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On Call with Dr. Porter


Try not to smile when you see a toddler joyously navigating an electric car through a maze of objects with a giddy grin on his face as wide as the Grand Canyon. Theres something infectious about an innocent smile. This months issue of What Doctors Know will certainly bring a smile to your face when you read our cover feature about Dr. Cole Galloway, an associate professor of physical therapy at the University of Delaware who gives kids with special needs mobility and joy. No more being pushed in a mundane wheel chair. These kids literally take control of the wheel and happily navigate from point a to point b with little effort. Summer is here so weve included some important information about Summer Safety. Read about skin care tips and the importance of hydration. Speaking of hydration, there are a lot of myths about the fluids we drink to beat the heat. To help you rethink your drink, weve included a comprehensive feature on liquids in this issue. This should help you not only be safe in summer, but it will help you live healthy as well. Stay safe and stay healthy this summer.

Steve Porter, MD Publisher and Chairman

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WHAT DOCTORS KNOW


And you should, too!

Taking Control
11 Controlling Chronic Disease 18 Know itHepatitis 22 Catching a Cold When Its Warm

P11

Health Hints
25 CDC Vital Signs: Recipe
for Food Safety

P29

29 Caring for Your Babys Skin 34 Rethink Your Drink

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Vol. 2 Issue 7

Contents

Inquiring Minds
42 Do You Have ACC? 48 High-Tech Dieting 54 Timing is Everything

P54

In Every Issue
01 On Call With Dr. Porter 04 Medicine in the News 50 Know Your Specialist
Dermatologist

On The Cover
12 The Drive to Explore 30 Health Hub from
Cleveland Clinic

52 Whats Your UV:IQ?

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Pretesting Cervical Tumors Predicts Response To Treatment


ST. LOUIS, Mo. Doctors at Washington University School of Medicine in St. Louis have shown testing cervical tumors before treatment for vulnerability to chemotherapy predicts whether patients will do well or poorly with standard treatment. The study supports the future possibility of personalized medicine for cervical cancer, a tumor normally addressed with a one-size-fits-all approach. Even though this is a small study, its strength is that it links a lab test of the tumors chemotherapy response to survival outcomes for the patients, said Julie K. Schwarz, MD, PhD, assistant professor of radiation oncology. Very few cancers have been studied this way, and this is the first such report for cervical cancer. Since 1999, nearly all cervical cancer cases have been treated the same way: daily radiation therapy targeted to the tumor plus a weekly intravenous infusion of the chemotherapy drug cisplatin. We believe radiation does the majority of the work with cervical cancer, said Schwarz. But a randomized trial published in 1999 showed combining it with cisplatin chemotherapy improved survival outcomes. Even today, according to Schwarz, doctors have no way of knowing who will do well or poorly with the combined radiation and chemotherapy every patient receives. Now, Schwarz and her colleagues have shown the
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tumors response to chemotherapy, independent of radiation, may be a major deciding factor in whether a patient will do well with the standard treatment. This is evidence that cisplatin is not just helping the radiation work better, Schwarz said. It is having some direct toxic effect on cancer cells that may be hiding elsewhere in the body, some place where the radiation is not hitting it, since we target the radiation so precisely to the main tumor. We think it would be beneficial for that drug to be selected appropriately for the patients individual tumor. Cervical cancers can be divided into two main types based on how they look under a microscope squamous cell carcinoma and adenocarcinoma. The nonresponsive number was even worse for patients diagnosed with the more common squamous cell carcinoma, with 46 percent disease-free survival at two years.

Texting Becoming a Pain in the Neck


upper back in abnormal positions for a long period of time; enough that other people coined the phrase text neck, which is essentially referring to postural pain, said Chris Cornett, M.D., orthopaedic surgeon and spine specialist at UNMCs Department of Orthopaedic Surgery and Rehabilitation. The term, text neck, was first coined by a chiropractor in Florida. Its defined as overuse syndrome involving the head, neck and shoulders, usually resulting from excessive strain on the spine from looking in a downward position at hand held devices such as cell phones, mp3 players, e-readers and computer tablets. When you hold your body in an abnormal position, it can increase stress on the muscles, cause fatigue, muscle spasms and even stress headaches, Dr. Cornett said. With every degree of motion to the front or side that you move your head, the stress on your neck is magnified beyond just the weight of the head. Over time, as technology use continues to expand, more people will experience this kind of discomfort and injuries from text neck, he said. However, Dr. Cornett suggested a few ways to help alleviate or avoid text neck becoming a pain in your neck.

OMAHA, Neb. Too much texting and tilting your head down can become a pain in the neck for some people. An excessive amount of leaning your head forward and down, while looking at a phone or other mobile device could result in what some people call text neck. People get so focused on these devices that they end up holding their neck and

Modify the position of the device

Instead of having the device in your lap or causing you to lean your head down, find a way to hold the device at a neutral, eye level.

Take breaks

Be aware that youre using these technology devices throughout the day and force yourself to take a break and to change or alter your position.

Physical fitness

Having a strong, flexible back and neck will help you deal with abnormal stresses and reduce musculoskeletal issues.

FDA Proposing Stricter Regulations for Tanning Beds


WASHINGTON, D.C. The FDA is proposing to raise the classification for sunlamps and tanning beds to a Class II level, which institutes stricter regulations to protect public health. Currently, indoor tanning devices are Class I, the category for items as much potential for harm as adhesive bandages and tongue depressors. In 2010, the FDA convened an Advisory Panel hearing to examine the current classification and regulations of tanning beds. Dermatologists and researchers testified before the panel highlighting the risks associated with indoor tanning and the need to protect the public from these dangers. Following the hearing, the AADA has been working closely with the FDA, and both state and federal legislatures to protect minors from the dangers of indoor tanning. With a reclassification, tanning bed and lamp manufacturers will be required to show their products have met certain performance testing requirements. In addition, tanning bed and lamp manufacturers will be required to label the devices so they:

* clearly inform consumers about the risks of using tanning beds * warn frequent users of sunlamps to be regularly screened for skin cancer and * alert users that tanning lamps are not recommended for people under 18 years old.
Under the proposed changes, manufacturers would be required to provide updated labeling for all products on the market within one year of the FDAs final order. The risk of developing melanoma

increases by 75 percent for individuals who have been exposed to UV radiation from indoor tanning and the risk increases with each use and 2.3 million teens tan indoors in the United States annually, said Dr. Dirk M. Elston, MD, FAAD, president of the AADA. Therefore, restricting teens access to indoor tanning is critical to preventing skin cancer. As medical doctors who diagnose and treat skin cancer, dermatologists are committed to reducing its incidence and saving lives. We will continue to communicate to the FDA the need for stricter regulations on the use and sale of indoor tanning devices for minors under the age of 18.
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New test eliminates need for chemotherapy for some breast cancer patients Has become new standard of care
OMAHA, Neb. A new gene test for patients with breast cancer called MammaPrint could dramatically reduce the number of women who need to undergo chemotherapy to treat the disease. The test is available at the University of Nebraska Medical Center and its hospital partner, The Nebraska Medical Center. It analyzes 70 key genes and accurately determines which patients are at low risk of breast cancer recurrence and could safely choose not to undergo chemotherapy. The test has been validated in a peer-reviewed study called MicroarRAy PrognoSTics in Breast CancER (or RASTER), conducted in 16 community-based clinics in the Netherlands. The results were published online earlier this year in the The International Journal of Cancer and will later appear in the journals print edition. The five-year study involved 427 breast cancer patients who were given the MammaPrint test. The test determined 219 women to be low risk and 208 to be high risk. This is an important breakthrough for breast cancer patients, said James Edney, M.D., UNMC professor of surgical oncology. By incorporating MammaPrint
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results along with the traditional clinical parameters, such as tumor size, grade, patient age and lymph node status, we can significantly reduce the number of women who need chemotherapy. In doing so, they can avoid the side effects and toxicity of chemotherapy treatment, some of which can be permanent and debilitating. Long-term side effects of chemotherapy could include damage to the heart, kidneys, lungs, nerves or reproductive organs. There is also the chance of developing a second cancer as a result of chemotherapy, Dr. Edney said. Dr. Edney said MammaPrint can be administered to virtually all early-stage breast cancer patients. It requires a breast cancer assay performed on either fresh or fixed tumor tissue. The study showed that MammaPrint identified 30 percent more patients as low risk than the traditional clinical parameters often used in the U.S. to determine risk of recurrence. The test has been cleared by the U.S. Food and Drug Administration. MammaPrint was developed by Agendia, a molecular diagnostic company headquartered in Amsterdam, the Netherlands with a genomics laboratory in Irvine, Calif.

A link with postpartum depression and oxytocin, sometimes called the "love hormone"?
CHAPEL HILL, N.C. Three researchers at the University of North Carolina School of Medicine are starting a 5-year study, funded by the National Institutes of Health (NIH), that's aimed at understanding the role of oxytocin in postpartum depression and bonding between mothers and babies. "The conventional wisdom is that breastfeeding reduces postpartum depression yet we see tremendous overlap between moms who struggle with breastfeeding and moms who have postpartum depression or anxiety symptoms," said Alison Stuebe, MD, first author of the pilot study and assistant professor in UNC's Department of Obstetrics and Gynecology. She is also assistant professor in the Department of Maternal and Child Health in the UNC Gillings School of Global Public Health. "In this study, we measured levels of oxytocin, the 'love hormone', in mothers with mild anxiety or depression and in normal controls. The mothers who were more anxious had lower oxytocin

levels during breastfeeding. We can't tell from this study whether feeling anxious reduces oxytocin, or whether not having enough oxytocin causes anxiety, but the results suggest that the two problems are connected. It may be that a problem with oxytocin both contributes to postpartum depression symptoms and makes breastfeeding less enjoyable," Stuebe said.

High-dose steroids increase bacterial infection in children with juvenile arthritis


BIRMINGHAM, Ala. Children with juvenile idiopathic arthritis have higher rates of bacterial infection requiring hospitalization, and use of high-dose steroids significantly increases that risk, according to research from the University of Alabama at Birmingham. In findings published in Arthritis & Rheumatism, the journal of the American College of Rheumatology, the researchers show that steroid use led to increased risk, while other commonly used medications methotrexate and tumor necrosis factor inhibitors did not increase infection risk in children with JIA. Among children with JIA, questions have persisted about a possible increased risk of serious infections associated with the use of TNF inhibitors, one of the so-called biologics which have become increasingly popular as a treatment for JIA, said Timothy Beukelman, M.D., MSCE, associate professor of pediatric rheumatology and scientist in the UAB Center for Clinical and Translational Science. But the relationship between JIA and serious bacterial infections has not been extensively studied and is not well understood. Beukelmans team set out to answer several questions. They wanted to know the infection rates for children with JIA in general, along with the rates for children whose disease was managed by methotrexate, TNF inhibitors and steroids known as oral glucocorticoids, another commonly used treatment. This finding suggests the inflammatory or autoimmune process itself may predispose children to infection regardless of therapy, said Beukelman. Beukelmans group also found that the infection rate among JIA patients was not any higher in children treated with either methotrexate or TNF inhibitors, but that the rate was significantly higher in those children treated with high-dose glucocorticoids. The use of a high dose of glucocorticoid, more than 10 mg of prednisone daily, was consistently associated with a doubling of the infection rate, Beukelman said. This strongly indicates that a treatment strategy that limits steroid use may reduce the risk of serious infection in children with JIA. Arthritis is an inflammation of the joints that causes pain, swelling, stiffness and can lead to disability. JIA is the most common type of childhood arthritis and may affect 300,000 children in the United States, according to the American College of Rheumatology.

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'Roadmap' of human metabolism offers new understanding of cancer, obesity, more


CHARLOTTESVILLE, Va. An international consortium of researchers has created the largest computer model of human metabolism to date, an astonishingly detailed roadmap that points the way to better understanding of cancer, obesity, diabetes, heart disease and a host of other conditions. Its a powerful new tool that will speed the development of new drugs and treatments and, eventually, may allow doctors to tailor medicine to each patients personal biology.

