extend their screening intervals to three years with no adverse consequences, Katki added.

"This generates the question, should HPV testing become the standard at some point," Bevers said.

This might be especially important in developing countries that often don't have the capability to interpret Pap tests, Bevers said.

"HPV testing is much easier," she added. "It's kind of like doing a pregnancy test at home. It's positive or negative."

There is still a role, however, for the Pap test -- to follow up a positive HPV test, said Katki. "The Pap test can identify women who have more immediate disease," he said.

"But many women equate a Pap smear with their annual gynecological exam and one of the arguments against three-year screening intervals is that women would no longer see their doctor every year and get other necessary tests, such as blood pressure, cholesterol and testing for sexually transmitted infections," Capen said.

Capen, though, thinks that won't happen. "Young women may be on the pill or they may be pregnant, so hopefully they will still get the medical care they need," he said.

Since the study findings are to be presented at a medical meeting, they should be considered preliminary until published in a peer-reviewed journal.

SOURCES: Charles Capen, M.D., chief of gynecology/oncology, Scott & White Healthcare, Temple, Texas; Therese Bevers, M.D., medical director, Cancer Prevention Center, University of Texas M.D. Anderson Cancer Center, Houston; May 18, 2011, teleconference with Hormuzd Katki, Ph.D., principal investigator, division of cancer epidemiology and genetics, U.S. National Cancer Institute; U.S. National Cancer Institute study abstract, May 18, 2011

Gallbladder and Biliary Tract

Gallbladder and Biliary Tract

The gallbladder is a small, pear-shaped, muscular storage sac that holds bile. Bile is a greenish yellow, thick, sticky fluid. It consists of bile salts, electrolytes (dissolved charged particles, such as sodium and bicarbonate), bile pigments, cholesterol, and other fats (lipids). Bile has two main functions: aiding in digestion and eliminating certain waste products (mainly hemoglobin and excess cholesterol) from the body. Bile salts aid in digestion by making cholesterol, fats, and fat-soluble vitamins easier to absorb from the intestine. The main pigment in bile, bilirubin, is a waste product that is formed from hemoglobin (the protein that carries oxygen in the blood) and is excreted in bile. Hemoglobin is released when old or damaged red blood cells are destroyed.

Bile flows out of the liver through the left and right hepatic ducts, which come together to form the common hepatic duct. This duct then joins with a duct connected to the gallbladder, called the cystic duct, to form the common bile duct. The common bile duct enters the small intestine at the sphincter of Oddi (a ring-shaped muscle), located a few inches below the stomach.

About half the bile secreted between meals flows directly through the common bile duct into the small intestine. The rest of the bile is diverted through the cystic duct into the gallbladder to be stored. In the gallbladder, up to 90% of the water in bile is absorbed into the bloodstream, making the remaining bile very concentrated. When food enters the small intestine, a series of hormonal and nerve signals triggers the gallbladder to contract and the sphincter of Oddi to relax and open. Bile then flows from the gallbladder into the small intestine to mix with food contents and perform its digestive functions.

After bile enters and passes down the small intestine, about 90% of bile salts are reabsorbed into the bloodstream through the wall of the lower small intestine. The liver extracts these bile salts from the blood and resecretes them back into the bile. Bile salts go through this cycle about 10 to 12 times a day. Each time, small amounts of bile salts escape absorption and reach the large intestine, where they are broken down by bacteria. Some bile salts are reabsorbed in the large intestine. The rest are excreted in the stool.

The gallbladder, although useful, is not necessary. If the gallbladder is removed (for example, in a person with cholecystitis), bile can move directly from the liver to the small intestine.

