No New AIDS Infections by 2015: Goal Set at International AIDS Conference

July 23, 2010 (Vienna, Austria) — A goal of 0 new infections and 0 AIDS deaths by 2015 was set at an interactive town hall meeting organized by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the International AIDS Society, where speakers and meeting delegates shared ideas to help reshape the response to AIDS to achieve universal access to HIV prevention, treatment, care, and support for all in need. An underlying tenet of the discussion was that any efforts must respect human rights and that all governments must respect the human rights of people with HIV/AIDS.

The town hall meeting, entitled Towards a Paradigm Shift in HIV Treatment and Prevention, was held prior to the AIDS 2010: XVIII International AIDS Conference and enlisted a distinguish panel of speakers.

South Africa Pledges Strong Response to Fighting HIV Epidemic

South African Deputy President Kgalema Motlanthe committed his country to vigorously fight South Africa's HIV epidemic. Efforts have led to a drop in infections among the young for the first time, he said. "Patients started on treatment need to be maintained on treatment, even though we are going through an economic recession, because we believe that investing in HIV is investing in development," he said, "and South Africa has prioritized the AIDS response as an investment in life, hope, health systems, and human development with a view to improve the quality of life."

To "break the trajectory of the AIDS epidemic," South Africa has embarked on a very public campaign of testing and counseling for HIV, as well as for tuberculosis, diabetes, and cholesterol, Mr. Motlanthe said. "It is important for all of our people to know their [HIV] status."

South Africa has made a priority of mother-to-child HIV transmission, and the country is promoting medical male circumcision, which has been shown to reduce the risk for HIV transmission by 60%. "That has to be reintroduced" after being discontinued for more than 200 years in some areas, even if it means going against tradition, Mr. Motlanthe said. Traditional leaders have been brought on board to communicate this message.

Law is another area of reform in the South African response to HIV. "We are putting human rights and law to work for HIV [control] because we believe we cannot achieve a prevention revolution, or effective responses in general, without the protection and promotion of the rights of vulnerable groups, including people living with HIV, sex workers, men who have sex with men, [injection drug users], transgender people, women and girls, and prisoners," Mr. Motlanthe stated.

"Bringing culturally contentious issues, such as circumcision, injection drug use, and men who have sex with men, to the fore of public dialogue provides the impetus to shift social norms in support of more effective responses, because it frees people from being prisoners to prejudice," he said. South African President Jacob Zuma has openly supported these efforts.

Barbara Lee, a United States congresswoman from the 9th District of California, said that "it's important for leaders to get tested publicly" to show support for testing policies and to show that they, too, are willing to do it publicly and without embarrassment.

Mr. Motlanthe warned that programs on health must not be cut back under any circumstances, lest the gains that have been made be lost. "If we fail, we would be failing future generations, since it is our generation that is in the eye of this pandemic," he said.

Key Element in Fight Is Respect for Human Rights

Session moderator James Chau, news anchor for China Central Television and UNAIDS Goodwill Ambassador for China, asked Mphu Ramatlapeng, MD, minister of health and social welfare of Lesotho, her view of human rights. She responded by saying that "it means government has to have programs that protect the voiceless, the weak, the ill; in this particular respect, it means that we should have in place programs that will protect unborn children and women . . . programs that are accessible to all people."

She said she could be accused of "contravening civil rights because, honestly, I will have every pregnant woman tested. I'll have every child who is born tested in Lesotho." She said HIV is a national emergency: "If it means I'm accused of civil rights [violation], so be it. That's what I mean by human rights."

Congresswoman Lee added that "the struggle for human rights means providing equal access to everyone, including as it relates to healthcare, HIV, and AIDS, for the [men who have sex with men] community, for the [lesbian, gay, bisexual, transgender] community, for women who are commercial sex workers, for injection drug users, for women, for children, for everyone who has been shut out, for the most vulnerable."

An animated Mr. Chau asked the audience members to vote on issues and respond to questions by holding up a red or green card indicating their positions. Although low-tech, this audience-response system worked well, and the level of consensus was evident just by looking at the predominant color in the sea of cards.