Predicting the genome


The model, called Recon 2, details thousands of metabolic functions that occur within humans cells. By understanding these functions, their interactions and how they influence cellular activity, scientists can get the big picture of the microscopic cellular universe. Metabolism is central to much of our bodys function, and this model captures thousands of different metabolic processes, explained Jason Papin, PhD, a researcher at the University of Virginia School of Medicine involved in the project. We start with the human genome. This modeling effort is a way to functionalize the genome, a way to make value out of that sequence information. With the genome, you have a parts list, the components. What this model does is take the functions associated with those components and put them together in a mathematical way so that you can start to predict how it will behave. The model is by far the most complete computer representation of metabolism yet, incorporating several previous models and more than a thousand papers. It represents a collaborative effort of a substantial percentage of the top metabolism researchers from around the globe. By bringing together so much of sciences understanding of metabolism, the researchers have created a way to better understand the metabolic mistakes that cause disease -- and to speed future breakthroughs to battle those diseases.

patients tumor becomes resistant to existing therapies, these models of metabolism can help point to new therapies or new pathways that we can target with drugs to help stop growth, Papin said. Cancer growth is a function of metabolism. Metabolism is there to help it grow. And were hoping this modeling effort will help us know how to inhibit some of those key processes.

Freely available
The researchers describe the model in a paper in the May issue of the journal Nature Biotechnology. They have made the model freely available online, at www.humanmetabolism.org, and theyre already at work making it even more comprehensive. This is really a starting point, Papin said. The model has much, much to be improved, for sure. But in the end what we want to be able to do is have a computer model of the whole cell, and with that computer model hopefully be able to make all kinds of useful predictions and guide new experiments and help interpret new data thats generated. So while this is a first step, I think its an important, big first step.

Personalized medicine
Take cancer, for example. The idea would be that if a

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University of Michigan Researchers To Study Use Of Medical Marijuana


ANN ARBOR, Mich. With a new $2.2 million, four-year federal research grant, a team of University of Michigan Medical School researchers will try to document medical marijuanas potential impact in a more scientific way, in one of the states that has authorized its use. The funding, from the National Institute on Drug Abuse, will pay for a two-year study of 800 Michigan patients who are seeking to obtain state certification for the use of medical marijuana for pain. The team will approach patients who are at their first doctors appointment as part of the process to obtain the certification thats needed to become a registered medical marijuana user in Michigan. Patients may not proactively volunteer for the study. With the ongoing policy debate and the growing popularity of medical marijuana programs in the United States, it is essential to understand the ramifications of medical marijuana use for individuals who seek access to it, says study leader Mark Ilgen, Ph.D., an experienced researcher on topics related to substance use and abuse. We hope that with this study can help inform the debate. A psychologist who has studied substance use and abuse for 10 years, Ilgen is an associate professor in the U-M Department of Psychiatry and the principal investigator on the new grant. Marijuana is the most frequently used drug in the nation, and has been legalized for medical use in many ways, yet we have very little understanding of how individuals using medical marijuana do over time, says Frederic Blow, Ph.D., a co-investigator on the study and experienced substance abuse researcher who directs the Mental Health Services Outcomes & Translation Section at the U-M Medical School. We hope this study will help provide much-needed data on the characteristics of those who seek medical marijuana, and the longerterm impact on their health and lives. Across the country, patients use marijuana in hopes that it will ease the symptoms of conditions such as cancer, seizures, glaucoma and pain. Twenty states and the District of Columbia have made this use legal including Michigan, where more than 135,000 patients are now in a four-year-old statewide registry of approved medical marijuana users.

Technology Offers New Hope for Children Born with Heart Defects
MIAMI, Fla. A surgeon at Miami Childrens Hospitals Congenital Heart Institute has performed the nations first heart valve replacement on a premature infant with a severe heart defect by using CorMatrix extracellular matrix material an innovation that saved one-yearold Analiah Duarte Escorcias life and may make it possible for her to avoid future valve replacements common when mechanical or biological valves are used. Dr. Redmond P. Burke, Director of Cardiovascular Surgery at Miami Childrens Hospital, performed the operation in February 2012. Analiah was born with two defective heart valves and had very limited options, said Dr. Burke. Her heart was massively enlarged and had compressed both of her lungs severely. The mortality rate for this defect is among the highest for any congenital heart problem.

intestines by CorMatrix Cardiovascular, to craft the new valve in the operating room. The valve was then implanted, with sutures anchoring it to the support structures in the childs right ventricle. Analiah, now at home with her family, has had a remarkable recovery, with a gradual decrease in her heart's size, and expansion of her lungs to near normal dimensions. The valve also shows near normal function. The ultimate test of the technology will be the demonstration of growth over time. At a year follow up, the valve continues to function well and she is on minimal medication. Dr. Burke noted the ECM shows great promise for babies requiring valve repairs and replacements, as the material stimulates the patients natural wound-healing mechanisms, allowing the patient to regrow healthy tissue, effectively becoming an integrated part of the patients body. Children receiving transplants with current biological or mechanical valves typically must undergo reoperations for valve replacement procedures every 10 years or so, or as the valve wears out or the child outgrows it.

New options, new hope

prevalent approach is to close the valve completely with a patch and turn the child's heart into a rudimentary single ventricle, requiring multiple subsequent operations. However, no available mechanical or biological valve would safely fit within the childs heart. Dr. Burke used extracellular matrix (ECM) material, developed from porcine

Current treatment options are limited for patients with these challenges. One

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WHAT DOCTORS KNOW


And you should, too!
Special Thanks To:
Published by What Doctors Know, LLC Publisher and Chairman Steve Porter, MD Editorial Advisory Board Vicki J. Lyons, MD, Chairman Editorial and Design Director Bonnie Jean Thomas Senior Designer Suki Xiao Design Associate Raulin Huang Executive Director, Marketing Larry Myers Production Kai Xiao, Vice President IT Manager Eric Lu

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Calling All Doctors. Our readers want to hear from you. What healthcare issues do you want to address? What do you want to tell patients all over the country? Whats new in your practice, in your specialty? Drop us a line and let us know about any healthcare topic you want to address in What Doctors Know. Remember, we want to inform and educate our readers. We know, an informed reader has the opportunity to live longer and happier. You can be part of that healing process. Our readers look forward to hearing from you.

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Controlling Chronic Disease


They then identify several tools used by psychologists and behavioral economists that can change behavior but which have not been employed often in medical care, and suggest that research on such alternative approaches is an urgent need. These approaches include:

ne of the most important health problems in the United States is the failure of patients with chronic diseases to take their medications and do all that is necessary to control their illnesses. In a study published online in the Journal of General Internal Medicine, UCLA researchers and their colleagues suggest that physicians take a serious look at tools and strategies used in behavioral economics and social psychology to help motivate their patients to assert better control over chronic diseases. Breaking large goals into smaller, more manageable parts, for example, may help patients better manage diseases such as diabetes, the researchers say. Diagnosing diseases and discovering effective treatments aren't the only challenges facing health care professionals in the United States, said Braden Mogler, the paper's lead author and a third-year medical student at the David Geffen School of Medicine at UCLA and Charles R. Drew University of Medicine and Science. "One of the big challenges is simply finding ways to help the many patients with chronic diseases understand why treatment is important and how to follow it," Mogler said. "Many doctors often lack effective tools to encourage patients in these ways. There is a lot of research from the social sciences on human behavior and encouraging individual change, and this paper shows how that research can potentially be applied to doctorpatient interactions." In the study, the researchers highlight the shortcomings of some approaches frequently used to try to get individuals to control their diseases, such as scaring patients, overwhelming them with technical information, and focusing on consequences that are far in the future.

Helping patients form very specific plans to achieve their health goals for example, identifying the time when they will take their medicines, having them determine what they will do if their prescriptions run out and they don't have a doctor's appointment, and giving them a place to record whether they took the medicines. Breaking big goals into smaller tasks that get patients to their ultimate goal step-by-step useful for goals like extreme weight loss, adhering to medication regimens and checking blood sugar every day, or exercising several times a week. Using cash payments to patients as a motivator to get them on track but supplementing that with strategies that will increase their desire to stay healthy and live longer.
If studies show these techniques make a difference, they might improve health and decrease health care costs, said co-author Dr. Martin Shapiro, chief of the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA.

"Helping patients get their chronic diseases under control sometimes requires changing medications but mostly comes down to helping patients understand why treatment is important and how they can follow it in their busy lives," Shapiro said. "There is a lot of exciting research on how we can help people change to achieve their goals in other fields, and we believe translating those ideas to health care is an important next step in medical research." The study's authors found that some of these techniques are being used to a limited degree in health care settings helping patients quit smoking by settling on an exact quit date, for instance, has proven more effective than speaking in general terms about quitting soon. Still, many other potentially effective techniques have not been studied in medical settings, and the authors stress the need for clinical trials to evaluate their effectiveness. -This information provided courtesy of UCLA Health Sciences

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11

THE DRIVE TO

by Diane Kukich Photos by Evan Krape

For kids with limited mobility, modied toy racecars provide an engine for social development.
Modular Design
Driving Module (shown) converts to Power Walker to provide maximum mobility.

biodriven mobility unit supports driving and walking.

2020 Prototype: DARE2B

the incUbatoR
UD is the ideal place to put this cool technology in action. the Mechanical systems Laboratory provides the manufacturing plant for the vehicles, while the early Learning center provides the young drivers, indoor and outdoor test tracks and expert early educators and pediatric therapists.

Customizable steering, seating and acceleration options enable modicationto t any childs abilities.

Multi-Terrain

Scale 2.5 ft.

Device is small, light and rugged for indoor/outdoor all-weather use.

hen Cole Galloway takes his research show on the road, one of his favorite things to share with his audience is a video of a newly mobile baby wreaking havoc in a living room lled with toys. Galloway heightens the eect by showing the movie at triple speed so that the audience quickly becomes as exhausted as both the baby and her parents are at the end of the day.

As a physical therapist and developmental scientist, Galloway knows that the basic movement behaviors of kids between the ages of one and three the so-called toddler years are more than just movements. e continuous stream of activity is a complex exploratory engine that children use to build bigger, better bodies, construct more complex brains, form their rst friendships and lay the foundation for school readiness.

Adults have long recognized that childrens brains and behavior expand during the early years, Galloway says. More recent is the recognition that their mental, social and emotional development is intimately linked to their physical and social exploration of the world. For adults trying to keep up with a toddler, exploration can be simultaneously frustrating, exhausting and exhilarating. Toddlers will paint your new furniture with chocolate pudding, force pants into

12 whatdoctorsknow.com 40 | UD ReseaRch

the evoLUtion
the vehicles in the baby mobility project have evolved over the years from a custom robotic device (2007) to a lightweight, convertible power chair/walker (2010) to modied toy cars (2012) to the DaRe2b prototype (~ 2020).

Monitors Unit relays childs daily mobility and socialization performance to UD hQ.

2007
Cole Galloway, associate professor of physical therapy (left) and Sunil Agrawal, professor of mechanical engineering, have outtted kid-sized robots to provide mobility to children who are unable to explore the world on their own.

2010

2012
Sensory Aware
Force and motion sensors assist mobility, socialization and learning.

help create the technology with special needs training that will allow children with special needs to become wild, and all families to discover the engines within their children. To Galloway, the exploration gap between typically developing children and children with mobility issues is simply unacceptable, and he has devoted much of his career to doing something about it. Several years ago, he began working with mechanical engineering professor Sunil Agrawal to develop robot-enhanced devices that provide mobility to children as young as six months.

Closing the gap

2020

the dishwasher and try to ride the cat and thats all before breakfast, he continues. As a developmental scientist, Im interested in quantifying the who, what, when, where, why and how of these babies gone wild. As a clinical scientist, I want to

UD was the ideal place to launch their collaboration. Agrawals Mechanical Systems Laboratory provided the manufacturing plant for the vehicles, while the Universitys Early Learning Center (ELC) provided the young drivers, indoor and outdoor test tracks, and expert early educators and pediatric therapists such as Tracy Stoner and Terri Peey. e data collected using robots developed in the rst phases of the project convinced Galloway and Agrawal that they were on the right track.

Driving Sunils robots literally provided children who were not crawling or walking with a vehicle for exploration, Galloway says. e onset of crawling and walking is a causal factor for cognitive, emotional and social development. Powered mobility via driving appears to be a similar trigger for developmental change in young children who are not walking. Mobility and socialization typically co-develop over the rst two years of life, he adds. If they dont, the child may end up with splinter skills in which mobility and socialization emerge separately. As Galloway and his team discovered when they placed a mobility robot in an ELC preschool class, children who have experienced several years of immobility may learn to drive without understanding how to use their newfound mobility to play with friends or with teachers. We realized then that we needed to start our driver training during infancy, in activities with other children and always in natural environments such as the ELC, he says. Our hope is that mobility and socialization will coemerge for the driving toddler, just as it does for the walking toddler.