Hard masses consisting mainly of cholesterol (gallstones) may form in the gallbladder or bile ducts. Gallstones usually cause no symptoms. However, gallstones may block the flow of bile from the gallbladder, causing pain (biliary colic) or inflammation. They may also migrate from the gallbladder to the bile duct, where they can block the normal flow of bile to the intestine, causing jaundice (a yellowish discoloration of the skin and whites of the eyes) in addition to pain and inflammation. The flow of bile can also be blocked by tumors. Other causes of blocked flow are less common

Returning Home after a Disaster: Be Healthy and Safe

Returning Home after a Disaster: Be Healthy and Safe

Stay safe from hazards a storm may leave in your home.
Be Careful of Getting Sick or Hurt
Clean your home as recommended to stop mold. Never mix bleach and ammonia, because the fumes could kill you.
Prevent carbon monoxide poisoning by placing generators, pressure washers, charcoal grills, camp stoves, or other fuel-burning devices outside and away from open doors, windows, and air vents.
Eat and drink only food and water you know are safe.
Avoid tetanus and other infections by getting medical attention for a dirty cut or deep puncture wound.
Drive safely, wear your seatbelt, and don’t drink and drive.
Do not enter a building if you smell gas. Call 911. Do not light a match or turn on lights.
Wear waterproof boots and gloves to avoid floodwater touching your skin.
Wash your hands often with soap and clean water, or use a hand-cleaning gel with alcohol in it.
Clean Your Home and Stop Mold
Take out items that have soaked up water and that cannot be cleaned and dried.
Fix water leaks. Use fans and dehumidifiers and open doors and windows to remove moisture.
To remove mold, mix 1 cup of bleach in 1 gallon of water, wash the item with the bleach mixture, scrub rough surfaces with a stiff brush, rinse the item with clean water, then dry it or leave it to dry.
Check and clean heating, ventilating, and air-conditioning systems before use.
To clean hard surfaces that do not soak up water and that may have been in contact with floodwater, first wash with soap and clean water. Next disinfect with a mixture of 1 cup of bleach in 5 gallons of water. Then allow to air dry.
Wear rubber boots, rubber gloves, and goggles when cleaning with bleach. Open windows and doors to get fresh air. Never mix bleach and ammonia. The fumes from the mixture could kill you.
See also Flood Water After a Disaster or Emergency
See also Mold after a Disaster
Protect Yourself from Carbon Monoxide Poisoning

Do not use generators, pressure washers, charcoal grills, camp stoves, or other fuel-burning devices indoors or in enclosed or partially enclosed areas such as garages, even with doors or windows open. Do not put these devices outside near an open door, window, or air vent. You could be poisoned or killed by carbon monoxide, an odorless, colorless gas from burning fuel such as gasoline, charcoal, or propane. Make sure a battery or electric powered CO detector is functional to alert you to dangerous levels of carbon monoxide in your home.

See also What You Need to Know When the Power Goes Out Unexpectedly.
Keep Drinking Water and Food Safe.

Listen to public announcements to find out if local tap water is safe for drinking, cooking, cleaning, or bathing. Until the water is safe, use bottled water or boil or disinfect water.
If a "boil water" advisory is in effect, do not drink tap water or use it to brush your teeth unless water has come to a rolling boil for at least 1 minute or is treated with unscented household chlorine bleach. To treat water, add 1/4 teaspoon (approximately 1.5 mL) bleach to 1 gallon of cloudy water or 1/8 teaspoon (approximately 0.75 mL) bleach to 1 gallon of clear water . Stir well and let it stand for 30 minutes before you use it.
Do not eat food that smells bad, looks bad, or has touched floodwater. When in doubt, throw food out.
See also Food, Water, Sanitation, and Hygiene Information for use Before and After a Disaster or Emergency
See also Keep Food and Water Safe After a Disaster or Emergency
Prevent Electrical Injuries
Do not touch fallen electrical wires. They may be live and could hurt or kill you.
Turn off the electrical power at the main source if there is standing water. Do not turn on power or use an electric tool or appliance while standing in water.
Avoid Contact with Animals and Insects
Reduce mosquito bites. Consider avoiding outdoor activities during the evening and early morning, which are peak biting times for many mosquitoes. Use an insect repellent with DEET or Picaridin.
Stay away from wild or stray animals. Stray dogs may be hurt or afraid and may bite. Call local authorities to handle animals.
Get rid of dead animals according to local guidelines.
Drive Safely
Stop and look both ways at all intersections. Drive slowly and keep space between you and other vehicles. Watch out for trash on the road.
Wear your seatbelt.
Do not drive if you have been drinking.