When he asked whether human rights is the most important issue to be addressed, he estimated that about 80% of the audience held up green cards, indicating a "yes" vote. He then rushed into the audience to probe the reasoning behind people's answers. One "red card" respondent said that although he believes people should have a right to universal access to health services, he disagreed with mandatory testing and said people should have free choice whether to get tested.

Dr. Ramatlapeng emphasized to Medscape Medical News that although her position of universal mandatory testing could be seen as contravening civil rights, she does not see that it would violate human rights. She said she believes her role as minister of health is "to protect the voiceless, unborn children, and women who don't have enough information." Therefore, she said she will offer HIV testing as part of the battery of tests that pregnant women get but not require it if a woman declines. In any case, she said the newborn will be tested. "I have yet to meet a single mother who says 'I'm unhappy that I was tested, and I'm unhappy that my child has been looked after'."

Lesotho has been devastated by HIV and AIDS, Dr. Ramatlapeng explained. The government Web site reports that 31% of the population is HIV-positive. Life expectancy now is 45 years for men and 54.2 years for women, down from more than 60 years just 10 years ago. In a current population of 1.88 million (down from 2.1 million in 2001), there are 120,000 orphans, many of whom are looking after their siblings, she noted.

But she has confidence that Lesotho's program of testing, treatment, and counseling (even for seronegative individuals) is working. She said the incidence of HIV is already decreasing in people 15 to 25 years of age.

Better Access to Treatment Is Needed

Rolake Odetoyinbo, executive director of Positive Action for Treatment Access in Lagos, Nigeria, emphasized that "treatment is nonnegotiable." Adults must have access to treatment so that they can "stay alive to take care of our children," she said. "We do not want to become vehicles for HIV-negative orphans." She urged that infections in women and girls be addressed and that access to testing services for all pregnant women be provided.

Julio Montaner, MD, president of the International AIDS Society and chair of the AIDS 2010 Conference, did not recommend treating all infected individuals, but said that all who need treatment should be able to receive it. He said it would benefit the individuals and have a secondary effect in society by helping to prevent transmission of HIV. "Remember, it's not just preventing HIV. It's also preventing tuberculosis, putting people [back] to work, and consolidating families," he said.

Michel Sidibé, executive director of UNAIDS, stressed that in terms of funding prevention, screening, and treatment efforts, "it's not time to scale down. It's time to scale up." He urged full funding of the Global Fund to Fight AIDS, Tuberculosis, and Malaria by donor nations that pledged resources but have not committed them.

At a news conference at the AIDS meeting, Michel Kazatchkine, MD, executive director of the Global Fund, said that drugs for HIV treatment in Africa can be obtained for $120 per year per patient, and the total cost to treat 1 person is $460 per year.

Mr. Sidibé discussed Treatment 2.0, a simplified treatment platform that can be initiated in AIDS treatment centers and continued in primary care clinics. He and Dr. Kazatchkine linked treatment and prevention, because by treating HIV-infected individuals, new infections can be reduced.

The town hall meeting concluded with an appearance by Annie Lennox, singer, songwriter, long-time AIDS activist, and International UNAIDS Goodwill Ambassador, who concluded the session by asking the leaders and activists on the program and the delegates in the audience to recommit their efforts and to take them further.

AIDS 2010: XVIII International AIDS Conference: XVIII International AIDS Conference. Presented July 18, 2010

Glaucoma Patients Struggle With Applying Eyedrops

NEW YORK (Reuters Health) Jul 22 - People most in need of sight-preserving eyedrops may be the least successful in landing the therapy in their eyes, suggests a new study.

Based on observations of a large number of people with glaucoma, the researchers found that more than half struggled to apply their eyedrops properly -- including many patients who thought their technique was perfect.

"Getting eyedrops into the eye is not the same as asking a patient to swallow a pill, or use a skin cream," lead researcher Dr. Amy Hennessy of The Johns Hopkins Bloomberg School of Public Health, in Baltimore, told Reuters Health in an e-mail. "It's easier said than done."

After noticing that many of their glaucoma patients were doing a "miserable job" of putting drops in their eyes, frequently launching them onto cheeks and eyelids, Dr. Hennessy and her colleagues decided to videotape about 200 glaucoma patients with impaired vision as they gave themselves eyedrops the way they would at home.