Toddlers will paint your new furniture with chocolate pudding, force pants into the dishwasher and try to ride the cat and thats all before breakfast. cole Galloway
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High-tech + low-tech = Go-Tech


By 2010, the science and technology in the project were emerging, but the pace was a challenge for Galloway. With no new commercial devices on the market to provide early power mobility, he became increasingly frustrated at his inability to help parents, clinicians and educators who were excited about the work but wanted help for their children now. We were moving at the speed of science, which is of course acceptable at some level, he says. However, constantly saying no to a community asking if we had robots for their children or clinic began to drive me a bit nutty. Galloway is a bit of a toddler himself. Like a child in the throes of the terrible twos, he doesnt like the word no. So he adopted another behavior common to devious youngsters if dad says no, ask mom or better yet, climb up and get it yourself. One day about a year ago, he found himself at ToysRUs admiring a colorful array of plastic ride-on cars and trucks. Aer purchasing an assortment of the inexpensive vehicles, he went to Jo-Ann Fabric & Cras and Home Depot, where he bought fabric, foam, straps, fasteners and PVC pipe. Back

the Facts

From 6 months to 3 years of age, healthy MONTHS children have the ability to move toward items that capture their interest. this allows more opportunitites to learn from their environment and form important neurological connections for brain and behavioral development.

85%
1

the majority of brain synapses or connections form by age 3, and 85% of a childs brain development is completed by age 5.

MILLION
More than a half-million children suer from mobility issues from birth on.

number of pediatric power wheelchairs currently available for children under 2.

on campus, Galloway and his students began using the materials to customize the cars for use by individual kids. Babies Driving Robots had spun o a new project: Babies Driving Racecars. Galloway says the low-tech is not replacing the high-tech but complementing it. Like children, scientists thrive on trialand-error learning cycles, he says. For real impact, you want those cycles to be rapid and cheap with clear, meaningful results. By modifying o-the-shelf toy cars, we can make lots of low-cost mistakes and quickly arrive at a range of ideal design features. at knowledge can then be fed back into Sunils ongoing robotics work. Galloways inner toddler was becoming a bit calmer. Marrying the high-tech to the low-tech is leading us to new Go-Tech possibilities in which scientic rigor is strapped to a racecar, he says. e ubiquitous presence of the cars is also paving the way for globalization of the program. Its not uncommon to nd distributors of ride-on toy cars in countries that dont have stable governments or clean water for their citizens, Galloway says. is takes us from having two robots in house here at UD to millions of toy cars around the world. e potential for such rapid globalization stretches our creative thinking about car modication design as well as our scientic methods.

Marrying the high-tech to the low-tech is leading us to new Go-Tech possibilities.... cole Galloway

The Baby Mobility Lab houses an entire eet of customized vehicles for kids with motor and developmental delays.

14 whatdoctorsknow.com 42 | UD ReseaRch

Mastering Mater

brenden bolens Mater truck wasnt a birthday present, but the plastic ride-on vehicle was a gift of another sort it enabled the two-year-old to be in the middle of the fun with the guests at his party. For brenden, who has cerebral palsy, Mater is more than a toy. its an avenue to the socialization and exploration he would otherwise miss out on. its an entre into the world of kids. its the rst step toward turning him into a knucklehead. and when youre two years Kimmy Burge and Brenden old, youre supposed to be a catch a moment together. wonderful knucklehead. his customized car has opened the door for brenden to interact with other toddlers at UDs early Learning center. at home, its enabled him to play ball with his dad and pet a therapy dog from PaWs for People. he absolutely loves it, says his mother, Kimmy burge. his favorite thing is to go outside with the car, and all of the kids think its great that he has Mater. Prof. cole Galloway sees family involvement as a critical element in driving success. its best when not only the parents but also the grandparents and the rest of the extended family play an active role, he says. in brendens case, his family took the reins and oored us with how fast they wanted to move forward. Galloway likens the racecar project to habitat for humanity on a miniature scale. adapting a car to meet the childs needs is a chance to become invested in building something, he says. Families can actively participate helping modify the car allows them to physically work to help their child. Mater is part of research that tracks brendens progress quantitatively, and his mother already has anecdotal evidence that the car is driving brendens development. ive seen big changes in him since he started driving Mater, she says. hes more alert, he reaches more and he has better head and trunk control. When he gets in the car, he knows exactly what to do. Kimmy realizes that brenden will soon outgrow Mater, but shes not worried. after seeing how its done in the lab at UD, i know we can adapt another, larger car ourselves, she says. and im sure theyd be happy to help us theyve been extremely accommodating to us throughout this whole process.

whatdoctorsknow.com 15 www.udel.edu/researchmagazine | 43

Paying it forward
e project is also providing a rich learning environment for graduate student Christina Ragonesi and postdoctoral researcher Hsiang-han (Sara) Huang. Ragonesi is working simultaneously on a doctorate of physical therapy degree in UDs nationally ranked physical therapy program and a Ph.D. in the Biomechanics and Movement Science Program. When Galloway challenged her and Huang to design a car that works a childs leg strength and standing balance, she instrumented the seat of a toy car so that the car goes forward only if the child stands and instantly stops if he sits back down. Kids will work hard to stand and keep standing if it means they can get the car to move, she says. Huang joined Galloways group in August 2011 aer earning her research doctorate at Boston University. I chose Dr. Galloways lab because of his determination to incorporate creative ideas into the clinical eld and his focus on empowering the family, Huang says. is type of research not only helps families directly but also provides evidence for moving forward scientically. Every week, families in our research share with me what they have observed about their childrens performance, and I encourage them to become involved in modifying the cars, she continues. ey have their own interesting ideas about how to incorporate the cars into their kids everyday lives. As a researcher, I can imagine no better outcome it means were helping to orchestrate positive changes for children and their families. Since arriving at UD in 2000, Galloway has also involved hundreds of undergraduates and high school students in various projects. Last summer, for example, 16-year-old David Glanzman engineered some electrical and mechanical modications by adapting a Mater truck so that it would meet the needs of then-19-monthold Brenden, who has cerebral palsy (see p. 43). With plans to pursue a career in electrical engineering, Glanzman gained valuable insight into what happens when engineering meets kids.

Sara Huang encourages Brenden to use a shape-sorting toy.

allow laboratory-grade data gathered from living rooms, playgrounds and backyards around the world to be sent back to the UD lab. Several years ago, Galloway and Agrawal envisioned programming a device to take a child to the edge of a group, to just wander or to follow a specic child or an instrumented toy such as a ball. is capability would enable us to place the child in the ow of the social scene and see what happens, Galloway says. Sunil and Xi Chen, his graduate student, are conducting this project on socially mobile robotics right now at the ELC with our mobile robot. If this is successful, Galloway plans to implement the same concept with racecars for children who have social impairments such as autism.

In electrical engineering, you have problems with dened solutions, he says. Its dierent with pediatrics. Kids are dynamic, and they change over time you have to be creative to adapt to that. Glanzman is set to return this summer to continue his work.

It takes a village
One of Galloways current goals for the racecar project is to take what he and his team are learning and create a toolkit for families, medical and educational professionals, and researchers who want to adapt the cars for kids with special needs. He emphasizes the importance of doing this right. We make sure to stay within the manufacturers intent, which is to use these cars as toys, he says. eyre not medical devices. We dont alter their use, and we dont alter the safety factors built into the cars. In fact, several of our modications increase the safety for children with special needs. e next step is to determine how many of the high-tech advances that have been incorporated into the robotic devices developed in Agrawals lab can be added back to the low-tech platform. Potential add-ons include force and motion sensors, GPS and other performance-tracking capabilities such as onboard microcomputers and web cameras. is will

Cole Galloway, Christina Ragonesi, and Sara Huang pose with a miniature Mater in front of Miles, Dover International Speedways symbolic monster.

16 whatdoctorsknow.com 44 | UD ReseaRch

Right now, his overriding goal is to get the technology into every possible environment where kids are from homes and playgrounds to preschools and even long-term care facilities for medically fragile children. is project demands that our research stay nested deeply within the community, Galloway says. Discussing the technology and training of powered mobility with community audiences, from third graders to business leaders, is a key connection. is project has something for everyone.

Fun is fundamental
Galloway emphasizes that in both the low- and high-tech realms of his research, the use of mobility devices

never replaces eorts to develop a childs own ability to walk and run. Providing mobility and exploration with these cars likely helps encourage their exploratory drive, he says. For example, typically developing infants who spent 30 minutes a few times a week driving, crawled and walked early, as well as had advanced cognitive and language scores. Our future work needs to test this with children with special needs. Galloway never stops looking for creative ways to help individual children while also seeking avenues to spread the message and the technology to parents and clinicians. One idea he is currently exploring is to pilot racecar camps. e research team would outt the campers with cars, spend a week teaching them to

drive, and then Web extRa send the kids and cars home. Watch a video clip of this project involving e childrens babies driving race cars. progress would be monitored for the next six to nine months. Fun is the beginning and the end for our science, Galloway says. Our entire pediatric mobility program is built on a foundation of maximum fun and discovery. When your main goal is providing socialization for infants and toddlers, you cant ask for better collaborators than Barbie and Mater.

www.udel.edu/gobabygo
FUtURe WoRK

Delaware is the only state with a Special Racers Research Program... but not for long.

Babies Start Your Engines


one community sector that cole Galloway recently connected with is the world of auto racing. With Dover international speedway less than 50 miles from the UD campus, he saw potential for a collaboration with Dover Motorsports inc. the organization has strong ties to autism speaks, which could provide the perfect window for the racecar project. Racecars may oer children with autism a mode of play with the physical space that they need to be emotionally comfortable while enabling them to engage in a fun activity typical of their peers, Galloway says. Gary camp, senior director of communications for Dover international speedway, has already seen the positive eect of the car connection. a parent whose child has autism recently told me that his kid has become who he is because of nascaR he knows all the drivers and their numbers and their cars. Kids learn through the sport they love the cars and the speed, and they end up learning and becoming engaged as a result.

childre : eds. email special ne del.edu

S VER DRIN D E T : WAn un der 5 with


u gobabygo@

whatdoctorsknow.com 17 www.udel.edu/researchmagazine | 45

DoUG baKeR

Know it...Hepatitis

T
18 whatdoctorsknow.com

ogether hepatitis B and C represent one of the major threats to global health. Hepatitis B and C are both silent viruses, and because many people feel no symptoms, you could be infected for years without knowing it. If left untreated, both the hepatitis B and C viruses can lead to liver scarring (cirrhosis). If you have liver cirrhosis, you have a risk of life-threatening complications such as bleeding, ascites (accumulation of fluid in the abdominal cavity), coma, liver cancer, liver failure and death. In the case of chronic hepatitis B, liver cancer might even appear before you have developed cirrhosis. In some cases, a diagnosis is made too late and the only option is a liver transplant. If you think you have been at risk, it is important that you get tested as soon as possible and, if diagnosed, consider your treatment options and self-management strategies. Patients with hepatitis B infection can also be infected with a second virus known as hepatitis delta virus, hepatitis D virus or simply HDV. You can find out more about hepatitis D at hepatitis-delta.org

The Difference Between Hepatitis B and C While there is a vaccine that protects against hepatitis B infection, there is no vaccine available for hepatitis C Both viruses can be contracted though blood-to-blood contact Hepatitis B is more infectious than hepatitis C and can also be spread through saliva, semen and vaginal fluid In the case of hepatitis B, infection can occur through having unprotected sex with an infected person. Please note that this is much rarer in the case of hepatitis C While unlikely, it is possible to contract hepatitis B through kissing. You cannot contract hepatitis C through kissing Neither virus is easily spread through everyday contact. You cannot get infected with hepatitis B or C by shaking hands, coughing or sneezing, or by using the same toilet. There are different treatments for the two viruses. While treatment can control chronic hepatitis B, it can often cure hepatitis C Even if treatment is not an option for you, you can do something about your disease. A healthy lifestyle is important. Alcohol, smoking, eating fatty foods, being overweight or extreme dieting (eating no food at all) may worsen your liver disease. Therefore, try to avoid all alcohol, stop smoking, eat a low fat diet with enough fruit and vegetables, and reduce your weight if necessary Hepatitis B
The World Health Organization (WHO) recognizes that hepatitis B is one of the major diseases affecting mankind today. Hepatitis B is one of the most common viral infections in the world and the WHO estimates that two billion people have been infected with the hepatitis B virus and approximately 350 million people are living with chronic (lifelong) infections. 500,000 700,000 people die every year from hepatitis B. The hepatitis B virus is highly infectious and about 50-100 times more infectious than HIV. In nine out of ten adults, acute hepatitis B infection will go away on its own in the first six months. However, if the virus becomes chronic, it may cause liver cirrhosis and liver cancer after up to 40 years, but in some cases as little as five years after diagnosis.