Selenium Might Help Treat Symptoms in Graves' Eye Disease Study finds improved quality of life in patients with mild eye problems due to the autoimmune disorder

Selenium Might Help Treat Symptoms in Graves' Eye Disease
Study finds improved quality of life in patients with mild eye problems due to the autoimmune disorder


WEDNESDAY, May 18 (HealthDay News) -- The trace mineral selenium improves quality of life and slows the progression of eye problems in people with the autoimmune disorder known as Graves' disease, a new study says.

Italian researchers report that they compared daily selenium use to both a medication called pentoxifylline and a placebo, and found that selenium could benefit people with Graves' disease with eye involvement, without causing side effects.

"Our study demonstrates that patients with mild Graves' orbitopathy, [who are] usually not given any specific treatment, can benefit from a six-month course of selenium selenite [100 micrograms twice daily], both in terms of amelioration of eye manifestations and improvement in quality of life," said study author Dr. Claudio Marcocci, a professor of endocrinology at the University of Pisa, Italy.

Graves' disease is an autoimmune disease that usually affects the thyroid gland, causing hyperthyroidism, according to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Common symptoms of the disease include nervousness, irritability, weight loss, fatigue, muscle weakness, hand tremors and trouble sleeping, according to the NIDDK.

The disease can also cause the immune system to attack the area around the eyes, causing inflammation in the tissue behind the eye socket. This can cause the eyes to protrude, a common sign of Graves' disease. When the eyes are affected by Graves' disease it's often referred to as Graves' ophthalmopathy or Graves' orbitopathy.

Symptoms of Graves' ophthalmopathy include dry eyes, puffy eyelids, double vision, sensitivity to light, a feeling of eye pain or pressure and difficulty moving the eyes, according to NIDDK. Approximately one out of four people with Graves' disease will develop mild to moderate eye symptoms that usually last for a year or two and then resolve on their own, reports NIDDK. Fewer than 5 percent of people with Graves' develop severe eye symptoms.

There aren't any known effective treatments for Graves' ophthalmopathy, said Dr. Jacob Warman, chief of endocrinology at the Brooklyn Hospital Center in New York City. Lubricant eye drops can help relieve some symptoms, but they don't alter the course of the disease.

Pentoxifylline is an anti-inflammatory medication and selenium acts as an antioxidant. The researchers suspected that both substances had properties that could help prevent some of the damage caused by Graves' eye disease.

The study authors recruited 159 people with mild Graves' orbitopathy, and randomly assigned them to receive two daily doses of either 100 micrograms of selenium, 600 milligrams of pentoxifylline or a placebo.

After six months, the researchers found that selenium treatment, but not pentoxifylline or the placebo, was associated with an improved quality of life. Selenium was also found to slow the progression of Graves' orbitopathy and reduce eye symptoms compared to the placebo and pentoxifylline.

Additionally, the researchers found that the benefits of selenium lasted for at least another six months after the study ended.

There were no adverse effects reported with selenium or placebo use. Several people on pentoxifylline reported nausea, bloating and abdominal discomfort.

Results of the study are published in the May 19 issue of the New England Journal of Medicine.

One caveat noted by Marcocci is that the population in the area where this study was conducted tends to be selenium-deficient. So, in an area where people get sufficient selenium, it's not clear if additional amounts of this trace element would still provide benefit. Selenium is found in plant sources, such as corn, wheat and soybean, according to the U.S. Office of Dietary Supplements. It's also found in some meats, such as chicken, beef and turkey.

Warman pointed out that another limitation of this study is that it's quite small, with only about 50 people in each treatment group.

"There doesn't appear to be a downside to selenium, so it might be worthwhile to try this relatively simple treatment to prevent eye symptoms. But, a larger study should be done," he noted.

Marcocci said he would recommend that people with Graves' orbitopathy try selenium for six months to see if their symptoms improve.

SOURCES: Claudio Marcocci, M.D., professor, endocrinology, University of Pisa, Italy; Jacob Warman, M.D., chief, endocrinology, Brooklyn Hospital Center, New York City; May 19, 2011, New England Journal of Medicine

Neuromuscular scoliosis

Neuromuscular scoliosis
Disease Information

Overview

Patients come here from around the world for their scoliosis treatment. We're happy to be able to provide world-class care for them and for our local patients.

