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Moose Offer Trail of Clues on Arthritis
By PAM BELLUCK, The New York Times, August 16, 2010
In the 100 years since the first moose swam into Lake Superior and set up shop on an island, they have mostly minded their moosely business, munching balsam fir and trying to evade hungry gray wolves.
But now the moose of Isle Royale have something to say — well, their bones do. Many of the moose, it turns out, have arthritis. And scientists believe their condition’s origin can help explain human osteoarthritis — by far the most common type of arthritis, affecting one of every seven adults 25 and older and becoming increasingly prevalent.
The arthritic Bullwinkles got that way because of poor nutrition early in life, an extraordinary 50-year research project has discovered. That could mean, scientists say, that some people’s arthritis can be linked in part to nutritional deficits, in the womb and possibly throughout childhood.
The moose conclusion bolsters a small but growing body of research connecting early development to chronic conditions like osteoarthritis, which currently affects 27 million Americans, up from 21 million in 1990.
Osteoarthritis’s exact cause remains unknown, but it is generally thought to stem from aging and wear and tear on joints, exacerbated for some by genes. Overweight or obese people have greater arthritis risk, usually attributed to the load their joints carry, and the number of cases is increasing as people live longer and weigh more.
But the moose work, along with some human research, suggests arthritis’s origins are more complex, probably influenced by early exposures to nutrients and other factors while our bodies are developing. Even obesity’s link to arthritis probably goes beyond extra pounds, experts say, to include the impact on the body of eating the wrong things.
Nutrients, experts say, might influence composition or shape of bones, joints or cartilage. Nutrition might also affect hormones, the likelihood of later inflammation or oxidative stress, even how a genetic predisposition for arthritis is expressed or suppressed.
“It makes perfect sense,” said Dr. Joanne Jordan, director of the Thurston Arthritis Research Center at the University of North Carolina. “Osteoarthritis starts way before the person knows it, way before their knee hurts or their hand hurts. It’s very clear that we’re going to have to start looking back” at “things in the early life course.”
Such research could lead to nutritional steps people can take to protect against osteoarthritis, a condition that is often painful or debilitating, and according to federal data, costs billions of dollars annually in knee and hip replacements alone.
“It would be helpful to know if we want to make sure pregnant moms are taking certain vitamins or if you need to supplement with such and such nutrition,” said Dr. David Felson, an arthritis expert at Boston University School of Medicine. “The moose guy is right in that we probably should study weight or some other nutritional factor almost through adolescence when the bones or joints have stopped forming.”
The “moose guy” is Rolf Peterson, a Michigan Technological University scientist on the Isle Royale project, which began in 1958 and is reportedly the longest-running predator-prey study.
For half the year, Dr. Peterson and his colleagues are the only humans allowed on the 45-mile-long island, part of a national park. They stay in yurts, a log cabin or a wood-stove-heated lodge, navigate the wilderness without roads or cars, and share a single staticky phone line. They analyze everything from wolves’ moose-hunting strategies to moose feces. Collecting bones of more than 4,000 moose, they noticed that out of 1,200 carcasses they analyzed, more than half had arthritis, virtually identical to the human kind. It usually attacked the hip and instantly made the moose vulnerable.
“Arthritis is a death sentence around here — you need all four legs,” Dr. Peterson said. “Wolves pick them off so quickly that you don’t even see them limping.”
What is more, the arthritic moose were often small, measured by the length of the metatarsal bone in the foot. Small metatarsals indicate poor early nutrition, and scientists determined that the arthritic moose were born during times when food was scarce, so their mothers could not produce enough milk.
Dr. Peterson said if the arthritis were caused by excess wear and tear on the moose’s joints, that would have meant that times of food scarcity occurred when the moose were already grown, since the extra wear would have happened to moose walking farther to find edible plants. But the arthritic moose had had plentiful food as adults.
For people, several historical cases may suggest a nutritional link. Bones of 16th-century American Indians in Florida and Georgia showed significant increases in osteoarthritis after Spanish missionaries arrived and tribes adopted farming, increasing their workload but also shifting their diet from fish and wild plants to corn, which “lacks a couple of essential amino acids and is iron deficient,” said Clark Larsen, an Ohio State University anthropologist collaborating with Dr. Peterson. Many children and young adults were smaller and died earlier, Dr. Larsen said, and similar patterns occurred when an earlier American Indian population in the Midwest began farming maize.
British scientists studying people born in the 1940s found low birth weight (indicating poor prenatal nutrition) linked to osteoarthritis in the men’s hands, Dr. Felson said. And Dr. David Barker, a British expert on how nutrition and early development influence cardiac and other conditions, said “studies of people in utero during the Great Chinese Famine” of the late 1950s found that “40, 50 years later, those people have got disabilities.”
Overeating can be as problematic as undereating. Dr. Lisa A. Fortier, a large-animal orthopedist at Cornell University’s College of Veterinary Medicine, said she saw “abnormal joint and tendon development from excessive nutrition” in horses overfed “in utero or in the postnatal life,” probably ingesting “too much of the wrong type of sugar that may cause levels of inflammation.”