The hepatitis B virus is transmitted between people through contact with the blood or other body fluids (i.e. saliva, semen and vaginal fluid) of an infected person. Although not all people will have any signs of the virus, those that do may experience the following symptoms:

Flu-like symptoms Fatigue Nausea Jaundice (yellowing of the skin) Stomach ache Diarrhea/dark urine/bright stools Aching joints
Unlike hepatitis C, there is a vaccine that can prevent infection. If you think you are at risk, you should get vaccinated as soon as possible.

Hepatitis C
Hepatitis C is different from hepatitis B in that the virus more frequently stays in the body for longer than six months, and therefore becomes chronic. Four out of five people develop a chronic infection, which may cause cirrhosis and liver cancer after 1530 years. There are approximately 170 million people chronically infected with hepatitis C worldwide. In 2000, the WHO estimated that between three and four million people are newly infected every year. Hepatitis C is mainly spread through blood-to-blood contact and, similarly to hepatitis B, there are often no symptoms but if they are present can include:

Flu-like symptoms Fatigue Nausea Aching muscles and joints Anxiety and depression Poor concentration Stomach ache Loss of appetite Dark urine/bright stools

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19

Prevention
The hepatitis B virus (HBV) is transmitted between people through contact with the blood or other body fluids (i.e. saliva, semen and vaginal fluid) of an infected person. Please note that it is very unlikely it can be contracted through kissing or sharing cutlery. The hepatitis C virus (HCV) is spread through direct contact with infected blood. Very rarely it may be passed on through other body fluids. Most common routes of transmission for hepatitis B or C viruses are the following:

Diagnosis
To diagnose hepatitis B the blood needs to be checked for the HB surface antigen (HBsAg). The HBs antigen is a part of the virus and will usually appear in your blood six to twelve weeks after infection. If the test is positive, you have hepatitis B. In that case, your doctor should conduct further tests to check if your hepatitis B infection is new or old, if it is harming your body or not, and if you need treatment or not. If you have naturally cleared the virus, or if you have been vaccinated against hepatitis B, you will have antibodies to hepatitis B (antiHBs). Your body made these to destroy the virus. It is good to have anti-HBs, because that means you are protected against future infection by the hepatitis B virus. For hepatitis C, your doctor will first check for HCV antibodies (anti-HCV). If the test is positive, this means you either have the virus now, or have had the virus and cleared it. Hepatitis C antibodies usually take seven to nine weeks to appear in your blood after infection. If your immune system is weakened (e.g. by HIV) your body may take longer to produce HCV antibodies, or it may not produce any at all. If the first test is positive, your doctor will then test for the virus itself (HCV RNA). If this is positive, you have hepatitis C. If you are diagnosed with hepatitis B or C you will face many challenges, but it is better to confront the disease head on, know how to avoid transmitting the infection to others and consider your treatment options and self-management strategies as early as possible. For further information about whether you might be, or have been, at risk and how you can get tested, please contact your local patient group, who will be able to provide you with the information that you need.

Blood transfusions and blood products using unscreened blood (in most countries, but not all, blood has been screened since about 1990) Medical or dental interventions without adequate sterilization of equipment Mother to infant during childbirth Sharing equipment for injecting drugs Sharing straws, notes etc. for snorting cocaine Sharing razors, toothbrushes or other household articles Tattooing and body piercing if done using unsterilized equipment
In the case of hepatitis B, infection can also occur through having unprotected sex with an infected person. If you think you could have been at risk from either hepatitis B or C, it is important to get tested. Getting immunized is the best way of preventing hepatitis B infection. More than one billion doses of the hepatitis B vaccine have been used since the early 1980s and it has been shown to be effective in approximately 95% of cases. There is currently no vaccine for hepatitis C.
20 whatdoctorsknow.com

Hepatitis B Treatment
Acute hepatitis B: it is not usually necessary to treat a new hepatitis B infection in the first six months. Nine out of ten new infections go away on their own, with or without treatment. In this early stage of disease, treatment makes very little difference to the chances of a cure. Antiviral drugs may only be necessary and helpful in rare cases, if the acute infection causes very aggressive liver inflammation. Chronic (long-lasting) hepatitis B: consult with your doctor about your situation. Some people need treatment, while others should wait. Treatment does not usually cure you of hepatitis B, but it can turn an aggressive hepatitis B infection into a mild infection. This can stop the liver from being damaged. If the infection is considered mild, it might be better to monitor it and wait until later for treatment. You can treat chronic hepatitis B with peg-interferon or with pills, which are called nucleoside or nucleotide analogues. Peg-interferon alfa comes in a syringe and stimulates the immune system against the virus. This treatment may have side effects, such as fatigue, flu-like symptoms, depression, skin and hair problems and changes in blood chemistry, amongst others. Treatment continues for 24 to 48 weeks and while not all hepatitis B patients respond well to interferon, certain types of hepatitis B infection do. For example, patients with genotype A, HBeAg positive, with elevated liver enzymes but NO cirrhosis can often successfully reduce their viral infection to a milder state. Your doctor needs to monitor your interferon treatment closely. Interferon treatment should not be used if you already have cirrhosis of the liver. Nucleoside and nucleotide analogues come in pills. They stop the virus from replicating. The pills have very few side effects, and even patients with cirrhosis can take them. However, patients need to take their pills every day, for several years and sometimes a lifetime. If the virus becomes resistant to one type of pill, it might stop working, and another, different drug will need to be added to their treatment to get the virus back under control. Your doctor should monitor your viral load (HBV DNA) to make sure that your treatment works. Do not forget to take your pills, even if you feel well. If you miss many doses or stop treatment too early, the disease might become worse than it was before. Make sure that you will have access to medication for several years before you start treatment with pills.

treatment, have been launched in different countries given their significantly higher success rates. Pegylated interferon alfa and ribavirin: this is still being used as first line therapy choice for HCV patients with genotypes 2,3,4,5 and 6. It is also being used to treat HCV genotype 1 patients in countries where the new protease inhibitors have not been approved yet or where decisions on how to commission the drugs have not been taken yet. Pegylated interferon alfa and ribavirin cures approximately half of all hepatitis C patients. A patient is considered to be cured if there is no virus in the blood six months after the end of treatment. This is different from hepatitis B therapy, which controls rather than cures the infection. Interferon comes in a syringe and ribavirin is available in pills. The treatment may have side effects such as fatigue, flu-like symptoms, depression, hair and skin problems, and changes in blood chemistry. Therefore, treatment should be monitored by an experienced doctor or clinic. The duration of treatment is different from patient to patient. You usually need 24 to 48 weeks of treatment, but in some cases, 72 weeks may be recommended. There are several subtypes of the hepatitis C virus, which are called genotypes. They do not seem to influence the course of the disease, but they respond differently to treatment. Patients infected with genotypes 1, 4, 5 and 6 are more difficult to cure than those infected with genotypes 2 and 3. There are a number of new hepatitis C treatments that are in development. -This information provided courtesy of World Hepatitis Alliance

Hepatitis C Treatment
In many countries, the second quarter of 2011 marked the arrival of a new current standard of care for people with HCV genotype 1; Boceprevir (Victrelis) and Telaprevir (Incivek), which are protease inhibitors taken orally and added to the Pegylated interferon alfa and ribavirin combination

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What's the Deal with Summertime Sniffles?


22 whatdoctorsknow.com

Catching a Cold When It's Warm

Treating a Cold
resting in bed. drinking plenty of fluids. taking acetaminophenTylenol, for examplefor headache or fever. gargling with warm salt water or using ice chips, throat sprays or lozenges for a sore throat. using a decongestant or saline nasal spray for nasal symptoms.
Theres no cure for a cold, but you can relieve symptoms by:

ost everyone looks forward to summertime to get away, get outside and have some fun. So what could be more unfair than catching a cold when its warm? How can cold symptoms arise when its not cold and flu season? Is there any way to dodge the summertime sniffles? Cold symptoms can be caused by more than 200 different viruses. Each can bring the sneezing, scratchy throat and runny nose that can be the first signs of a cold. The colds we catch in winter are usually triggered by the most common viral infections in humans, a group of germs called rhinoviruses. Rhinoviruses and a few other cold-causing viruses seem to survive best in cooler weather. Their numbers surge in September and begin to dwindle in May. During summer months, the viral landscape begins to shift. Generally speaking, summer and winter colds are caused by different viruses, says Dr. Michael Pichichero, a pediatrician and infectious disease researcher at the Rochester General Hospital Research Institute in New York. When you talk about summer colds, youre probably talking about a non-polio enterovirus infection. Enteroviruses can infect the tissues in your nose and throat, eyes, digestive system and elsewhere. A few enteroviruses can cause polio, but vaccines have mostly eliminated these viruses from Western countries. Far more widespread are more than 60 types of nonpolio enteroviruses. Theyre the second most common type of virusafter rhinovirusthat infects humans. About half of people with enterovirus infections dont get sick at all. But nationwide, enteroviruses cause an estimated 10 million to 15 million illnesses each year, usually between June and October.

Enteroviruses can cause a fever that comes on suddenly. Body temperatures may range from 101 to 104 F. Enteroviruses can also cause mild respiratory symptoms, sore throat, headache, muscle aches and gastrointestinal issues like nausea or vomiting. All age groups can be affected, but like most viral infections, enterovirus infections predominate in childhood, says Pichichero. Adults may be protected from enterovirus infections if theyve developed antibodies from previous exposures. But adults can still get sick if they encounter a new type of enterovirus. Less common enteroviruses can cause other symptoms. Some can lead to conjunctivitis, or pinkeye a swelling of the outer layer of the eye and eyelid. Others can cause an illness with rash. In rare cases, enteroviruses can affect the heart or brain. To prevent enterovirus infections, says Pichichero, its all about blocking viral transmission. The viruses travel in respiratory secretions, like saliva or mucus, or in the stool of an infected person. You can become infected by direct contact. Or you might pick up the virus by touching contaminated surfaces or objects, such as a telephone, doorknob or babys diaper. Frequent hand washing and avoiding exposure to people who are sick with fever can help prevent the spread of infection, says Pichichero. The summer colds caused by enteroviruses generally clear up without treatment within a few days or even a week. But see a health care provider if you have concerning symptoms, like a high fever or a rash. -Source: NIH News in Health, June 2012, published by the National Institutes of Health and the Department of Health and Human Services. For more information go to www.newsinhealth.nih.gov

whatdoctorsknow.com

23

A liver transplant gave Sonia her life back.


In the fall of 1996, Sonia was diagnosed with end stage liver disease. The most difficult thing for her to accept was that she was no longer able to drive herself. Now she is driving again and has taken up a new hobby, making rosary beads which are distributed to people around the world.

You have the power to Donate Life. Be an organ, eye and tissue donor.
To find out how, go today to www.donatelife.net or call 1-800-485-7427 .

Recipe for Food Safety


Protecting people from deadly Listeria food poisoning

1,600
About 1,600 people in the US get sick from Listeria germs each year.

3rd
Listeria is the 3rd leading cause of death from food poisoning.

Many germs can be spread through food. Some, like Listeria, can be deadly. Listeria strikes hard at pregnant women and their newborns, older adults, and people with weakened immune systems. Listeria can cause miscarriage and meningitis. Most people found to have Listeria infection require hospital care and about 1 in 5 people with the infection die. Outbreak investigations tell us what foods make people sick and what needs to change to make food safer and save lives. We have made some progress against Listeria, which is the third leading cause of death from food poisoning. However, we can do more to protect people at higher risk for food poisoning and make food safer for everyone. If you, or someone you make food for, are pregnant, 65 or older, or have a weakened immune system, you must be especially careful when selecting, preparing, and storing foods. Know your risk of food poisoning. Select, prepare, and store food safely. Follow the safe food guidelines Clean, Separate, Cook, Chill at www.FoodSafety.gov Learn more about how to prevent food poisoning and outbreaks.
Want to learn more? Visit
www

90%
At least 90% of people who get Listeria infections are either pregnant women and their newborns, people 65 or older, or people with weakened immune systems.

http://www.cdc.gov/vitalsigns

National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne, Waterborne, and Environmental Diseases

Listeria is a deadly germ Problem that is hard to control


Listeria is challenging because
When someone eats food contaminated with Listeria, sickness or miscarriage may not occur until weeks later when it is difficult to identify which food was the source. Listeria can contaminate many foods that we dont usually cook, like deli meats, cheeses and sprouts. Some foods we might not suspect can be contaminated with Listeria and cause sickness and outbreaks, such as cantaloupe and celery. Listeria is a hardy germ that can even grow on foods that are refrigerated. Listeria can hide unnoticed in the equipment or appliances where food is prepared, including in factories and grocery stores.