--Spinal Program Team, Department of Orthopedic Surgery

If your child has been diagnosed with neuromuscular scoliosis, we know that you and your family are under stress, and are already dealing with the underlying neuromuscular condition that’s associated with his scoliosis. So, at Children’s Hospital Boston, we’ll approach your child’s treatment with sensitivity and support—for your child and your whole family. And it will be our constant goal to maximize your child’s function, strength and quality of life.

You can have peace of mind knowing that the team in the Children’s Spinal Program has treated many children with spinal problems—some of which are so rare that few pediatric doctors have ever come across them—and we can offer you expert diagnosis, treatment and care.

About scoliosis

Scoliosis is a condition in which the spine—in addition to the normal front to back curvature—has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it to form a multidimensional curve.

Scoliosis occurs, and is treated, as three main types:
neuromuscular scoliosis: associated with a neuromuscular condition such as cerebral palsy, myopathy or spina bifida

congenital scoliosis: present at birth, caused by a failure of the vertebrae to form normally—the least common form

idiopathic scoliosis: occurring with no definite cause

About neuromuscular scoliosis

Neuromuscular scoliosis is the form that’s associated with your child’s underlying nerve and/or muscular condition, which may be:
cerebral palsy
spina bifida
muscular dystrophy
paralysis from spinal cord injury
myopathy
poliomyelitis
spinal cord tumors
spinal muscular atrophy

These types of neuromuscular conditions cause muscles to become weak, spastic or paralyzed—and unable to support the spine, resulting in spinal curvatures.

The Children’s Hospital Boston approach

Children’s Spinal Program is known for clinical innovation, research and leadership. We’ll provide your child with the most advanced diagnostics and treatments—several of which were developed by our own researchers and clinicians.

As one of the first comprehensive programs, Children’s Orthopedic Care Center is the largest and most experienced pediatric orthopedic surgery center in the United States, performing more than 6,000 surgical procedures each year. Our program—ranked #1 in the country by U.S. News & World Report—is the nation’s preeminent care center for children and young adults with neuromuscular, developmental, congenital and post-traumatic problems of the musculoskeletal system.

Some of our team’s unique accomplishments include our:
development of the Boston Brace, a custom bracing system widely used throughout the United States and Europe

unique experience in the treatment of adolescent hip conditions

success with the VEPTR™(vertical expandable prosthetic titanium rib) procedure: In 1998, Children’s was selected as a site for the first extensive VEPTR use outside San Antonio, where it was developed. Children’s has the second most extensive VEPTR experience in the nation.

experience with, and emphasis on, treating infantile (early-onset) scoliosis

experience with, and research in, brachial plexus birth palsy, including our international, multi-center study of this complex condition

Sports Medicine Program, including its pioneering research into the regeneration of ACL tissue and growth plate-sparing surgeries for ACL repair in pre-adolescents

extensive orthopedic research laboratories

Clinical Effectiveness Research Center for the study of children’s musculoskeletal disorders

Each year, our Spinal Program caregivers provide comprehensive evaluation, diagnosis, consultation, treatment and follow-up care for children during more than 6,000 outpatient visits. And every year, our orthopedic surgeons perform more than 300 spine procedures.We offer orthopedic care in lots of places
Children’s provides orthopedic care—including for scoliosis and other spine problems—at Children’s satellite locations in Lexington, Peabody and Waltham, as well as at our main campus in Boston.
If you come from far away, we can help
As an international pediatric orthopedics center, Children’s treats young patients from all over the world. Our International Center assists families residing outside the United States: we facilitate the medical review of patient records; coordinate appointment scheduling; and help families with customs and immigration, transportation, hotel and housing accommodations.