Dr. Peter Bales, an orthopedic surgeon affiliated with University of California, Davis, Medical Center, who has written about nutrition and arthritis, sees similar problems in overweight patients. He said the causes were not as “simplistic” as “carrying more weight around,” but might involve nutritional imbalances that could hurt joints and erode cartilage. Much is unknown about nutrition’s relevance. Isle Royale moose, for example, also seem to have genetic predispositions for arthritis, suggesting that nutrition might be amplifying or jump-starting the genes.
“Genes are not Stalinist dictators,” said Dr. Barker, now at Oregon Health and Science University. “What they do, how they’re expressed, is conditional on the rest of the body. The human being is a product of a general recipe, and the specific nutrients you get or don’t get.”
Studying nutrition in people is much more complicated than in moose. Dr. Peterson said the early moosehood developmental window occurred in utero through 28 months, but humans’ developmental time frame lasted into the teens. Some experts say prenatal nutrition is most critical; others see roles for nutrients after birth and beyond.
“Up until the growth plates close, which is through adolescence and even early adulthood, the effects of nutrition are magnified,” said Dr. Constance R. Chu, director of the Cartilage Restoration Center at the University of Pittsburgh, who said nutrients might affect the number of healthy cells in cartilage and its thickness. “But in my opinion, it’s relevant throughout life.”
Vaccination Is Steady, but Pertussis Is Surging
By TARA PARKER-POPE, The New York Times, AUGUST 16, 2010
For four weeks, my 11-year-old daughter has been coughing. It is not your run-of-the-mill summer cold, but a violent, debilitating cough that takes over her body, usually at night.
During these fits, her face turns red, and tears start streaming from her eyes. She coughs so hard she eventually starts to gasp for air, making a horrifying sucking sound that at one point had me reaching for the phone to call 911. But eventually she catches her breath. Several times she has coughed so hard she begins to throw up.
It took a few visits to the pediatrician before she finally got a diagnosis: pertussis, the bacterial disease better known as whooping cough.
That may sound surprising, since like most other children she was vaccinated against the disease on schedule, as an infant and again in preschool. But in recent years, pertussis has made an alarming comeback — even among adolescents and adults who were vaccinated as children.
Highly contagious, spread by coughs and sneezes, pertussis is now epidemic in California, with 2,774 confirmed cases in 2010 — a sevenfold increase from last year, putting the state on track for the worst outbreak in 50 years. Seven infants have died.
This month the Pennsylvania Department of Health issued an alert to physicians, and a top health official noted an unusually high rate of pertussis among 8-to-12-year-olds in the Philadelphia suburbs — including, incidentally, the county where I live. Outbreaks have also been reported in upstate New York, South Carolina and Michigan.
No one knows exactly why this is happening. In the 1920s and ’30s, pertussis was a feared childhood killer, with an annual toll as high as 250,000 cases and 9,000 deaths, according to the Centers for Disease Control and Prevention. In the 1940s, health authorities introduced a combined vaccine against diphtheria, pertussis and tetanus (often called D.P.T. or DTaP), and by 1976 pertussis was virtually eliminated, with just 1,010 reported cases.
But since the 1980s it has been rising, albeit in cycles, despite the introduction of new vaccines with far fewer side effects and a C.D.C. recommendation for adolescents and adults to get a booster.
In 2008 there were 13,000 cases, and health authorities say the actual figure may be far higher — 800,000 to 3.3 million a year — because reported cases reflect only those confirmed by testing, and many adult and adolescent cases go undiagnosed.
There are several explanations for the rise in pertussis, but the most likely is waning immunity after vaccination. “Immunity wears off, especially for adults who are decades past their most recent vaccination,” said Dr. Tom Clark, an epidemiologist with the C.D.C.
Moreover, adults and adolescents often wait weeks before seeking treatment for a chronic cough — and even then, doctors may not recognize it as pertussis.
“You only begin to think about pertussis when it’s been going on for weeks and weeks,” Dr. Clark said, “and then treatment is much less likely to make a difference, and you’ve spread it to other people.”
Another factor may be the declining use of antibiotics to treat simple coughs and colds. While doctors legitimately worry that indiscriminate use of antibiotics can lead to the development of drug-resistant bacteria, it may be that in the past the drugs inadvertently cured many cases of undiagnosed pertussis.
The rise in pertussis doesn’t seem to be related to parents’ refusing to have their children vaccinated for fear of potential side effects. In California, pertussis rates are about the same in counties with high childhood vaccination rates and low ones. And the C.D.C. reports that pertussis immunization rates have been stable or increasing since 1992.
Efforts are under way to raise awareness of pertussis and encourage booster vaccinations of older children, teens and adults. The March of Dimes and the vaccine maker Sanofi-Aventis are sponsoring public-service announcements, and Web sites like whoopingcough.net offer audio and video of adults and children with pertussis. Some health departments and hospitals, including those in California and Pennsylvania, are offering free vaccines to mothers of infants.