Most patients had been using eyedrops for at least 6 months, but when the researchers watched the videos, more than a quarter were unable to get a drop into their eye, they reported online June 25th in Ophthalmology.

And of those that could, only about 40% managed to administer just one drop -- the prescribed amount -- onto the eye without touching the bottle to its surface. The average number of drops instilled was almost one and a half.

The study was partly funded by Alcon, an eyedrop manufacturer. One of the authors is an Alcon employee, and another has consulted for the company.

Applying either too few or too many drops could lead to insufficient treatment and faster progression of glaucoma, Dr. Hennessy noted. For example, patients could run out of the medicine before insurance allows them to refill their monthly prescription.

"What was more surprising was that patients also had a poor perception of their abilities to administer drops," she added. A quarter of the patients who denied ever touching the bottle to the surface of their eye were observed doing just that.

A few of the video recordings did pleasantly surprise the team, and provided hope that the challenge was not insurmountable. "Some patients who could no longer see the eye chart had developed a system of localizing the drop over their eye," said Dr. Hennessy, "and got it in correctly -- every time!"

The researchers also looked to see what kind of factors, including sex and years with glaucoma, might influence successful application of the eyedrops. In the end, only age appeared important: Patients at least 70 years old were 60% less likely to apply the drops successfully compared to younger patients.

Dr. Hennessy suggests that these findings highlight the need for eye care providers to teach patients the best way to administer the drops, which is usually with a mirror, tilting the head back and placing the drop in the eye while holding down the lower eyelid. Family members and certain devices may also be of help.

"Glaucoma patients are not the only ones using drops -- other areas of eye care also rely on drops," she said. "So this is not a small problem, especially with our aging population."

Bone 'turnover' link to diabetes

The skeleton has a key role in regulating blood sugar and may be the underlying cause of diabetes in some people, say US researchers.

A study in mice found that the breakdown of old bone to make way for new bone growth also helps to keep a healthy level of glucose in the blood.

A hormone called osteocalcin seems to be the link, it showed.

The Columbia team, writing in Cell, say the findings may lead to better drugs to help control Type 2 diabetes.

Study leader Dr Gerard Karsenty, from Columbia University Medical Center, had already done work showing osteocalcin, which is released by bone, can regulate glucose levels.

It switches on the production of insulin in the pancreas which in turn improves the ability of other cells to take in glucose from the blood.

But in the latest study, he found that osteocalcin only works when bone is being broken down during its natural turnover.

Further tests on osteocalcin and glucose levels in a small group of patients with a genetic defect in their bone turnover supported the initial findings in mice.

'Important implications'

Type 2 diabetes is the most common form of the condition and is caused when the body no longer properly responds to insulin leading to out of control blood sugar.
The results suggest that for some people, diabetes may be triggered by changes in the skeleton.

Also drugs designed to stimulate this link between bone and insulin may lead to better treatments for type 2 diabetes, he adds.

One important consequence of the finding is that bone-strengthening drugs used in conditions such as osteoporosis may interfere with this process and cause problems with blood sugar.

"This research has important implications for both diabetes and osteoporosis patients," he said.

"First, this research shows that osteocalcin is involved in diabetes onset

"Secondly, bone may become a new target in the treatment of type 2 diabetes as it appears to contribute strongly to glucose intolerance

"And finally, osteocalcin could become a treatment for type 2 diabetes."

Dr Victoria King, head of research at Diabetes UK, said: "The research is interesting and this area of investigation could open up the possibility of more targets for drugs to treat or prevent type 2 diabetes."

But she warned the research was in the very early stages.

"What we do know at this stage is that lifestyle changes such as maintaining a healthy weight, eating a balanced diet and being more physically active can help to reduce your risk of developing type 2 diabetes, and can also help people diagnosed with the condition to manage it more effectively."

Fecal Calprotectin a Sign of Inflammatory Bowel Disease

July 22, 2010 — A new approach to the diagnosis of inflammatory bowel disease (IBD) — fecal calprotectin testing — is a useful tool for identifying patients who are most likely to need endoscopy for suspected IBD, thereby reducing the number of unnecessary endoscopies, according to a meta-analysis published online July 16 in the British Medical Journal.