Neuromuscular scoliosis: Reviewed by John Emans, MD

Spotlight on Research 2011 Scientists Correct Genetic Defect in Blistering Skin Disease in Mouse Model

Spotlight on Research 2011

Scientists Correct Genetic Defect in Blistering Skin Disease in Mouse Model

A new study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) shows it may be possible to grow healthy new skin for people with a rare disfiguring skin disease called recessive dystrophic epidermolysis bullosa (RDEB). Caused by a defect in the gene coding for a protein called type VII collagen, RDEB is characterized by painful blistering of the skin and mucous membranes that leaves people prone to infections, scarring and skin cancer. Currently, the only treatment for the disease is targeted at relieving pain and improving quality of life.

While some scientists have tried using grafts of the patients’ own skin to replace damaged areas of skin in people with RDEB, these grafts have failed because they contain the same genetic defect that causes the disease. The new study, however, used skin grown from cells of patients with RDEB that were modified to express a normal type VII collagen gene.

After taking a small biopsy of skin cells called keratinocytes from people with RDEB, the scientists used a viral vector – a harmless virus engineered to deliver normal genes into cells – to correct the type VII collagen defect in the cells. The modified keratinocytes were then grown into sheets in the lab and transplanted onto laboratory mice.

Twelve months later, when the study was terminated, the skin on the mice was still attached and healthy, and the cells of the transplanted tissue continued to express the normal type VII collagen gene, says Alfred T. Lane, M.D., professor of dermatology and pediatrics at Stanford University School of Medicine, who led the study.

Now that the researchers know they can successfully transplant the modified skin on mice, the next step is to try growing larger sheets of skin and graft them back onto the people affected by RDEB, Dr. Lane says. Such skin-growing technology is already in place, and studies in adults could begin within a few months.

The greatest uncertainty with the procedure is whether the modified grafts will transplant successfully on skin that has been affected with lesions for 20 years or more, as is often the case in adults with the disease, says Dr. Lane. His goal, eventually, is to test the modified grafts on children in hopes of treating the disease before it has caused extensive or long-term damage.

Telehealth: When health care meets cyberspace

Telehealth: When health care meets cyberspace
From researching treatment options to emailing with your doctor, telehealth gives you the tools to better manage your health.


How many times have you heard it said that the Internet has transformed modern life? Indeed it's probably changed how you stay in touch with family and friends, purchase goods and services, and even search for information about health problems. But are you using the array of telehealth tools available to improve your health and wellness? If not, you may be falling behind the times.
What is telehealth? Why should you care?

Telehealth is simply using technology, such as computers and mobile devices, to manage your health and well-being. Telehealth, also called e-health or m-health (mobile health), includes a variety of health care services, including but not limited to:
Online support groups
Online health information and self-management tools
Email and online communication with health care providers
Electronic health records
Remote monitoring of vital signs
Video or online doctor visits

Consider how people with diabetes could use telehealth to manage their health — all without having to leave home:
Use a mobile phone or other device to upload food logs, medications, dosing, and blood sugar levels for review by a nurse who responds electronically.
Watch a how-to video on carbohydrate counting and download an application (app) for it to your mobile phone.
Use the same app to estimate, based on your diet and exercise level, how much insulin you need.
Send an email or text message to a nurse or diabetes educator when you have questions.
Order testing supplies and medications online.
Research the pros and cons of alternate treatments, such as insulin pumps.
Get email, text or phone reminders when you need a flu shot, foot exam or other preventive care.

Does that pique your interest? If so, check out the following ways technology can help you better manage your health.
E-visits

An e-visit is a doctor's appointment you do online instead of in person. You type in your question or problem, usually through a progression of questions. Your message is sent to your health care provider, who reviews it and sends a response. You may receive a prescription for medication, a recommendation for a follow-up appointment or other advice. Your messages are secure — meaning no one else can see or read them. Visits can also take place in real time via videoconference.

E-visits can save you — and your doctor — time compared with office visits. They can be especially helpful for people in rural areas or those who don't have access to transportation.
Personal health records

A personal health record is simply a collection of information about your health that you control and maintain. If you have a shot record or a box of medical papers, you already have a basic personal health record. And you've probably encountered the big drawback of paper records: You rarely have them with you when you need them.

Electronic personal health record systems — often called PHR systems — remedy that problem by making your personal health record accessible to you anytime via a Web-enabled device, such as your computer, phone or PDA.