Dr. Stephen Ostroff, Pennsylvania’s acting physician general, said his office issued a health alert to doctors this month after seeing higher than usual pockets of pertussis in several counties.
“Once the kids come back to school,” he said, “all it takes is for one kid to bring it into the school and you have this endless chain of transmission that is hard to stop.” The bacteria may incubate as long as three weeks after contact with someone who has pertussis.
For the first one to two weeks of illness, the symptoms are mild. But during the second phase, which can last one to six weeks, there can be severe fits of coughing, and some but not all patients will develop the characteristic whooping or gasping.
Testing to confirm pertussis can be chancy. A culture of nasal secretions may be ordered, but results can take up to two weeks. A rapid PCR test, which involves a cheek swab to look for the germ’s genetic material, can produce results in a few days, but not every lab performs the test. Both tests are typically reliable only in the earliest days of illness, before antibiotics are given. And a lack of knowledge about which test to order, and technicians’ inexperience in taking swabs, can result in a false negative diagnosis.
“These are relatively new lab tests, and we need to do a better job of educating physicians about what diagnostic tests are available,” said Dr. Neil Fishman, an infectious disease specialist at the University of Pennsylvania.
Alarmingly, pertussis is sometimes referred to as “the 100-day cough.” Often most of the damage is done before it is even diagnosed, because the bacteria release toxins that inflame the lining of the lungs. Recovery can be long and difficult, even after antibiotic treatment. (Doctors say my daughter may be coughing for weeks, although she’s no longer contagious and can start school next month.)
“It takes a long time for that healing process to occur,” says Dr. Ostroff. “Think of it like a tornado going through your neighborhood. The tornado may go through relatively quickly, but it takes a long time to clean up the damage. That’s true of this infection as well.”
Old Maxim of Fertility and Stress Is Reversed
By RONI CARYN RABIN, The New York Times, August 16, 2010
Even as more and more fertility clinics adopt stress-management programs like yoga, cognitive therapy and biofeedback, the role of stress in infertility remains a matter of debate. Some experts still recite an old maxim: while infertility undoubtedly causes stress, stress does not cause infertility.
Now researchers suggest that the two conditions may indeed be linked.
In a study published online in the journal Fertility and Sterility, the scientists reported that women who stopped using contraceptives took longer to become pregnant if they had high saliva levels of the enzyme alpha-amylase — a biological indicator of stress.
The authors say this is the first study to link a biomarker for stress with delayed conception in normal, healthy women, and they suggest that finding ways to reduce or manage stress may be a low-tech solution for some infertile couples.
“Even when couples just start trying to conceive, people are really stressed out,” said the study’s lead author, Germaine Buck Louis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
“There’s an expectation — they want to have their family now,” Dr. Buck Louis said. “Stress is the one most consistent factor that shows an effect on how long it take to get pregnant, of all the lifestyle factors studied to date.”
Repeated failures to conceive month after month could potentially set off a vicious cycle in which it becomes ever more difficult to become pregnant, she said.
The study tracked 274 British women ages 18 to 40 who had just started trying to conceive, following them for six months or until they became pregnant.
The volunteers were given at-home fertility test kits to track their monthly cycles, and on the sixth day collected saliva samples that were tested for the stress hormone cortisol and for alpha-amylase, which is secreted when the nervous system produces catecholamines, which initiate another stress response.
Although there was no adverse effect apparent from high cortisol levels, women with the highest concentrations of alpha-amylase were 12 percent less likely to become pregnant each month than those with the lowest levels.
“This is one more piece of the puzzle that’s adding up to the same conclusion: that stress is not necessarily a good thing for our reproductive system,” said Alice Domar, executive director of the Domar Center for Mind/Body Health at the fertility center Boston IVF, who was not involved in the research.
The surprising finding was that even low levels of stress can have an impact on conception, said Dr. Sarah Berga, head of obstetrics and gynecology at Emory University, who has studied the effect of stress management on women who are not ovulating.
“This shows that even low levels of stress play a role,” she said. “You don’t have to get stressed out to the point of losing your period, apparently, to have an impact on your fertility.”
Curiously, the odds of conceiving were higher for women who had elevated concentrations of cortisol during the fertile period. Cortisol is secreted when the endocrine system responds to stress; alpha-amylase is part of the “fight or flight” response, usually activated by the sympathetic nervous system in response to acute stresses.
Women who have been treated for infertility say the process can be highly stressful — in fact, all-consuming. Amy Cafazzo, 38, of Framingham, Mass., said stress-reduction classes at Boston IVF taught her coping skills she uses to this day — now to cope with her active 19-month-old twin boys.
“When you’re going through this, people often say, ‘Relax, it’ll happen,’ and you just want to smack them,” Mrs. Cafazzo said. “You can’t just relax.”
The classes taught breathing techniques, yoga and other relaxation strategies and provided her with a support network of women going through the same experience. Did it actually help her conceive?