We can prevent Listeria infections by


Identifying outbreaks fast by using special laboratory tests and disease detectives. Rapidly finding and removing contaminated food before people eat it. Using lessons from outbreaks, including environmental investigations, to make food safer. Applying new safety measures for food production, like those included in the Food Safety Modernization Act (FSMA), so that food doesnt get contaminated in the first place. Reducing Listeria contamination of ready-to-eat meat and poultry products by following USDA guidance. Having a robust public health system that provides the tools and resources needed to promote food safety. Learning more about which polices and practices work best.

Detecting more outbreaks points the way to prevention


Outbreaks from Listeria in the 1990s traced to hot dogs, and later to deli meats, led to changes that made processed meats safer and reduced the number of such outbreaks. But, Listeria infection rates have not gone down since 2001.

Faster detection and response saves lives and protects people

Number of infections per million people

9 8 7 6 5 4 3 2 1 0

1988: Single deadly case of Listeria linked to hot dog


New laws and industry changes New technology (PulseNet) detects more outbreaks, disease goes down Progress stalls, outbreaks continue Progress needed to meet the 2020 goal, FSMA enacted in 2011

Listeria Outbreaks
Days from outbreak detection to first public warning

Soft Cheese

Cantaloupe

1985

31

2011

1990

1995

2000

2005

2010

2015

2020

SOURCES: New England Journal of Medicine, 1988; Morbidity and Mortality Weekly Report, 2011

SOURCES: JAMA, 1995; CDC, 2012

Who has a higher risk of getting Listeria food poisoning?


Lessons from Listeria outbreaks: Food poisoning can happen to anyone. Each year, about 48 million people
in the US (1 in 6) get sick from eating contaminated food. It can be especially dangerous for pregnant women and their newborns; older adults; and people with immune systems weakened by cancer, cancer treatments, or other serious conditions (like diabetes, kidney failure, liver disease, and HIV/AIDS). Listeria is a prime example of how germs that contaminate food can cause sickness and death in these groups.

Pregnant women, fetuses, and newborn infants


Listeria can pass from pregnant women to their fetuses and newborns. It can cause miscarriages, stillbirths, and newborn deaths.

People with weakened immune systems


Listeria can spread through the bloodstream to cause meningitis, and often kills. The weaker your immune system, the greater the risk. Contaminated celery
LISTERIA OUTBREAK: Pre-cut celery

Chancy cheese
LISTERIA OUTBREAK: Queso fresco (a type of soft cheese) sickened 142 people, killed 10 newborns and 18 adults, and caused 20 miscarriages.

in chicken salad served at hospitals sickened 10 people who had other serious health problems. Five of them died as a result.

Adults 65 or older
Listeria can spread through the bloodstream to cause meningitis, and often kills. The older you are, the greater the risk. Tainted cantaloupes
LISTERIA OUTBREAK: Contaminated whole cantaloupes sickened 147 people in 28 states and caused one of the deadliest foodborne outbreaks in the US. There were 33 deaths, mostly in adults over 65, reported during the outbreak.
SOURCE: CDC, 2013

What foods are risky?


When it comes to Listeria, some foods are more risky than others. Meet some of the other foods where Listeria is known to hide.

Raw Sprouts Raw Milk


(unpasteurized)

Soft Cheeses

Deli Meats and Hot Dogs


(cold, not heated)

Smoked Seafood
3

What Can Be Done


Federal, state, and local governments are
Providing guidance to industry and developing regulations, like FSMA, to focus food safety efforts on safer production and handling of foods. Tracking Listeria infections to identify opportunities to improve policies and practices, particularly to protect groups at higher risk. Investigating and stopping outbreaks by recalling contaminated foods and warning the public. Applying CDCs enhanced approach to investigating Listeria infections in all states so disease detectives can rapidly solve outbreaks by: DNA fingerprinting the Listeria germ to identify outbreaks and contaminated foods, and interviewing people who are sickquickly and uniformlyabout what they ate. See Listeria Initiative, http://www.cdc.gov/listeria/
pdf/ListeriaInitiativeOverview_508.pdf

Health care providers can


Tell pregnant women, older adults, and people with weakened immune systems about Listeria and other dangerous germs spread through food. Report Listeria infections quickly to the local health department to help spot and stop outbreaks.

People at higher risk and those who cook for them can
Know which foods are risky for pregnant women, older adults, and people with weakened immune systems, and avoid these foods. See http://www.cdc.gov/listeria/prevention.html Heat deli meats and hot dogs until steaming hot before eating. Not drink raw (unpasteurized) milk or eat soft cheeses made from it. Be aware that Mexican-style cheeses made from pasteurized milk, such as queso fresco, likely contaminated during cheese-making, have caused Listeria infections. Refrigerate leftovers within 2 hours in shallow covered containers and use within 3-4 days. Be careful to avoid cross-contamination in the refrigerator or other places in the kitchen. Use a thermometer to make sure your refrigerator is 40F or lower and your freezer is 0F or lower.

Building public health capacity for advanced genome sequencing and analysis, which will make it possible to more quickly detect Listeria infections and outbreaks, and track them to their sources.

Food industry and places that sell or serve food can


Promptly communicate recalls of foods at risk for contamination. Follow related guidance and regulations that address foods that are more likely to be contaminated. Adopt proven actions like good sanitation and refrigeration in all food production and service facilities for Listeria control. Identify and apply research to better prevent Listeria growth and cross-contamination in factories and stores, such as retail delis.
www

Everyone can
Know the risks of food poisoning and follow the Clean, Separate, Cook, Chill guidelines. Visit http://www.FoodSafety.gov for the latest information on preventing food poisoning.
For more information, please contact

http://www.cdc.gov/vitalsigns http://www.cdc.gov/mmwr

Telephone: 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov


Web: www.cdc.gov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Publication date: 6/4/2013

www

CS239776B

Caring for Your

Baby's Skin

eathers, down comforters, teddy bears, snow, the inside of a sweatshirt, worn leather, cotton candy and kitten fur. Yes, these things are soft. But they cant come close to the soft, delicate skin of a baby. To help protect your babys skin from rashes, irritation or other skin conditions, here are few tips on how to care for your babys skin. Newborns stay relatively clean and dont need to be bathed frequently. Bathing also strips away the natural oils that protect the skin, so a sponge bath two to three times a week is sufficient. Infants with darker skin tones do best when bathed once a week or less since they tend to have dryer skin and higher risk of skin problems such as eczema. Use a gentle, fragrancefree cleanser or just water for the first month or so. Dont worry if you see a few breakouts on your babys face during the first few weeks. Little white bumps, called milia, and infant acne will eventually go away on their own. Wash the breakouts with water and leave them alone. Many children also have birthmarks that may be present anywhere on the body and can grow as your baby grows. Usually they are nothing to worry about and do not need treatment. However, if you are concerned about your babys birthmark, talk with your pediatrician. Diaper rash is caused by the irritation of a wet, soiled diaper. The only way to prevent it is to check your babys diaper frequently and change dirty diapers right away. Diaper rash should be washed with warm water and a cloth, gently dried, and then covered with a diaper rash ointment or petroleum jelly to seal moisture away from the skin.

Cradle cap is another common skin condition that can appear in the first few months. These crusty, oily, scaly patches on the babys head or face are caused by overactive oil glands under the hair and skin. You can manage cradle cap by washing your babys head with mild baby shampoo every few days, or rubbing in a little baby oil and then brushing or washing it off. Cradle cap usually clears by the time your baby is about eight months old. Eczema can appear as a red, itchy rash that is sometimes accompanied by little oozing bumps. It could make your baby feel very itchy on the face, scalp, elbows or behind the knees. The skin condition can be caused by coming in contact with anything that can irritate the babys skin, from saliva or a new detergent on fabric, or triggered by an ingested allergen such as cows milk. Eczema is usually treated with a topical steroid cream or ointment. Dont forget to protect your babys skin while out in the sun. You can apply a sunscreen with a SPF of 15 of higher when clothing or shade doesnt provide adequate protection against sunburn. -This information provided courtesy of St. Christopher's Hospital for Children

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29

Health Hub

Be Skin Smart in the Sun Learn what to watch for, and what to avoid

kin cancer is now the most common form of cancer in the United States. Melanoma the deadliest skin cancer is on the rise among 15-to-29-year-olds. The main culprit for the increase in young people is indoor tanning.

Know your ABCDEs


To do a proper skin self-exam, be on the lookout for changes in moles and other skin lesions. Watch for: Asymmetry: the shape of one half doesnt match the other Border: edges that are ragged, blurred or poorly defined Color: variations of brown, black, tan, and sometimes patches of red, blue or white Diameter: larger than the size of a pencil eraser Evolving: lesions that appear to be changing Lesions with one or more of these traits need to be checked as quickly as possible by a dermatologist. So do lesions that bleed, scab, come and go or dont heal. Enjoy the outdoors without risking your health. Apply sunscreen liberally and frequently even on cloudy days.

The good news is that most skin cancers are highly treatable when detected early, say Cleveland Clinic dermatologists. Self skin exams and annual skin exams from your doctor or dermatologist are critical if youre at high risk of skin cancer.

Risk factors include: A history of indoor tanning Skin thats fair or that burns, freckles or reddens easily Personal history of skin cancer Family history of melanoma Heavy sun exposure at work or recreationally Many sunburns early in life Blue or green eyes Blonde or red hair Certain kinds of moles
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Avoiding Heat-Related Illness During Summer


How to stay safe and cool
The summer months are fast approaching, and with that can come the increased risk of heat-related illness (HRI) ranging from heat cramps and exhaustion to heat stroke especially for athletes. Signs and symptoms include headache, nausea, decreased urination, and in extreme situations can lead to delirium, coma and even death. Its important for coaches, athletic trainers, parents and professional and recreational athletes to know how to prevent HRI and to have knowledge of the signs and symptoms. fluids at the last minute. Both water and electrolyte replacement may be used during activities.

Precautions
There are many things we can do to prevent being overheated. Steps include:

Hyperthermia
Heat production is generated with physical activity and production of sweat as a cooling mechanism through evaporation. When this thermoregulation is not working properly elevated core body temperature (hyperthermia) can result.

Limiting sun exposure and exercising in the early morning or evening when it is not as hot and humid and limiting time and intensity Slowly acclimating to warmer climates over about a period of 10 to 14 days. This makes spring/late summer training sessions an important prevention strategy Removing unnecessary clothing and equipment during practice Having adequate fluid and electrolyte replacement throughout the activity Being aware of the signs and symptoms of dehydration.
Heat overload may accumulate over days, so being aware of development of the symptoms noted above is crucial to early detection.

Dehydration
Dehydration is a loss of total body water, leading to decreased blood volume characterized by sodium depletion (hypovolemia). Signs of dehydration include dry lips and tongue, increased thirst, headache, weakness, dizziness, nausea, cramps and dark urine. Sweating allows dissipation of heat, so replacement of fluids and electrolytes to replenish volume and maintain the cooling mechanism is important. Hypovolemia may lead to reduction in sweat production resulting in a rise in core temperature. Despite adequate fluid replacement, when relative humidity rises above 75 percent, evaporation becomes ineffective, and thermoregulation is compromised. Excessive water consumption can lower the relative sodium content of the blood, causing a condition known as hyponatremia. Signs and symptoms include nausea, vomiting, confusion and headache. It is important to drink according to thirst, and to maintain a state of normal hydration during activity and in the days leading up to activities rather than attempting to replenish

Treatment
Be sure to seek medical attention immediately if the athlete is showing any mental status changes. Cooling and fluid replacement by trained personnel may also be initiated to decrease core body temperature and rehydrate the athlete.

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Health Hub

Dont Let Heart Disease Derail Travel Plans

A little preparation will allow for a great vacation

Talk with your doctor If you are having any new symptoms, make an appointment to see your doctor before you travel. If you have had a recent procedure or hospitalization, ask your doctor when it is safe to travel. Be prepared: check with your cardiologist to find out if he or she knows of a doctor to contact or find the closest medical center in your travel location in case of problems. If you have an irregular heartbeat, ask your doctor for a copy of your electrocardiogram (ECG). If you are a Cleveland Clinic patient, sign up for MyChart so your medical records are at your fingertips. Be sure to have any immunizations required for the country youre visiting and be up to date on your immunization and antimalarial recommendations. You may want to visit a travel clinic before you go.
Check your insurance coverage and make sure it will cover you where you are traveling. Consider purchasing medical evacuation insurance if your health insurance doesnt cover medical evacuation. Youll be glad you did. You may want to consider Cleveland Clinics Global CARE (Critical Air Rescue and Evacuation) program.*

eart disease does not need to limit your ability to travel. Here are some key pointers to follow so that you can have a comfortable and heart-healthy vacation.