Having a personal health record can be a lifesaver, literally. In an emergency, you can quickly give emergency personnel vital information, such as a disease you're being treated for, medications you take, drugs you're allergic to, and how to contact your family doctor.
Personal health apps

Websites and digital apps can be used for more than making dinner reservations. A multitude of products have been created to help consumers better organize their medical information, and that of their family members, in one secure, online space. These digital tools allow you to store health records, upload information from devices such as a blood glucose monitor or blood pressure cuff, and share information with your health care providers. Some even offer personalized reminders and recommendations.

A number of future-thinking companies provide their employees with access to a portal — or suite — of health care apps as a workplace benefit. These websites allow employees to complete health assessments, get medical advice, find a plan-approved health care provider, and get advice and information on staying healthy. Some companies are even experimenting with e-visits so that employees can "see" the doctor without having to take time away from work.
Home health monitoring

Do you check your blood pressure at home? How do you get your results to your doctor? Home health monitoring makes that easy. Devices such as blood pressure monitors can be connected to the Internet or to video equipment that allows real-time, face-to-face interaction with health care providers. Home health monitoring can be particularly useful for people with chronic diseases, such as heart disease, as well as those who live in rural or remote areas. The benefits are greater convenience, fewer office visits, and easier access to medical care and advice.

Even more exciting is the advent of wearable monitoring systems. These devices are connected through wired or wireless networks to a clinic or monitoring center. These devices can assess sounds, images, body motion, and vital signs such as blood pressure, body temperature, heart rate and pulse, body weight, and blood oxygenation. Devices can also monitor sleep patterns and physical activity.

"Smart homes" take home monitoring one step further. A smart home is equipped with sensors and automated devices designed for remote monitoring, early detection of problems or emergencies, and promotion of safety and quality of life. Such a home might include a sensor system that assesses vital signs and activity and provides security monitoring and response. Smart homes and wearable monitoring devices offer the potential of enabling older adults to live independently, if they prefer, rather than in assisted living facilities.
Doctors talking to doctors

Doctors can also take advantage of technology to provide better care to their patients. One example is virtual consultations that allow primary care doctors to get input from specialists when they have questions about a particular diagnosis or treatment. The primary care doctor sends test results, X-rays or other images to the specialist to review. The specialist can respond electronically or request a face-to-face meeting if needed. In some cases, the specialist may even "see" the patient via video.
The potential of telehealth

While technology undoubtedly has a cool factor, it isn't just fun and games. Technology has the potential to improve the quality of health care and to make it accessible to more people. Indeed, the U.S. Department of Health and Human Services has included greater use of technology as one of its "Healthy People 2020" objectives for improving the health of all Americans. Isn't it time to make telehealth work for you?

Fat Cats, Dogs Developing Diabetes, Report Finds Illness jumped 32 percent in dogs in just five years

Fat Cats, Dogs Developing Diabetes, Report Finds
Illness jumped 32 percent in dogs in just five years

(Healthline News) -- Like all good pet owners, Christine Wong didn't hesitate to go to a veterinary clinic near her home in Austin, Texas, when her cat, Kiki, wasn't feeling well.

"She just wasn't acting like herself," recalled Wong.

After running a blood and urine test, the doctor discovered the Persian-mix feline has diabetes.

Diabetes is on the rise as America's cats and dogs grow fatter, according to a new report by Banfield Pet Hospital, a national chain of pet hospitals headquartered in Portland, Ore. Since 2006, diabetes jumped 32 percent in dogs and 16 percent in cats, says the report, which analyzed trends in common and preventable illnesses from the past five years.

Just as in people, diabetes is often linked to obesity and may require lifelong monitoring and treatment.

"The most important thing we can do for a cat with diabetes is getting it on a weight loss program," said Dr. Denise Elliott, a veterinarian with Banfield.

"We know that if we can get the weight off in conjunction with insulin injections, in many cases we can resolve the cat's diabetes," she added.

Fat cats are six times more likely to develop diabetes than their thinner feline cousins, Elliott said.

For the report, researchers crunched data from the records of 2.5 million dogs and cats cared for last year in its 770 hospitals nationwide.