“I just don’t know,” she said. “But I’m a Type A personality that needs an actionable plan, and this gives you something to do, so you feel productive and aren’t caught in a downward spiral of stress.”
Steep Drop Seen in Circumcisions in U.S.
By RONI CARYN RABIN, The New York Times, August 16, 2010
Despite a worldwide campaign for circumcision to slow the spread of AIDS, the rate of circumcision among American baby boys appears to be declining.
A little-noted presentation by a federal health researcher last month at the International AIDS Conference in Vienna suggested that the rate had fallen precipitously — to fewer than half of all boys born in conventional hospitals from 2006 to 2009, from about two-thirds through the 1980s and ’90s.
Last week, officials at the Centers for Disease Control and Prevention cautioned that the figures in the presentation were not definitive. But they are already stirring a sharp debate on the Internet.
The numbers were presented to the AIDS conference by a C.D.C. researcher, Charbel E. El Bcheraoui. The presentation was not covered by any mainstream news outlets, but a report by the news service Elsevier Global Medical News, along with a photograph of a slide from the presentation, quickly made the rounds of the blogosphere.
The slide portrays a precipitous drop in circumcision, to just 32.5 percent in 2009 from 56 percent in 2006. The numbers are based on calculations by SDI Health, a company in Plymouth Meeting, Pa., that analyzes health care data; they do not include procedures outside hospitals (like most Jewish ritual circumcisions) or not reimbursed by insurance.
Andrew Kress, the chief executive of SDI Health, cautioned that the data had not yet been published and was still being analyzed, but he confirmed that the trend had been toward fewer circumcisions each year.
He added that measuring the circumcision rate was not the purpose of the study, which was designed to measure the rate of complications from the procedure.
Opponents of circumcision hailed the trend as a victory of common sense over what they call culturally accepted genital mutilation. For federal health officials, who have been debating whether to recommend circumcision to stem the spread of AIDS, the news suggests an uphill battle that could be more difficult than expected.
C.D.C. officials last week declined requests for interviews about the study, but a spokeswoman, Elizabeth-Ann Chandler, answered questions by e-mail. She reiterated that the agency used the SDI figures to calculate the rate of complications, not of circumcisions.
“C.D.C. was not involved in the collection of the data that was cited, nor has C.D.C. undertaken any review of this particular data for the purpose of calculating rates,” she wrote. “As such, we cannot comment on the accuracy of this particular estimate of infant male circumcision.”
But she did not dispute the waning popularity of circumcision. “What we can tell you is that male infant circumcision rates have declined somewhat in this decade,” she wrote.
The study found a very low rate of complications associated with newborn circumcisions; most were considered mild and no babies died.
Organizations opposed to circumcision said parents may be responding to the message their groups have been spreading through their Web sites and a video distributed to childbirth educators.
“Word has gotten out that it’s not necessary, it’s harmful and it’s painful,” said Georganne Chapin, executive director of Intact America, a nonprofit organization based in Tarrytown, N.Y.
Greater awareness about female circumcision may have influenced parents as well, she said, asking, “How can you think it’s O.K. to cut little boys, when you are horrified by the idea of cutting little girls?”
Both the C.D.C. and the American Academy of Pediatrics have been reviewing the scientific evidence on circumcision with an eye to issuing new policy recommendations, but so far neither body has done so, although the federal agency was to have issued its new recommendations by the end of last year.
Officials from the pediatrics academy said its new policy would be issued by early 2011; a task force that studied the topic has completed its report, which is being reviewed by several other committees, said Dr. Michael Brady, chairman of pediatrics at Nationwide Children’s Hospital in Columbus, Ohio, who served on the task force. The academy is likely to adopt a more encouraging stance than its current neutral position and to state that the procedure has health benefits beyond H.I.V. prevention, Dr. Brady said.
The World Health Organization in 2007 endorsed male circumcision as “an important intervention to reduce the risk of heterosexually acquired H.I.V.”
“No one is going to tell a parent, ‘You have to circumcise your child.’ That would be foolish,” Dr. Brady said. “The key thing physicians should be doing is providing information on both risks and benefits and allow the parent to make the best decision.”
Several state Medicaid programs stopped covering circumcision after the academy issued its current policy in 1999, and Dr. Brady said that may be one reason fewer parents opt for the procedure. Other possible reasons include a growing Hispanic population that has traditionally been disinclined to circumcision, as well the anti-circumcision movement and a broader trend among parents to spurn medical interventions like vaccination.
Some 80 percent of American men are circumcised, one of the highest rates in the developed world. Yet even advocates of circumcision acknowledge that an aggressive circumcision drive in the United States would be unlikely to have a drastic impact on H.I.V. rates here, since the procedure does not seem to protect those at greatest risk, men who have sex with men.
And while studies in Africa found that circumcision reduced the risk of a man’s becoming infected by an H.I.V.-positive female partner, it is not clear that a circumcised man with H.I.V. would be less likely to infect a woman.