"Endoscopic evaluation with histopathological sampling is generally considered indispensable in the investigation of patients with suspected [IBD]," write Patrick F. van Rheine, MD, from Beatrix Children's Hospital, University Medical Center Groningen, the Netherlands, and colleagues. "In a relatively large proportion of people with suspected [IBD,] the results of endoscopy will be negative."

The aim of this meta-analysis was to evaluate whether adding fecal calprotectin testing to the work-up of patients with suspected IBD would reduce the number of unnecessary endoscopies.

Calprotectin is a major protein found in inflammatory cells. It is stable in stool samples for up to 7 days at room temperature, and 1 sample of less than 5 g is sufficient to allow for reliable measurement.

The analysis included 13 prospective studies that compared fecal calprotectin testing with endoscopy as the reference test. Six were done in adults (n = 670), and 7 in children and teenagers (n = 371).

IBD was confirmed in 32% (n = 215) of the adults and in 61% (n = 226) of the children and teenagers. In adults, the pooled sensitivity of fecal calprotectin testing was 0.93 (95% confidence interval [CI], 0.85 - 0.97), and the pooled specificity was 0.96 (95% CI, 0.79 - 0.99). In children and teenagers, the pooled sensitivity was 0.92 (95% CI, 0.84 - 0.96), and the pooled specificity was 0.76 (95% CI, 0.62 - 0.68).

The lower specificity in children and teenagers was significantly different from that in adults (P = .048).

The authors report that screening with fecal calprotectin would reduce the number of adults requiring endoscopy by 67%. They add that 3 of 33 adults who undergo endoscopy will not have IBD but may have a different condition that would still necessitate having an endoscopy.

In children and teenagers, screening with fecal calprotectin would reduce the number of endoscopies by 35%.

However, the downside of such screening would be a delayed diagnosis in 6% (2/32) of affected adults and in 8% (5/61) of affected children because of false-negative test results.

The authors write that the clinical consequences of missing patients with IBD should be balanced against patients without the disease being subjected to endoscopy. A false-negative fecal calprotectin test would lead to delayed treatment and continuation of symptoms, whereas a false-positive test would lead to an unnecessarily invasive endoscopy with possible complications from colonic perforation or tear and anesthesia.

The researchers also point out methodological limitations of their meta-analysis. Two of the included studies in adults did not sample intestinal mucosa, which might have caused some patients to be misclassified as normal. In addition, none of the studies used a well-defined set of clinical findings or flow chart to identify patients with a high probability of IBD. In addition, the number of studies included in the meta analysis was limited, and the studies were restricted to those written in English.

Despite these limitations, the study demonstrates that measuring fecal calprotectin levels is a useful screening tool for identifying patients most likely to need endoscopy, and the test can contribute important information to guide patient management at a tertiary-care level, the authors write.

Finally, they note that the pooled sensitivity and specificity found in their study should be interpreted with caution. "Despite a strict selection of studies based on proper patient recruitment and study design, heterogeneity was considerable."

In an accompanying editorial, Robert Logan, MD, from Kings College Hospital, London, United Kingdom, writes that the sensitivity of 93% and specificity of 96% of the fecal calprotectin test is remarkable, "considering the diverse and complex antigenic environment of faeces."

However, the test cannot be recommended as a diagnostic test for IBD in primary care because the results of the study apply to patients referred to secondary care. In primary care, patient characteristics and populations are "probably different," which would affect the negative and positive predictive value of fecal calprotectin screening.

"If studies conducted in primary care find a high diagnostic accuracy of the faecal calprotectin test it will be an important step forward in how [IBD] is diagnosed," he concludes.

The study authors and Dr. Logan, the editorialist, have disclosed no relevant financial relationships.

Tips for preventing heat stroke and dehydration while exercising.

Tips for preventing heat stroke and dehydration while exercising.

Toxic Makeup Draws Congressional Attention

Congress and the cosmetics industry are both calling for tighter regulation of the chemicals used in cosmetics and other personal care products due to concerns over possible carcinogens and other toxic ingredients.