Symptoms of diabetes in both dogs and cats may include excessive urination, increased thirst and weight loss, despite a hearty appetite. If not detected and treated early, dogs in advanced stages of the disease might develop cataracts and cats may experience hind-limb weakness, Elliott said.

There are two types of diabetes mellitus. Dogs often get type 1 (insulin-dependent), which is similar to the form seen in children, in which the pancreas produces little or no insulin, a hormone that helps cells turn sugar into energy. Breeds prone to the condition are bichon frise, cairn terrier, dachshund, keeshond, miniature poodle and puli.

Cats are commonly affected by type 2 diabetes, or non-insulin dependent, in which the pancreas produces insulin but the body does not respond normally to it. At-risk breeds include Maine coon, Russian blue and Siamese.

For dogs with diabetes, it's usually a lifelong battle. Along with a special diet, they typically need insulin injections twice a day, veterinarians say. Once clinical signs resolve, blood glucose concentrations are monitored every three to four months to determine if changes to the treatment plan are necessary.

But the outlook for dogs is good. "Typically dogs that are treated properly for diabetes go on to live a long, full life," said Dr. Charles Wiedmeyer, assistant professor of veterinary clinical pathology at the University of Missouri in Columbia.

Wiedmeyer and colleague Dr. Amy DeClue, assistant professor of veterinary internal medicine, recently adapted a device used to monitor glucose in humans to help dogs with diabetes that don't respond well to conventional treatment. Continuous glucose monitors (CGM) are flexible devices inserted an inch or so into the skin to provide detailed information on sugar levels.

Using a CGM, a dog's blood sugar levels can be monitored at home in everyday situations rather than in a cage at the animal hospital, they say. Normally, veterinarians create an insulin regimen by taking blood from the animal in the clinic every two hours over the course of a single day. But test results are often inaccurate, he said, because of stress felt by pets from being in an unfamiliar environment.

Adapting to the needs of a diabetic pet isn't easy. When Kiki, Wong's cat, was diagnosed three years ago with diabetes, the toughest part was getting used to giving the insulin shots, Wong said.

Now it's a breeze, she noted. Kiki receives insulin injections every 12 hours -- before Wong leaves for work and when she returns home -- plus occasional check-ups and a modified diet.

It costs Wong about $65 a month to manage her pet's disease. But she doesn't mind the added cost or extra time spent in caring for Kiki.

"In the end, she and I are definitely closer for all of it," said Wong. "She lives well and seems healthy and happy these days, far from the end. And this makes it all worth it."

SOURCES: Charles Wiedmeyer, D.V.M., assistant professor of veterinary clinical pathology, University of Missouri, Columbia; Christine Wong, Austin, Texas; Denise Elliott, D.V.M., veterinarian, Banfield Pet Hospital; 2011 State of Pet Health Report, Banfield Pet Hospital

Tips to Maintain Good Posture

Tips to Maintain Good Posture

We often hear that good posture is essential for good health. We recognize poor posture when we see it formed as a result of bad habits carried out over years and evident in many adults. But only few people have a real grasp of the importance and necessity of good posture.

Why is good posture important?
Good posture helps us stand, walk, sit, and lie in positions that place the least strain on supporting muscles and ligaments during movement and weight-bearing activities. Correct posture:

• Helps us keep bones and joints in correct alignment so that our muscles are used correctly, decreasing the abnormal wearing of joint surfaces that could result in degenerative arthritis and joint pain.
• Reduces the stress on the ligaments holding the spinal joints together, minimizing the likelihood of injury.
• Allows muscles to work more efficiently, allowing the body to use less energy and, therefore, preventing muscle fatigue.
• Helps prevent muscle strain, overuse disorders, and even back and muscular pain.

Several factors contribute to poor posture-most commonly, stress, obesity, pregnancy, weak postural muscles, abnormally tight muscles, and high-heeled shoes. In addition, decreased flexibility, a poor work environment, incorrect working posture, and unhealthy sitting and standing habits can also contribute to poor body positioning.

How do I sit properly?