By PAM BELLUCK, The New York Times, August 16, 2010
In the 100 years since the first moose swam into Lake Superior and set up shop on an island, they have mostly minded their moosely business, munching balsam fir and trying to evade hungry gray wolves.
But now the moose of Isle Royale have something to say — well, their bones do. Many of the moose, it turns out, have arthritis. And scientists believe their condition’s origin can help explain human osteoarthritis — by far the most common type of arthritis, affecting one of every seven adults 25 and older and becoming increasingly prevalent.
The arthritic Bullwinkles got that way because of poor nutrition early in life, an extraordinary 50-year research project has discovered. That could mean, scientists say, that some people’s arthritis can be linked in part to nutritional deficits, in the womb and possibly throughout childhood.
The moose conclusion bolsters a small but growing body of research connecting early development to chronic conditions like osteoarthritis, which currently affects 27 million Americans, up from 21 million in 1990.
Osteoarthritis’s exact cause remains unknown, but it is generally thought to stem from aging and wear and tear on joints, exacerbated for some by genes. Overweight or obese people have greater arthritis risk, usually attributed to the load their joints carry, and the number of cases is increasing as people live longer and weigh more.
But the moose work, along with some human research, suggests arthritis’s origins are more complex, probably influenced by early exposures to nutrients and other factors while our bodies are developing. Even obesity’s link to arthritis probably goes beyond extra pounds, experts say, to include the impact on the body of eating the wrong things.
Nutrients, experts say, might influence composition or shape of bones, joints or cartilage. Nutrition might also affect hormones, the likelihood of later inflammation or oxidative stress, even how a genetic predisposition for arthritis is expressed or suppressed.
“It makes perfect sense,” said Dr. Joanne Jordan, director of the Thurston Arthritis Research Center at the University of North Carolina. “Osteoarthritis starts way before the person knows it, way before their knee hurts or their hand hurts. It’s very clear that we’re going to have to start looking back” at “things in the early life course.”
Such research could lead to nutritional steps people can take to protect against osteoarthritis, a condition that is often painful or debilitating, and according to federal data, costs billions of dollars annually in knee and hip replacements alone.
“It would be helpful to know if we want to make sure pregnant moms are taking certain vitamins or if you need to supplement with such and such nutrition,” said Dr. David Felson, an arthritis expert at Boston University School of Medicine. “The moose guy is right in that we probably should study weight or some other nutritional factor almost through adolescence when the bones or joints have stopped forming.”
The “moose guy” is Rolf Peterson, a Michigan Technological University scientist on the Isle Royale project, which began in 1958 and is reportedly the longest-running predator-prey study.
For half the year, Dr. Peterson and his colleagues are the only humans allowed on the 45-mile-long island, part of a national park. They stay in yurts, a log cabin or a wood-stove-heated lodge, navigate the wilderness without roads or cars, and share a single staticky phone line. They analyze everything from wolves’ moose-hunting strategies to moose feces. Collecting bones of more than 4,000 moose, they noticed that out of 1,200 carcasses they analyzed, more than half had arthritis, virtually identical to the human kind. It usually attacked the hip and instantly made the moose vulnerable.
“Arthritis is a death sentence around here — you need all four legs,” Dr. Peterson said. “Wolves pick them off so quickly that you don’t even see them limping.”
What is more, the arthritic moose were often small, measured by the length of the metatarsal bone in the foot. Small metatarsals indicate poor early nutrition, and scientists determined that the arthritic moose were born during times when food was scarce, so their mothers could not produce enough milk.
Dr. Peterson said if the arthritis were caused by excess wear and tear on the moose’s joints, that would have meant that times of food scarcity occurred when the moose were already grown, since the extra wear would have happened to moose walking farther to find edible plants. But the arthritic moose had had plentiful food as adults.
For people, several historical cases may suggest a nutritional link. Bones of 16th-century American Indians in Florida and Georgia showed significant increases in osteoarthritis after Spanish missionaries arrived and tribes adopted farming, increasing their workload but also shifting their diet from fish and wild plants to corn, which “lacks a couple of essential amino acids and is iron deficient,” said Clark Larsen, an Ohio State University anthropologist collaborating with Dr. Peterson. Many children and young adults were smaller and died earlier, Dr. Larsen said, and similar patterns occurred when an earlier American Indian population in the Midwest began farming maize.
British scientists studying people born in the 1940s found low birth weight (indicating poor prenatal nutrition) linked to osteoarthritis in the men’s hands, Dr. Felson said. And Dr. David Barker, a British expert on how nutrition and early development influence cardiac and other conditions, said “studies of people in utero during the Great Chinese Famine” of the late 1950s found that “40, 50 years later, those people have got disabilities.”
Overeating can be as problematic as undereating. Dr. Lisa A. Fortier, a large-animal orthopedist at Cornell University’s College of Veterinary Medicine, said she saw “abnormal joint and tendon development from excessive nutrition” in horses overfed “in utero or in the postnatal life,” probably ingesting “too much of the wrong type of sugar that may cause levels of inflammation.”