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Medications Make sure you will have enough medication to get you through the entire trip (if not, refill your prescription). Bring enough medication to cover you for a few extra days in case you are delayed for any reason. Make sure your medications are easily accessible in your bag while you are en route. If you are flying, bring all medication on your carry-on luggage. Make sure your medication is clearly labeled. Always have a water bottle in the event that you need to take your medication during travel time. Bring a snack if you need to take any medications with food. If you fly Travel with a suitcase and carryon that are on wheels; better yet, get help with your luggage from a porter or fellow travel mate. Request an aisle seat so you can easily get up and walk around. When traveling long distances, there is increased risk of blood clots (venous thrombosis). o This is due to slower blood circulation when you are sitting for many hours and lower oxygen levels in the plane cabin. o During the flight, get up from your seat at least once every two hours and walk up and down the aisles. o Wear comfortable shoes and socks and try to elevate your feet above your chest level whenever you can. o Wear compression stockings when traveling on a plane for more than eight hours or 3,100 miles. Stay hydrated with water and do not drink alcoholic beverages as they cause dehydration.

Flying with a heart device If you have a pacemaker or implanted cardiac defibrillator (ICD), try to request special security clearance with a hand search at the airport. If a handheld device is used to clear a person through security checkpoints, ask the examiner to hold the handheld device over the ICD for no more than a few seconds. If you are traveling abroad, bring all contact numbers and web site addresses for pacemaker and ICD manufacturers.
While the risk of heart attack or other heart problems is small, the Federal Aviation Administration has made it a requirement for passenger-carrying aircraft to have on board an automated external defibrillator (AED).

Diet and exercise Make sure you are well rested before your trip and get plenty of sleep while you travel. If youll be walking a lot on your getaway, start a walking program before you leave and wear the most comfortable travel shoes you can find. If you are on a special diet at home, follow your diet (as much as possible) on your trip. If you haveheart failure, eating too much salt can bring on symptoms. To avoid salty snacks on the plane and during the trip, bring low-salt snacks with you.
Finally, if you are on vacation and have any heart symptoms, dont be a hero. Dont be afraid to get checked for fear of spoiling your family vacation. Seek emergency room treatment should you have any chest pain, signs of a heart attack, or other symptoms of heart disease.

To find more great health tips and information, visit HealthHub from Cleveland Clinic at www.health.clevelandclinic.org

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Rethink your drink.

Department of Health and Human Services


Centers for Disease Control and Prevention

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When it comes to weight loss, theres no lack of diets promising fast results. There are low-carb diets, high-carb diets, low-fat diets, grapefruit diets, cabbage soup diets, and blood type diets, to name a few. But no matter what diet you may try, to lose weight, you must take in fewer calories than your body uses. Most people try to reduce their calorie intake by focusing on food, but another way to cut calories may be to think about what you drink.

What Do You Drink? It Makes More Difference Than You Think!


Calories in drinks are not hidden (theyre listed right on the Nutrition Facts label), but many people dont realize just how many calories beverages can contribute to their daily intake. As you can see in the example on the next page, calories from drinks can really add up. But there is good news: you have plenty of options for reducing the number of calories in what you drink.

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Occasion
Morning coffee shop run

Instead of Calories Try


Medium caf latte (16 ounces) made with whole milk 20-oz. bottle of nondiet cola with your lunch 265 Small caf latte (12 ounces) made with fatfree milk

Calories
125

Lunchtime combo meal

227

Bottle of water or diet soda

Afternoon break

Sweetened lemon iced tea from the vending machine (16 ounces)

180

Sparkling water with natural lemon flavor (not sweetened)

Dinnertime A glass of

nondiet ginger ale with your meal (12 ounces)

124

Water with a slice of lemon or lime, or seltzer water with a splash of 100% fruit juice

0 calories for the water with fruit slice, or about 30 calories for seltzer water with 2 ounces of 100% orange juice. 125-155

Total beverage calories

796

(USDA National Nutrient Database for Standard Reference)

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Substituting noor lowcalorie drinks for sugar-sweetened beverages cuts about 650 calories in the example on the previous page. Of course, not everyone drinks the amount of sugar-sweetened beverages shown. Check the list below to estimate how many calories you typically take in from beverages.

Type of Beverage
Fruit punch 100% apple juice 100% orange juice Lemonade Regular lemon/lime soda Regular cola Sweetened lemon iced tea (bottled, not homemade) Tonic water Regular ginger ale Sports drink Fitness water Unsweetened iced tea Diet soda (with aspartame) Carbonated water (unsweetened) Water

Calories in 12 oz
192 180 168 168 148 136 135 124 124 99 18 2 0* 0 0

Calories in 20 oz
320 300 280 280 247 227 225 207 207 165 36 3 0* 0 0

*Some diet soft drinks can contain a small number of calories that are not listed on the Nutrition Facts label. ( USDA National Nutrient Database for Standard Reference)

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Milk contains vitamins and other nutrients that contribute to good health, but it also contains calories. Choosing low-fat or fat-free milk is a good way to reduce your calorie intake and still get the nutrients that milk contains.

Type of milk
Chocolate milk (whole) Chocolate milk (2% reduced-fat) Chocolate milk (1% low-fat) Whole milk (unflavored) 2% reduced-fat milk (unflavored) 1% low-fat milk (unflavored) Fat-free milk (unflavored)
(USDA National Nutrient Database for Standard Reference)

Calories per cup (8 ounces)


208 190 158 150 120 105 90

Safe Weight Loss Experts have defined healthy weight loss as a loss of 1-2 pounds per week. Most people need to cut roughly 500 calories a day to lose one pound per week.You can do this by reducing the number of calories you take in through both food or drink.

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Learn To Read Nutrition Facts Carefully


Be aware that the Nutrition Facts label on beverage containers may give the calories for only part of the contents.The example below shows the label on a 20oz. bottle. As you can NUTRITION FACTS LABEL Serving Size 8 fl. oz. see, it lists the number Servings Per Container 2.5 of calories in an 8-oz. Amount per serving serving (100) even Calories 100 though the bottle contains 20 oz. or 2.5 servings.To figure out how many calories are in the whole bottle, you need to multiply the number of calories in one serving by the number of servings in the bottle (100 x 2.5).You can see that the contents of the entire bottle actually contain 250 calories even though what the label calls a serving only contains 100.This shows that you need to look closely at the serving size when comparing the calorie content of different beverages.

High-Calorie Culprits in Unexpected Places


Coffee drinks and blended fruit smoothies sound innocent enough, but the calories in some of your favorite coffee-shop or smoothiestand items may surprise you. Check the website or in-store nutrition information of your favorite coffee or smoothie shop to find out how many calories are in different menu items. And when a smoothie or coffee craving kicks in, here are some tips to help minimize the caloric damage: At the coffee shop: Request that your drink be made with fat-free (skim) milk instead of whole milk. Order the smallest size available. Forgo the extra flavoringthe flavor syrups used in coffee shops, like vanilla or hazelnut, are sugar-sweetened and will add calories to your drink.

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Skip the Whip.The whipped cream on top of coffee drinks adds calories and fat. Get back to basics. Order a plain cup of coffee with fat-free milk and artificial sweetener, or drink it black.

Sugar by Any Other Name: How To Tell Whether Your Drink Is Sweetened

Sweeteners that add calories to a beverage go by many different names and are not always obvious to anyone looking at the At the smoothie stand: ingredients list. Some Order a childs size if available. common caloric sweeteners are listed below. Ask to see the nutrition information for each If these appear in the type of smoothie and pick the smoothie with ingredients list of the fewest calories. your favorite beverage, you are drinking Hold the sugar. Many smoothies contain added a sugar-sweetened sugar in addition to the sugar naturally in fruit, beverage.

juice, or yogurt. Ask that your smoothie be prepared without added sugar: the fruit is naturally sweet.

High-fructose corn syrup Fructose Fruit juice concentrates Honey Sugar Syrup Corn syrup Sucrose Dextrose

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Better Beverage Choices Made Easy


Now that you know how much difference a drink can make, here are some ways to make smart beverage choices: Choose water, diet, or low-calorie beverages instead of sugar-sweetened beverages. For a quick, easy, and inexpensive thirst-quencher, carry a water bottle and refill it throughout the day. Dont stock the fridge with sugar-sweetened beverages. Instead, keep a jug or bottles of cold water in the fridge. Serve water with meals. Make water more exciting by adding slices of lemon, lime, cucumber, or watermelon, or drink sparkling water. Add a splash of 100% juice to plain sparkling water for a refreshing, low-calorie drink. When you do opt for a sugar-sweetened beverage, go for the small size. Some companies are now selling 8oz. cans and bottles of soda, which contain about 100 calories. Be a role model for your friends and family by choosing healthy, low-calorie beverages.

Department of Health and Human Services


Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Division of Nutrition and Physical Activity

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Do You Have ACC?

number of adults could be walking, talking, and going through life today functioning normally with part of their brain missing. And they dont know it.

These adults are among those who could be affected by a rare brain disorder called Agenisis of the Corpus Callossum (ACC). ACC is caused when the major bridge connecting the right and left sides of the brain partially develops or doesnt develop at all. While it sounds serious, the affects of ACC by itself are usually minor. However, most cases of ACC are be accompanied by another disorder. Then it can become serious. ACC (Agenisis of the Corpus Callossum) is rare, but then maybe its not so rare. Because ACC is virtually undetected without an MRI, a portion of the population goes undiagnosedand just how

big that portion is, the medical community has no idea. If the disorder were more common, physicians would run across it after an MRI is ordered for headaches or a head injury. Typically, doctors dont see ACC as an incidental finding very often. According Vinay Puri, the Head of the Child Neurology Department at the University of Louisville, ACC by itself can be asymptomatic, meaning there are no visible signs of anything being wrong with the affected individual. ACC could cause slow learning or other minor problems and the affected person would never know it was ACC. However, its the company ACC often keeps that causes the more serious problems such as inability to walk, talk, seizures, epilepsy and inability to develop normally. So while ACC alone can sound very serious, it is actually a minor issue unless its coupled by another problem. Unfortunately, ACC has a debilitating partner in a majority of cases.

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What types of callosal disorders can occur?


The type of callosal abnormality that occurs depends on the cause and timing of the disruption to prenatal brain development. If the corpus callosum does not form during the prenatal period, it will not develop later. Currently, there is some variation in how callosal conditions may be described in medical reports and by medical providers. Below is a list of the most common terms used to describe these conditions.

(ACC) Agenesis of the corpus callosum: All or a portion of the corpus callosum is absent; this includes both complete and partial ACC (AgCC) Agenesis of the corpus callosum: All or a portion of the corpus callosum is absent. This acronym has appeared more recently in some research literature. (c-ACC) Complete agenesis of the corpus callosum: The corpus callosum is completely absent (p-ACC) Partial agenesis of the corpus callosum: A portion of the corpus callosum is absent; most often it is the posterior (back) portion that is missing Hypogenesis of the corpus callosum: Another term sometimes used to describe partial ACC Hypoplasia of the corpus callosum: The corpus callosum is present, but is abnormally thin Dysgenesis of the corpus callosum: The corpus callosum is present but is malformed in some way; this includes p-ACC and Hypoplasia

Who is affected?
There are many different genetic explanations as well as non-genetic explanations for ACC. Some research points to a possibility of a contributing gene from one or both of the parents. However, the mystery surrounding ACC and the cause of it being so under diagnosed is due largely to a combination of how it is diagnosed, when it should be diagnosed, how it mirrors other medical issues such as Autism and Aspergers, and the wide range of symptoms. These swings range from seemingly healthy people going through normal life functions, but struggling with simple things such as school and social interactions, to individuals having difficulty trying to walk, talk or function in life at all. A growing number of adults are discovering they have ACC by accidentliterally. Todays advanced imaging technology is discovering the presence of ACC in adults who are being tested for potential brain issues after an automobile or some other accident. These MRI tests are uncovering ACC in varying degrees but this is a rare occurrence.

many general practice physicians and pediatricians arent fully educated about ACC. Based on available medical data, ACC is rare and while the technology is available today for an extremely accurate diagnosis, the steps to identify the disease early require an MRI on an infant. Not many parents or physicians are anxious to put a newborn or an infant through an MRI. After all, you cant tell a baby to sit still for the procedure. Therefore an MRI for an infant means sedation. Remember, ACC takes on the characteristics of a number of other medical problems, which should be ruled out first. Time isnt on the side of the ACC patient. The longer is takes to diagnose, the farther the patient falls behind in developmental benchmarks.

Why arent we catching ACC sooner?