• Keep your feet on the floor or on a footrest, if they don't reach the floor.
• Don't cross your legs. Your ankles should be in front of your knees.
• Keep a small gap between the back of your knees and the front of your seat.
• Your knees should be at or below the level of your hips.
• Adjust the backrest of your chair to support your low- and mid-back or use a back support.
• Relax your shoulders and keep your forearms parallel to the ground.
• Avoid sitting in the same position for long periods of time.

How do I stand properly?

• Bear your weight primarily on the balls of your feet.
• Keep your knees slightly bent.
• Keep your feet about shoulder-width apart.
• Let your arms hang naturally down the sides of the body.
• Stand straight and tall with your shoulders pulled backward.
• Tuck your stomach in.
• Keep your head level-your earlobes should be in line with your shoulders. Do not push your head forward, backward, or to the side.
• Shift your weight from your toes to your heels, or one foot to the other, if you have to stand for a long time.

What is the proper lying position?

• Find the mattress that is right for you. While a firm mattress is generally recommended, some people find that softer mattresses reduce their back pain. Your comfort is important.
• Sleep with a pillow. Special pillows are available to help with postural problems resulting from a poor sleeping position.
• Avoid sleeping on your stomach.
• Sleeping on your side or back is more often helpful for back pain.
• If you sleep on your side, place a pillow between your legs.
• If you sleep on your back, keep a pillow under your knees.

Your doctor of chiropractic can assist you with proper posture, including recommending exercises to strengthen your core postural muscles. He or she can also assist you with choosing proper postures during your activities, helping reduce your risk of injury.

Tips to Maintain Good Posture

Tips to Maintain Good Posture

We often hear that good posture is essential for good health. We recognize poor posture when we see it formed as a result of bad habits carried out over years and evident in many adults. But only few people have a real grasp of the importance and necessity of good posture.

Why is good posture important?
Good posture helps us stand, walk, sit, and lie in positions that place the least strain on supporting muscles and ligaments during movement and weight-bearing activities. Correct posture:

• Helps us keep bones and joints in correct alignment so that our muscles are used correctly, decreasing the abnormal wearing of joint surfaces that could result in degenerative arthritis and joint pain.
• Reduces the stress on the ligaments holding the spinal joints together, minimizing the likelihood of injury.
• Allows muscles to work more efficiently, allowing the body to use less energy and, therefore, preventing muscle fatigue.
• Helps prevent muscle strain, overuse disorders, and even back and muscular pain.

Several factors contribute to poor posture-most commonly, stress, obesity, pregnancy, weak postural muscles, abnormally tight muscles, and high-heeled shoes. In addition, decreased flexibility, a poor work environment, incorrect working posture, and unhealthy sitting and standing habits can also contribute to poor body positioning.

How do I sit properly?

• Keep your feet on the floor or on a footrest, if they don't reach the floor.
• Don't cross your legs. Your ankles should be in front of your knees.
• Keep a small gap between the back of your knees and the front of your seat.
• Your knees should be at or below the level of your hips.
• Adjust the backrest of your chair to support your low- and mid-back or use a back support.
• Relax your shoulders and keep your forearms parallel to the ground.
• Avoid sitting in the same position for long periods of time.

How do I stand properly?

• Bear your weight primarily on the balls of your feet.
• Keep your knees slightly bent.
• Keep your feet about shoulder-width apart.
• Let your arms hang naturally down the sides of the body.
• Stand straight and tall with your shoulders pulled backward.
• Tuck your stomach in.
• Keep your head level-your earlobes should be in line with your shoulders. Do not push your head forward, backward, or to the side.
• Shift your weight from your toes to your heels, or one foot to the other, if you have to stand for a long time.

What is the proper lying position?

• Find the mattress that is right for you. While a firm mattress is generally recommended, some people find that softer mattresses reduce their back pain. Your comfort is important.

• Sleep with a pillow. Special pillows are available to help with postural problems resulting from a poor sleeping position.

• Avoid sleeping on your stomach.

• Sleeping on your side or back is more often helpful for back pain.

• If you sleep on your side, place a pillow between your legs.

• If you sleep on your back, keep a pillow under your knees.

Your doctor of chiropractic can assist you with proper posture, including recommending exercises to strengthen your core postural muscles. He or she can also assist you with choosing proper postures during your activities, helping reduce your risk of injury.