Dr. Peter Bales, an orthopedic surgeon affiliated with University of California, Davis, Medical Center, who has written about nutrition and arthritis, sees similar problems in overweight patients. He said the causes were not as “simplistic” as “carrying more weight around,” but might involve nutritional imbalances that could hurt joints and erode cartilage. Much is unknown about nutrition’s relevance. Isle Royale moose, for example, also seem to have genetic predispositions for arthritis, suggesting that nutrition might be amplifying or jump-starting the genes.
“Genes are not Stalinist dictators,” said Dr. Barker, now at Oregon Health and Science University. “What they do, how they’re expressed, is conditional on the rest of the body. The human being is a product of a general recipe, and the specific nutrients you get or don’t get.”
Studying nutrition in people is much more complicated than in moose. Dr. Peterson said the early moosehood developmental window occurred in utero through 28 months, but humans’ developmental time frame lasted into the teens. Some experts say prenatal nutrition is most critical; others see roles for nutrients after birth and beyond.
“Up until the growth plates close, which is through adolescence and even early adulthood, the effects of nutrition are magnified,” said Dr. Constance R. Chu, director of the Cartilage Restoration Center at the University of Pittsburgh, who said nutrients might affect the number of healthy cells in cartilage and its thickness. “But in my opinion, it’s relevant throughout life.”
Vaccination Is Steady, but Pertussis Is Surging
By TARA PARKER-POPE, The New York Times, AUGUST 16, 2010
For four weeks, my 11-year-old daughter has been coughing. It is not your run-of-the-mill summer cold, but a violent, debilitating cough that takes over her body, usually at night.
During these fits, her face turns red, and tears start streaming from her eyes. She coughs so hard she eventually starts to gasp for air, making a horrifying sucking sound that at one point had me reaching for the phone to call 911. But eventually she catches her breath. Several times she has coughed so hard she begins to throw up.
It took a few visits to the pediatrician before she finally got a diagnosis: pertussis, the bacterial disease better known as whooping cough.
That may sound surprising, since like most other children she was vaccinated against the disease on schedule, as an infant and again in preschool. But in recent years, pertussis has made an alarming comeback — even among adolescents and adults who were vaccinated as children.
Highly contagious, spread by coughs and sneezes, pertussis is now epidemic in California, with 2,774 confirmed cases in 2010 — a sevenfold increase from last year, putting the state on track for the worst outbreak in 50 years. Seven infants have died.
This month the Pennsylvania Department of Health issued an alert to physicians, and a top health official noted an unusually high rate of pertussis among 8-to-12-year-olds in the Philadelphia suburbs — including, incidentally, the county where I live. Outbreaks have also been reported in upstate New York, South Carolina and Michigan.
No one knows exactly why this is happening. In the 1920s and ’30s, pertussis was a feared childhood killer, with an annual toll as high as 250,000 cases and 9,000 deaths, according to the Centers for Disease Control and Prevention. In the 1940s, health authorities introduced a combined vaccine against diphtheria, pertussis and tetanus (often called D.P.T. or DTaP), and by 1976 pertussis was virtually eliminated, with just 1,010 reported cases.
But since the 1980s it has been rising, albeit in cycles, despite the introduction of new vaccines with far fewer side effects and a C.D.C. recommendation for adolescents and adults to get a booster.
In 2008 there were 13,000 cases, and health authorities say the actual figure may be far higher — 800,000 to 3.3 million a year — because reported cases reflect only those confirmed by testing, and many adult and adolescent cases go undiagnosed.
There are several explanations for the rise in pertussis, but the most likely is waning immunity after vaccination. “Immunity wears off, especially for adults who are decades past their most recent vaccination,” said Dr. Tom Clark, an epidemiologist with the C.D.C.
Moreover, adults and adolescents often wait weeks before seeking treatment for a chronic cough — and even then, doctors may not recognize it as pertussis.
“You only begin to think about pertussis when it’s been going on for weeks and weeks,” Dr. Clark said, “and then treatment is much less likely to make a difference, and you’ve spread it to other people.”
Another factor may be the declining use of antibiotics to treat simple coughs and colds. While doctors legitimately worry that indiscriminate use of antibiotics can lead to the development of drug-resistant bacteria, it may be that in the past the drugs inadvertently cured many cases of undiagnosed pertussis.
The rise in pertussis doesn’t seem to be related to parents’ refusing to have their children vaccinated for fear of potential side effects. In California, pertussis rates are about the same in counties with high childhood vaccination rates and low ones. And the C.D.C. reports that pertussis immunization rates have been stable or increasing since 1992.
Efforts are under way to raise awareness of pertussis and encourage booster vaccinations of older children, teens and adults. The March of Dimes and the vaccine maker Sanofi-Aventis are sponsoring public-service announcements, and Web sites like whoopingcough.net offer audio and video of adults and children with pertussis. Some health departments and hospitals, including those in California and Pennsylvania, are offering free vaccines to mothers of infants.