Its only been with the advent of much more accurate imaging equipment that ACC can be more accurately diagnosed. Still, it is difficult to pin down because of the sensitive area it affects and the difficulty of diagnosing infants who cant describe what they are feeling. Adding to the problem, ACC is such a specialized disorder;
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An ACC diagnosis is rare, yet it is the most common malformation in newborns today. It affects one in 4,000 births. Most sources estimate callosal disorders can take place in up to four individuals per 1,000 in the general population but it happens more frequently among persons with developmental disabilities (22-24 per 1,000). A group of U.S. researchers reported an incidence rate of 1 in 4,000 live births, based on a review of prenatal and neonatal imaging studies, but these researchers suggested this might be an underestimate of the true occurrence rate. ACC is truly difficult. We have better technology than ever before. Still, we cant react too quickly yet, we cant wait too long, said Dr. Ryan Coates, Assistant Professor of Neurology from Loyola University. I recommend parents start looking closely at their childs development at around 9 months. If the child isnt hitting benchmarks, its a signal to start serious conversations with a pediatrician. ACC is under diagnosed and misdiagnosed. The difficulty of the disorder makes it difficult to diagnose, particularly for a pediatrician because they see so much. There are some obvious signs of ACC, but it is difficult for an infant to tell someone how they feel. Another more obvious and disturbing sign is seizures. Seizures point immediately to a brain problem and most likely will lead to a Neurologist visit with an MRI as part of the evaluation. Overall, ACC signs are difficult for parents to identify. Parents shouldnt panic, but if there is an abnormal pregnancy or abnormal birth, this might be a reason to start watching a little more closely at the childs development. I remind parents that a childs brain is continually developing until they are fully grown adults. So if ACC is diagnosed, the key is to get immediate help so the child wont fall even further behind, Dr. Coates noted. Early detection to start the child on a developmental program is essential. With ACC, the severity of the disorder is difficult to diagnose until the child reaches about age 5 when social and mental skills can be evaluated properly.

there are typically no other issues associated with the disorder. The more common form of ACC is called complex, meaning the patient has ACC along with other problems. This usually means the disorder is more severe and the outcomes are much worse. Adding, Dr. Puri says there is no specific symptoms in a developmentally delayed patient that point explicitly to ACC. When the diagnosis is suspected, an MRI of the brain is the study of choice.

What is the corpus callosum?


The corpus callosum is the largest midline structure of the brain.

It begins to develop around the 10th to 11th week of pregnancy Consists of over 200 million nerve fibers that connect the two hemispheres of the brain Transfers and integrates motor, sensory, and cognitive information between the cerebral hemispheres Continues to mature throughout pregnancy and into childhood and adolescence
The type of callosal abnormality that develops depends on the cause and timing of the disruption to prenatal brain development. If the corpus callosum does not form during the prenatal period, it will not develop later. Those with ACC can be affected in a range that runs from seemingly normal to seriously handicapped. The only way to detect ACC is through an MRI. There is no cure and the affects are permanent. As the affected individual grows, the disorder doesnt get worsebut then, it doesnt get better. Because it is a birth disorder, infants with obvious signs and symptoms such as lack of motor skill development, walking, talking, etc., are most likely to be diagnosed. Its those with less severe symptoms who are usually diagnosed later in lifeor not at

What is ACC and what are the symptoms?


ACC is a birth defect caused when the major bridge the Corpus Callosumconnecting the left and right side of the brain fails to develop properly. When this happens, motor skills and mental aptitude can be impacted. According to Dr. Sonjay Singh, chairman and professor in the Department of Neurology at Creighton University School of Medicine and boardcertified neurologist with Alegent Creighton Clinic, In one study, data showed about 25-30 percent of the ACC cases were considered isolated. This means

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all. Milder symptoms include difficulty in school, difficulty with social interactions and motor skills, which may be misinterpreted as clumsiness. ACC support groups are reporting adults experiencing head injuries and having MRIs with results showing the missing part of the brainthe bridge or the corpus callosum. These are adults who look back and talk about how difficult it was in school for them. They remember how they struggled with simple things and blamed everything on the assumption that they just werent as smart as others. Personally, I have never run across a patient who has told me about such an incident, said Dr. Michael Tennison Professor of Pediatric Neurology at the University of North Carolina Chapel Hill. Virtually all the children I have discovered with ACC have substantial developmental issues, usually much more than simply having learning difficulties. Its this seemingly normal group, labeled underachievers, which is among the undiagnosed and living with ACC. They will struggle with things like academics blaming their struggles simply on not being as smart. In reality, they are doing very well for having part of their brain missing. The problem with ACC is the range of how differently it affects individuals. It can be mild, with few symptoms and the affected person appearing normal to severe, unable to function mentally or physically.

What causes ACC and callosal conditions?


It is difficult to pinpoint the cause of a callosal abnormality; researchers are working to get a better understanding of callosal causes. Among the possible causes of ACC are:

Chromosome errors Inherited genetic factors Prenatal infections or injuries Prenatal toxic exposures Structural blockages, such as cysts Metabolic disorders Other unknown factors What are the early signs of ACC?
Diagnosing ACC has become more accurate in recent years because of the amazing advancements in imaging equipment. Todays equipment gives physicians clearer and better looks at specific areas of the brain. 3D images of the brain allows more accurate diagnosis while in years past, it was a guessing game. Once a child has been identified as having an ACC related disorder, the plan would be to treat the specific disorder. There is a specific treatment for the agenesis, which would cause the physician to look for associated abnormalities that may or may not have a genetically defined explanation. Because ACC impacts childhood development in every aspect, early detection is critical. To give a child every opportunity to function as close to normal depends greatly on early diagnosis. Without being diagnosed

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an 18-month old child functioning as a 15-month old can end up being years behind in development. But an infant, who has yet to walk or talk, cant tell a parent there is a problem. Many parents think their child is just getting off to a slow start and will eventually catch up. Sometimes this is the case. For one in every 4,000 births, the slow start is a sign of ACC.

So whats the answer? Do all parents routinely give their child an MRI?
Its just not that easy. Dr. Singh cautions by saying, you just cant start randomly doing MRIs on babies. Thats a bit aggressive and given the rarity of the disease, unnecessary. It would make more sense to take a more logical approach by working with the childs pediatrician to watch the benchmarks of development. Some children are a little slower in developing. But if there is concern, starting by communicating with a pediatrician. If a pediatrician feels there are concerns, most likely he or she will consult a pediatric neurologist. In general, an MRI scan to evaluate a child simply because there are some mild delays in development would have a low probability of showing anything useful and would be expensive. An MRI is approximately $2,500 to $3,500 if the cost of sedation is included. Imaging has come a long way from the equipment we had in the 80s and 90s and thats why so many cases were missed or misdiagnosed. But having this new equipment doesnt mean we should abuse its capabilities. But at what point does the parent become overbearing and at what point does the pediatrician listen more closely? In one case, a father in Virginia told his pediatrician he was concerned that his first child wasnt walking by the age of one. The pediatrician responded by telling the father to relax because in some cases it takes up to 18 months for a child to begin walking. That same father had a third child who, at 15 months wasnt walking or talking. He was concerned, but remembered the conversation with the pediatrician about his first son. Fortunately his wife, who has a masters degree in education and an understanding of child development benchmarks, began to question their sons inability to meet those benchmarks. She was sure their son was behind and insisted on further testing. Once again, the rehabilitation center tried to convince the parents that they were being a little overcautious. Still, they insisted. When the testing was done, their son was diagnosed with severe ACC. He was already three months behind and none of the medical experts could predict whether or not their child would ever walk or talk. Optimistically, everyone agreed he was diagnosed early enough to be able to maximize his potential to develop whatever that potential. Sadly, ACC has its ranges of progress. What the ultimate outcome will be typically isnt known until the child is about five years old.
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The ACC one-two punch.


The degree to which someone with ACC is affected depends on a trump card associated with the disorder. In about 30 percent of the cases, the corpus callosus or the bridgecan be partially developed or it could be missing. What exaggerates the effects of ACC is when there is another problem in the brain development. This happens in about 70 percent of the cases and its called complex ACC. Dr. Tennison points out that he has seen children with no other identifiable abnormality and they child still shows substantial developmental difficulties. In a majority of the complex ACC cases, the missing bridge isnt the major concern. As with most congenital birth defects, when one anomaly is discovered, others can be present. The missing bridge of ACC is often a red flag that signals the child has been delivered a one-two punch. What that second punch is we dont always know, said Dr. Tennison. Its this hidden wild card that determines the degree at which the patient is affected. Many times we cant find that other element. We just see how it affects the patients motor skills and mental development as he or she grows. Its at about age 5, that the extent of the disorder can be gauged because this is the age a reliable IQ test can be administered. Dr. Tennison explains its this unknown that affects the ultimate outcome of the disease. Coping with the disease means early detection so training can start. ACC is at a disadvantage because they dont have the skills or ability to keep up, so they can ill afford to get behind. They need extra time learning basic motor skills and mental functions. The sooner they are diagnosed, the better their chances are of getting the most out of their abilities and giving them more opportunities to be Normal.

What advancements are being made in the treatment of ACC?


ACC doesnt get worse and it doesnt get better. Dr. Tennison says instead of treatment, the best hope for the future is detecting a propensity to developmental abnormalities and predicting them and one day treating them, before they happen. For now, the only thing to do is treat the symptoms. And the symptoms vary with every ACC affected individual. Unfortunately, there are no major advancements in curing ACC however; there have been advancements in the treatment. Treatment in the case of ACC means helping the child maximize his or her potential for motor skills. A child with ACC will work with a rehabilitative team, which may include physical therapy, speech therapy, a neurologist and pediatrician.

The outlook.
There is no cure for ACC, those affected have to be taught to adjust and live within their limitations. But according to Dr. Singh, there is some promising research on potentially correcting malformation of the brain. The research is in the early stages, he cautions, new research shows that the arrested development of the brain can potentially be restarted by correcting the chemical imbalances which control the migration of brain cells. This has only been done in animal models and not in humans, but he results have brought new hope to this field of neuroscience. There are a number of adults walking around today with partial ACC. Some will never know. Others may find out by accident. And 1 in 4,000 babies will be born with ACC this yearthat we know about. The only answer is close communication with your pediatrician.

Pediatric Benchmarks Ages 8 18 months. What To Expect


There are specific developmental benchmarks for children. As the child develops, parents should carefully measure the benchmarks and share the progress as well as any concerns with your pediatrician. Among the benchmarks for children from 8 to 18 months that include: Experience new senses of adaptation and anticipation such as playing hide and seek, peek-a-boo and other games. Becomes more deliberate and purposeful in responding to people and objects. Comprehends simple words and intonation of language such as all gone and bye-bye Begins speaking and actively experiment with their own voice. Can follow simple instructions, especially with visual or vocal cues. Hold large crayons, move them between hands, and make marks on paper.

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HighTech Dieting

he most difficult thing about a diet is being honest about exercise and eating right. And even when you are being honest, translating the results of diet and exercise can be little more than a guess.

Weight Watchers has teamed up with Philips technology to give its members a hightech means to accurately track activity and diet with a nifty new device called ActiveLink.

values I earned just by dancing and singing! ActiveLink has made me look at activity in a whole new way, said Weight Watchers Ambassador Jennifer Hudson of Chicago. I always track what I eat, but now seeing the results of also tracking my activity each day is challenging me to set higher goals. Plus, its helping me earn activity PointsPlus values, which for me means more chocolate!