In Congress, Rep. Jan Schakowsky (D-Ill.) introduced a bill on Tuesday calling for cosmetics makers to register with the federal government and for larger cosmetics firms to pay user fees to enforce the regulation. The Safe Cosmetics Act of 2010 also would require all ingredients in a cosmetic product to be listed on the product's label and would give the Secretary of Health and Human Services two years to develop a list of prohibited or restricted ingredients.

Cosmetics manufacturers would be required to notify the federal government of consumers who reported experiencing adverse health effects from their cosmetics and to use alternatives to animal testing of products.
Schakowsky said during a teleconference Wednesday that she introduced her bill -- which was cosponsored by Reps. Tammy Baldwin (D-Wisc.) and Ed Markey (D-Mass.) -- because "Americans need to know that their cosmetics and personal care products don't contain chemicals that could harm them."

She noted that cosmetics manufacturers aren't currently required to list all their ingredients on the package, "and when investigators have gone looking, they have turned up toxic chemicals: A recent Chicago Tribune investigation sent skin lightening creams to a lab for testing and found dangerous levels of mercury -- a banned substance -- in some of the products."
Schakowsky said that current cosmetics laws are "woefully out of date, and Americans are at risk of being unknowingly exposed to harmful chemicals."

For its part, the Personal Care Products Council, a lobbying group for cosmetics manufacturers, released its own plan for regulation in mid-July, which included requiring all cosmetics manufacturing facilities to register with the U.S. Food and Drug Administration, to disclose all product ingredients to the FDA, and to report any serious adverse events to the agency. It also would require the FDA to establish safe levels for trace constituents in cosmetic ingredients and products.

Vitamin E–Rich Foods May Reduce Long-Term Risk for Dementia

July 22, 2010 — Vitamin E may play a modest role in altering the course of dementia, say researchers. Compared with participants with the lowest intake, investigators found that those patients with higher vitamin E intake were 25% less likely to develop dementia.

"When beta-amyloid — a hallmark of pathologic Alzheimer disease — accumulates in the brain, an inflammatory response is likely evoked that produces nitric oxide radicals and downstream neurodegenerative effects," report investigators led by Elizabeth Devore, ScD, from the Erasmus Medical Center in Rotterdam, the Netherlands. "Vitamin E is a powerful fat-soluble antioxidant that may help to inhibit the pathogenesis of dementia."
The results appear in the July issue of the Archives of Neurology and suggest that dietary antioxidants affect the early stages of dementia.

Vitamin E is found in whole-grain foods, eggs, milk, nuts, seeds, avocado, spinach, and unheated vegetable oils. The Rotterdam Study previously found that higher dietary intakes of vitamins E and C were associated with a lower risk for dementia and Alzheimer's disease.

In this new long-term follow-up of the Rotterdam Study, investigators followed participants for 9.6 years. The population-based prospective cohort study included 5395 people free of disease at baseline.

A total of 465 people developed dementia. Of these, 365 were diagnosed with Alzheimer's disease. The investigators found that higher dietary intake of vitamin E, but not vitamin C, beta carotene, or flavonoids, was associated with lower long-term risk for dementia.

These results conflict with previous findings, which suggested a link between vitamin C intake and dementia risk. "The result was modest in our analysis," note the investigators, who reported a hazard ratio of 0.66 (95% confidence interval, 0.44 - 1.00). "Chance is the most likely explanation," they add. "Alternatively, vitamin C intake could be important exclusively at later stages of dementia development, but this is less likely because results of previous studies suggest that dietary antioxidants affect early stages of dementia pathogenesis."

Long-Term Prospective Study

The investigators adjusted for age, education, apolipoprotein E ε4 genotype, total energy, alcohol intake, smoking habits, body mass index, and supplement use. They found that higher vitamin E intake at study baseline was associated with lower long-term risk for dementia (P = .02 for trend).

Asked by Medscape Medical News to comment, Maria Carrillo, PhD, senior director of medical and scientific relations at the Alzheimer's Association, pointed out the National Institutes of Health have been calling for long-term prospective studies such as this one. "These are important studies, and this one was conducted by a fantastic, internationally renowned group."

Dr. Carrillo acknowledged the finding is preliminary — it is still too early for specific recommendations on vitamin E intake, and excessive use can have negative cardiovascular effects, she said.