Dr. Stephen Ostroff, Pennsylvania’s acting physician general, said his office issued a health alert to doctors this month after seeing higher than usual pockets of pertussis in several counties.
“Once the kids come back to school,” he said, “all it takes is for one kid to bring it into the school and you have this endless chain of transmission that is hard to stop.” The bacteria may incubate as long as three weeks after contact with someone who has pertussis.
For the first one to two weeks of illness, the symptoms are mild. But during the second phase, which can last one to six weeks, there can be severe fits of coughing, and some but not all patients will develop the characteristic whooping or gasping.
Testing to confirm pertussis can be chancy. A culture of nasal secretions may be ordered, but results can take up to two weeks. A rapid PCR test, which involves a cheek swab to look for the germ’s genetic material, can produce results in a few days, but not every lab performs the test. Both tests are typically reliable only in the earliest days of illness, before antibiotics are given. And a lack of knowledge about which test to order, and technicians’ inexperience in taking swabs, can result in a false negative diagnosis.
“These are relatively new lab tests, and we need to do a better job of educating physicians about what diagnostic tests are available,” said Dr. Neil Fishman, an infectious disease specialist at the University of Pennsylvania.
Alarmingly, pertussis is sometimes referred to as “the 100-day cough.” Often most of the damage is done before it is even diagnosed, because the bacteria release toxins that inflame the lining of the lungs. Recovery can be long and difficult, even after antibiotic treatment. (Doctors say my daughter may be coughing for weeks, although she’s no longer contagious and can start school next month.)
“It takes a long time for that healing process to occur,” says Dr. Ostroff. “Think of it like a tornado going through your neighborhood. The tornado may go through relatively quickly, but it takes a long time to clean up the damage. That’s true of this infection as well.”
Old Maxim of Fertility and Stress Is Reversed
By RONI CARYN RABIN, The New York Times, August 16, 2010
Even as more and more fertility clinics adopt stress-management programs like yoga, cognitive therapy and biofeedback, the role of stress in infertility remains a matter of debate. Some experts still recite an old maxim: while infertility undoubtedly causes stress, stress does not cause infertility.
Now researchers suggest that the two conditions may indeed be linked.
In a study published online in the journal Fertility and Sterility, the scientists reported that women who stopped using contraceptives took longer to become pregnant if they had high saliva levels of the enzyme alpha-amylase — a biological indicator of stress.
The authors say this is the first study to link a biomarker for stress with delayed conception in normal, healthy women, and they suggest that finding ways to reduce or manage stress may be a low-tech solution for some infertile couples.
“Even when couples just start trying to conceive, people are really stressed out,” said the study’s lead author, Germaine Buck Louis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
“There’s an expectation — they want to have their family now,” Dr. Buck Louis said. “Stress is the one most consistent factor that shows an effect on how long it take to get pregnant, of all the lifestyle factors studied to date.”
Repeated failures to conceive month after month could potentially set off a vicious cycle in which it becomes ever more difficult to become pregnant, she said.
The study tracked 274 British women ages 18 to 40 who had just started trying to conceive, following them for six months or until they became pregnant.
The volunteers were given at-home fertility test kits to track their monthly cycles, and on the sixth day collected saliva samples that were tested for the stress hormone cortisol and for alpha-amylase, which is secreted when the nervous system produces catecholamines, which initiate another stress response.
Although there was no adverse effect apparent from high cortisol levels, women with the highest concentrations of alpha-amylase were 12 percent less likely to become pregnant each month than those with the lowest levels.
“This is one more piece of the puzzle that’s adding up to the same conclusion: that stress is not necessarily a good thing for our reproductive system,” said Alice Domar, executive director of the Domar Center for Mind/Body Health at the fertility center Boston IVF, who was not involved in the research.
The surprising finding was that even low levels of stress can have an impact on conception, said Dr. Sarah Berga, head of obstetrics and gynecology at Emory University, who has studied the effect of stress management on women who are not ovulating.
“This shows that even low levels of stress play a role,” she said. “You don’t have to get stressed out to the point of losing your period, apparently, to have an impact on your fertility.”
Curiously, the odds of conceiving were higher for women who had elevated concentrations of cortisol during the fertile period. Cortisol is secreted when the endocrine system responds to stress; alpha-amylase is part of the “fight or flight” response, usually activated by the sympathetic nervous system in response to acute stresses.
Women who have been treated for infertility say the process can be highly stressful — in fact, all-consuming. Amy Cafazzo, 38, of Framingham, Mass., said stress-reduction classes at Boston IVF taught her coping skills she uses to this day — now to cope with her active 19-month-old twin boys.
“When you’re going through this, people often say, ‘Relax, it’ll happen,’ and you just want to smack them,” Mrs. Cafazzo said. “You can’t just relax.”
The classes taught breathing techniques, yoga and other relaxation strategies and provided her with a support network of women going through the same experience. Did it actually help her conceive?
“I just don’t know,” she said. “But I’m a Type A personality that needs an actionable plan, and this gives you something to do, so you feel productive and aren’t caught in a downward spiral of stress.”