ActiveLink Technology
The ActiveLink monitor is a three-way accelerometer that tracks body motion and provides a measure of acceleration. When combined with ones age, gender, height, and weight, it calculates how many activity PointsPlus values a person earns while wearing it. ActiveLink subscribers can then plug the ActiveLink monitor into their computer to upload the information onto their dashboard and receive customized challenges that will gradually increase over time plus activity tips to keep them moving and motivated. At Philips, our goal is to improve peoples lives through meaningful innovation, said Gopi Koteeswaran, General Manager at Philips. Working together on ActiveLink, Weight Watchers and Philips are delivering an innovative behavioral change experience that seamlessly integrates activity into the Weight Watchers approach. By translating movement into activity PointsPlus values a language that Weight Watchers members speak and a lifestyle they live every day were helping people to take control of a healthy lifestyle in a fun and engaging way. The ActiveLink monitor is available exclusively to Weight Watchers members with eTools and Weight Watchers Online subscribers, and can be purchased at participating Weight Watchers locations or via the eCommerce store at www.weightwatchers. com, and requires an additional monthly ActiveLink subscription. To learn more about ActiveLink, go to www.weightwatchers. com/getactivelink. -This information provided courtesy of Weight Watchers

ActiveLink, is the first and only activity monitor and web experience that translates movements to activity into a point monitoring system Weight Watchers calls PointsPlus. ActiveLink is available exclusively to Weight Watchers members and Weight Watchers Online Subscribers. Most of us tend to underestimate the amount of food we eat, and overestimate how much activity we get. We rarely exercise enough to burn off that cheeseburger or dessert like we planned, said Stacy Gordon, Senior Vice President, Products, Licensing & Publishing, Weight Watchers North America. ActiveLink takes the guess work out of it by more accurately estimating our activity level, and motivates us to set that bar even higher by getting more active. While activity has always been a key component of the Weight Watchers approach, ActiveLink provides members with eTools and Online subscribers a more accurate account of their current activity levels, which in turn motivates the user to make increased activity a healthy habit they develop for a lifetime. Powered by Philips technology, ActiveLink allows users to set personalized goals, seamlessly track their activity routines from walking the dog to hitting the gym to help them reach their goal of becoming more active over time. It aligns with Weight Watchers integrated approach to successful weight loss, which combines smarter eating, healthy habits, activity and a supportive environment. I wore my ActiveLink monitor during a recent performance and couldnt believe how many activity PointsPlus
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KNOW YOUR SPECIALIST


Dermatologist

W
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hat is a Dermatologist?
Your skin is your body's largest organ and it works non-stop taking care of you. It protects your other organs, warms you up and cools you down, and can reflect how healthy you are inside.

diagnosis is made, effective treatment can be safely and conveniently provided in the dermatologist's office. Advances in research and technology allow today's dermatologist to protect and care for your skin with the latest medical, surgical and cosmetic treatments. Dermatologists can impact the lives of patients of all ages the infant with a red birthmark, the child with eczema, the young man with a new growth on his skin, the baby boomer with sun-damaged skin, or the senior citizen with shingles effectively treating their skin conditions and making them look and feel their best.

For all it does for you, your skin deserves the expert care of a dermatologist, a doctor with extensive medical education, training and experience in keeping your skin, hair, and nails healthy, and healthy-looking, throughout your lifetime.

There Are Thousands of Reasons to See a Dermatologist


Even if you've been to a dermatologist before, you may not know about the thousands of ways this medical specialist can improve and maintain your skin's health. Your dermatologist is uniquely trained to analyze your skin with their eyes. They can spot potential problems and diagnose a multitude of conditions ranging from minor to life-threatening. Once a

Your Dermatologist's Training


After attending college, earning their four-year medical degree and completing an internship, dermatologists receive three more years of specialty training dedicated to the skin, hair, and nails. During this training, dermatologists learn how to diagnose and treat the more than 3,000 diseases that can affect the skin, hair and nails. Many dermatologists have general practices and see patients with all types

of skin concerns. Some dermatologists gain additional training and expertise in specific areas of dermatology such as, cosmetics, dermatopathology,(the specialty of diagnosing skin diseases by looking at samples under a microscope), pediatrics, or surgery. Most dermatologists are board-certified. A boardcertified dermatologist has successfully completed all their medical education and passed the rigorous examination provided by the American Board of Dermatology. The board exam tests the doctor's knowledge, experience and skills. This is essential to provide quality patient care in dermatology. Members of the American Academy of Dermatology who are board-certified can use the designation FAAD, following their MD. This stands for Fellow of the American Academy of Dermatology and demonstrates that the dermatologist has passed their board examination.

Remember, when considering a cosmetic procedure, that it is not just about your appearance and convenience. Undergoing a cosmetic procedure is about your health and safety first. Therefore, before undergoing any cosmetic procedure, patients should feel comfortable asking questions of the dermatologist. These questions should include asking about the doctors credentials and if they are boardcertified; how many of these procedures has the doctor performed; what are the expected results; and are there any risks. In addition, doctors should be able to show you before-and-after pictures from previous patients. The American Academy of Dermatology has a downloadable list of questions to ask prior to any cosmetic procedure and a video that demonstrates the importance of seeking a board-certified dermatologist for any cosmetic procedure.

Specialized Medical Care for the Life of Your Skin


Whether you need medical, surgical, or cosmetic treatment for your skin, you can find a dermatologist who meets your needs. In fact, dermatologists are credited with developing many common treatments and technologies widely used in patient care today, from cortisone and antifungal creams to harnessing the power of the laser for skin resurfacing and tattoo removal.

Preventing Future Problems


Dermatologists are a great resource for learning how to prevent skin, hair, and nail concerns. They can teach you how to protect yourself from the sun to avoid skin cancer, caution you about hair care practices that can contribute to hair loss, and advise you on how to care for your nails to prevent common conditions such as nail fungus.

The Dermatologist as an Important Member of your Health Care Team


Whether your dermatologist provides general medical care for the skin or focuses on a specialized area of medical, surgical, or cosmetic dermatology, he or she can be your trusted partner in maintaining the health of your skin, hair, and nails. To learn more, visit the American Academy of Dermatologys Derm A to Z, where you can find information and tips to maintain healthy skin, hair and nails. You also can locate an Academy member dermatologist in your area by typing in your zip code at Find A Derm. -This information provided courtesy of the American Academy of Dermatology

Diagnosing and Treating Disease


Dermatologists devote their skills and energy to treating medical conditions of the skin, such as acne, rashes, rosacea, psoriasis, warts, and skin cancer. They use the latest research to treat acute or chronic diseases that can be life-altering. Dermatologists also treat a number of skin diseases that are not visible on the skin, such as excess sweating and itchy skin.

Providing Surgical Solutions


All dermatologists are trained in surgical procedures, and some choose to specialize in surgery. They use leading-edge techniques, often invented or perfected by below dermatologists. For example, dermatologists refined the techniques used in Mohs surgery, a special surgery to remove some of the most common types of skin cancer. Dermatologists also developed tumescent liposuction, a technique to remove fat deposits which is performed in the dermatologist's office requiring only local anesthetic.

Enhancing Your Skin's Beauty


Some dermatologists improve the health and appearance of your skin with a variety of surgical and non-surgical cosmetic treatments including filling in or smoothing out wrinkles and scars, eliminating spider veins or skin discolorations, resurfacing skin with microdermabrasion or chemical peels, and removing or transplanting hair.
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What's Your UV: IQ?

The skin is the body's largest organ. It protects against heat, sunlight, injury, and infection. Yet, some of us don't consider the necessity of protecting our skin.
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t's just smart to take good care of your skin

When to protect your skin


UV rays are their strongest from 10 am to 4 pm Seek shade during those times to ensure the least amount of harmful UV radiation exposure. When applying sunscreen be sure to reapply to all exposed skin at least 20 minutes before going outside. Reapply sunscreen every two hours, even on cloudy days, and after swimming or sweating.

The need to protect your skin from the sun has become very clear over the years, supported by several studies linking overexposure to the sun with skin cancer. The harmful ultraviolet rays from both the sun and indoor tanning sunlamps can cause many other complications besides skin cancer - such as eye problems, a weakened immune system, age spots, wrinkles, and leathery skin.

How to protect your skin


There are simple, everyday steps you can take to safeguard your skin from the harmful effects of UV radiation from the sun.

Wear proper clothing. Wearing clothing that will protect your skin from the harmful ultraviolet (UV) rays is very important. Protective clothing like long-sleeved shirts and pants are good examples. Also, remember to protect your head and eyes with a hat and UVresistant sunglasses. You can fall victim to sun damage on a cloudy day as well as in the winter, so dress accordingly all year round. Avoid the burn. Sunburns significantly increase one's lifetime risk of developing skin cancer. It is especially important that children be kept from sunburns as well. Go for the shade. Stay out of the sun, if possible, between the peak burning hours, which, according to the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), are between 10 a.m. and 4 p.m. You can head for the shade, or make your own shade with protective clothing - including a broad-brimmed hat, for example. Use extra caution when near reflective surfaces, like water, snow, and sand. Water, snow, sand, even the windows of a building can reflect the damaging rays of the sun. That can increase your chance of sunburn, even if youre in what you consider a shady spot. Use extra caution when at higher altitudes. You can experience more UV exposure at higher altitudes, because there is less atmosphere to absorb UV radiation. Apply broad-spectrum sunscreen. Generously apply broad-spectrum sunscreen to cover all exposed skin. The broad spectrum variety protects against overexposure to ultraviolet A (UVA) and ultraviolet B (UVB) rays. The FDA recommends using sunscreens that are not only broad spectrum, but that also have a sun protection factor (SPF) value of at least 15 for protection against sun-induced skin problems. Re-apply broad-spectrum sunscreen throughout the day. Even if a sunscreen is labeled as "water-resistant," it must be reapplied throughout the day, especially after sweating or swimming. To be safe, apply sunscreen at a rate of one ounce every two hours. Depending on how much of the body needs coverage, a full-day (six-hour) outing could require one whole tube of sunscreen.

Protecting your eyes


UV rays can also penetrate the structures of your eyes and cause cell damage. According to the CDC, some of the more common sun-related vision problems include cataracts, macular degeneration, and pterygium (non-cancerous growth of the conjunctiva that can obstruct vision).

Wear a wide-brimmed hat To protect your vision, wear a wide-brimmed hat that keeps your face and eyes shaded from the sun at most angles. Wear wrap-around style sunglass with 99 or higher UV blockEffective sunglasses should block glare, block 99 to 100% of UV rays, and have a wraparound shape to protect eyes from most angles. Using the UV index
When planning your outdoor activities, you can decide how much sun protection you need by checking the Environmental Protection Agency's (EPA) UV index. This index measures the daily intensity of UV rays from the sun on a scale of 1 to 11. A low UV index requires minimal protection, whereas a high UV index requires maximum protection. -This information provided courtesy of U.S. Department of Health and Human Services
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Timing is Everything

ost weight-loss plans center around a balance between caloric intake and energy expenditure. However, new research has shed light on a new factor that is necessary to shed pounds: timing. Researchers from Brigham and Womens Hospital (BWH), in collaboration with the University of Murcia and Tufts University, have found that its not simply what you eat, but also when you eat, that may help with weightloss regulation. The study will be published on January 29, 2013 in the International Journal of Obesity. This is the first large-scale prospective study to demonstrate that the timing of meals predicts weightloss effectiveness, said Frank Scheer, PhD, MSc, director of the Medical Chronobiology Program and associate neuroscientist at BWH, assistant professor of medicine at Harvard Medical School, and senior author on this study. Our results indicate that late eaters displayed a slower weight-loss rate and lost significantly less weight than early eaters, suggesting that the timing of large meals could be an important factor in a weight loss program. To evaluate the role of food timing in weight-loss effectiveness, the researchers studied 420 overweight study participants who followed a 20-week weightloss treatment program in Spain. The participants were divided into two groups: early-eaters and late-eaters, according to the self-selected timing of the main meal, which in this Mediterranean population was lunch.
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During this meal, 40 percent of the total daily calories are consumed. Early-eaters ate lunch anytime before 3 p.m. and late-eaters, after 3 p.m. They found that lateeaters lost significantly less weight than early-eaters, and displayed a much slower rate of weight-loss. Researchers found that timing of the other (smaller) meals did not play a role in the success of weight loss. However, the late eaterswho lost less weightalso consumed fewer calories during breakfast and were more likely to skip breakfast altogether. Late-eaters also had a lower estimated insulin sensitivity, a risk factor for diabetes. The researchers also examined other traditional factors that play a role in weight loss such as total calorie intake and expenditure, appetite hormones leptin and ghrelin, and sleep duration. Among these factors, researchers found no differences between both groups, suggesting that the timing of the meal was an important and independent factor in weight loss success. This study emphasizes that the timing of food intake itself may play a significant role in weight regulation explains Marta Garaulet, PhD, professor of Physiology at the University of Murcia Spain, and lead author of the study. Novel therapeutic strategies should incorporate not only the caloric intake and macronutrient distribution, as it is classically done, but also the timing of food. -This information provided courtesy of Brigham and Women's Hospital

Mom, I miss you so much


Type 2 diabetes steals the lives we cherish most.
Nearly a quarter million a year. But it can be prevented. Nearly 80 million Americans have prediabetes. But because prediabetes doesnt always have symptoms, nine out of ten people who have it dont even know it. Know your risk before its too late. Especially if youre over 45 or overweight. More importantly, do something about it. Eat better, stay active and lose weight.

You have a lot to live for. Stop Diabetes . For yourself, and the people you love.

Learn how you can help Stop Diabetes. Visit checkupamerica.org or call 1-800-DIABETES (342-2383).

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A group member blogs about it, inspiring a woman in Dallas to reconnect with her own family.

Every Connection Counts at MSconnection.org