Steep Drop Seen in Circumcisions in U.S.
By RONI CARYN RABIN, The New York Times, August 16, 2010
Despite a worldwide campaign for circumcision to slow the spread of AIDS, the rate of circumcision among American baby boys appears to be declining.
A little-noted presentation by a federal health researcher last month at the International AIDS Conference in Vienna suggested that the rate had fallen precipitously — to fewer than half of all boys born in conventional hospitals from 2006 to 2009, from about two-thirds through the 1980s and ’90s.
Last week, officials at the Centers for Disease Control and Prevention cautioned that the figures in the presentation were not definitive. But they are already stirring a sharp debate on the Internet.
The numbers were presented to the AIDS conference by a C.D.C. researcher, Charbel E. El Bcheraoui. The presentation was not covered by any mainstream news outlets, but a report by the news service Elsevier Global Medical News, along with a photograph of a slide from the presentation, quickly made the rounds of the blogosphere.
The slide portrays a precipitous drop in circumcision, to just 32.5 percent in 2009 from 56 percent in 2006. The numbers are based on calculations by SDI Health, a company in Plymouth Meeting, Pa., that analyzes health care data; they do not include procedures outside hospitals (like most Jewish ritual circumcisions) or not reimbursed by insurance.
Andrew Kress, the chief executive of SDI Health, cautioned that the data had not yet been published and was still being analyzed, but he confirmed that the trend had been toward fewer circumcisions each year.
He added that measuring the circumcision rate was not the purpose of the study, which was designed to measure the rate of complications from the procedure.
Opponents of circumcision hailed the trend as a victory of common sense over what they call culturally accepted genital mutilation. For federal health officials, who have been debating whether to recommend circumcision to stem the spread of AIDS, the news suggests an uphill battle that could be more difficult than expected.
C.D.C. officials last week declined requests for interviews about the study, but a spokeswoman, Elizabeth-Ann Chandler, answered questions by e-mail. She reiterated that the agency used the SDI figures to calculate the rate of complications, not of circumcisions.
“C.D.C. was not involved in the collection of the data that was cited, nor has C.D.C. undertaken any review of this particular data for the purpose of calculating rates,” she wrote. “As such, we cannot comment on the accuracy of this particular estimate of infant male circumcision.”
But she did not dispute the waning popularity of circumcision. “What we can tell you is that male infant circumcision rates have declined somewhat in this decade,” she wrote.
The study found a very low rate of complications associated with newborn circumcisions; most were considered mild and no babies died.
Organizations opposed to circumcision said parents may be responding to the message their groups have been spreading through their Web sites and a video distributed to childbirth educators.
“Word has gotten out that it’s not necessary, it’s harmful and it’s painful,” said Georganne Chapin, executive director of Intact America, a nonprofit organization based in Tarrytown, N.Y.
Greater awareness about female circumcision may have influenced parents as well, she said, asking, “How can you think it’s O.K. to cut little boys, when you are horrified by the idea of cutting little girls?”
Both the C.D.C. and the American Academy of Pediatrics have been reviewing the scientific evidence on circumcision with an eye to issuing new policy recommendations, but so far neither body has done so, although the federal agency was to have issued its new recommendations by the end of last year.
Officials from the pediatrics academy said its new policy would be issued by early 2011; a task force that studied the topic has completed its report, which is being reviewed by several other committees, said Dr. Michael Brady, chairman of pediatrics at Nationwide Children’s Hospital in Columbus, Ohio, who served on the task force. The academy is likely to adopt a more encouraging stance than its current neutral position and to state that the procedure has health benefits beyond H.I.V. prevention, Dr. Brady said.
The World Health Organization in 2007 endorsed male circumcision as “an important intervention to reduce the risk of heterosexually acquired H.I.V.”
“No one is going to tell a parent, ‘You have to circumcise your child.’ That would be foolish,” Dr. Brady said. “The key thing physicians should be doing is providing information on both risks and benefits and allow the parent to make the best decision.”
Several state Medicaid programs stopped covering circumcision after the academy issued its current policy in 1999, and Dr. Brady said that may be one reason fewer parents opt for the procedure. Other possible reasons include a growing Hispanic population that has traditionally been disinclined to circumcision, as well the anti-circumcision movement and a broader trend among parents to spurn medical interventions like vaccination.
Some 80 percent of American men are circumcised, one of the highest rates in the developed world. Yet even advocates of circumcision acknowledge that an aggressive circumcision drive in the United States would be unlikely to have a drastic impact on H.I.V. rates here, since the procedure does not seem to protect those at greatest risk, men who have sex with men.
And while studies in Africa found that circumcision reduced the risk of a man’s becoming infected by an H.I.V.-positive female partner, it is not clear that a circumcised man with H.I.V. would be less likely to infect a woman.
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Date: 2010-08-17 03:25 pm (UTC)no subject
Date: 2010-08-17 04:42 pm (UTC)