"Future studies should continue to evaluate dietary intake of antioxidants relative to dementia risk," note the investigators, "including different points at which antioxidant intake might modulate risk."

This study was supported by the Netherlands Organization for Scientific Research, the National Institutes of Health, and a US Fulbright Fellowship to the Netherlands. The researchers have disclosed no relevant financial relationships.

Two-Item and Nine-Item Screening Tests May Be Useful to Detect Major Depression

July 22, 2010 — Two-item and nine-item screening tests may be useful to detect major depression, according to the results of a large validation study reported in the July/August issue of Annals of Family Medicine.

"Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen," write Bruce Arroll, MBChB, PhD, from the Department of General Practice & Primary Health Care in Auckland, New Zealand, and colleagues. "Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9."

At Auckland family practices, 2642 consecutive adult patients completed the PHQ-9 and then completed the Composite International Diagnostic Interview as a reference standard for depression. The investigators determined sensitivity and specificity of the PHQ-2 and the PHQ-9 for diagnosing major depression.

For a score of 2 or higher on the PHQ-2, sensitivity was 86% and specificity was 78%. For a score of 3 or higher, values were 61% and 92%, respectively. A score of 2 or higher on the PHQ-2 identified more cases of depression than a score of 3 or higher.

For a score of 10 or higher on the PHQ-9, sensitivity was 74% and specificity was 91%. Use of this cutoff point detected more cases of major depression than the PHQ scoring for major depression initially described by the original authors of this test in 1999.

"The PHQ-2 score of 2 or higher had good sensitivity but poor specificity in detecting major depression," the study authors write. "Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression."

A limitation of this study is possible lack of generalizability to primary care settings other than in New Zealand.

"For clinicians who wish to screen their patients for depression, we suggest they ask patients to respond to the first 2 questions of the PHQ-9 (ie, the PHQ-2); if their score is positive (if they score 2 or more), the patients should then complete the PHQ-9," the study authors conclude. "....A reevaluation of the original PHQ-9 criteria for major depression may also be needed, as the simple additive score PHQ-9 of 10 or higher identified more patients with depression than the originally described (and more time-consuming) method for scoring the PHQ-9."

The Health Research Council of New Zealand supported this study. The study authors have disclosed no relevant financial relationships.

First-Morning Void May Be Best Predictor of Renal Events in Diabetic Nephropathy

July 22, 2010 — Albumin-to-creatinine ratio (ACR) in a first-morning void may be the best predictor of renal events in patients with type 2 diabetes and kidney disease, according to the results of the Reduction in Endpoints in Non Insulin Dependent Diabetes Mellitus with the Angiotensin-II Antagonist Losartan (RENAAL) trial reported Online First July 15 in the Journal of the American Society of Nephrology.

"From a clinical point of view, these results are very important, because they imply that collection of first morning voids, which is clearly more convenient than collecting a 24-hour urine, can be used for assessment of proteinuria," said lead author Hiddo J. Lambers Heerspink, PharmD, PhD, from University Medical Center Groningen, in Groningen, the Netherlands, in a news release.

With a study sample of 701 participants with type 2 diabetes and nephropathy enrolled in the RENAAL trial, the goal of the study was to compare prediction of renal events by urinary protein excretion (UPE) and urinary albumin excretion (UAE) from a 24-hour urine collection vs urinary albumin concentration (UAC) and ACR from a first-morning void. Time to a doubling of serum creatinine or end-stage renal disease was the main study endpoint.

There were 202 renal events during follow-up. For each 1-SD increase in the log-transformed measures, the hazard ratios (HRs) for the risk for a renal outcome were 3.16 (95% confidence interval [CI], 2.60 - 3.86) for UAE, 3.02 (95% CI, 2.53 - 3.62) for UPE, 3.23 (95% CI, 2.67 - 3.91) for UAC, and 4.36 (95% CI, 3.50 - 5.45) for ACR. Compared with the other measures, the area under the receiver operating characteristic curve was significantly higher for ACR.

"[F]or predicting renal disease progression in patients with type 2 diabetes and nephropathy, collecting first morning void urine samples and measuring the albumin:creatinine ratio appear to be superior when compared with measuring 24-hour urinary albumin excretion," the study authors write. "These results are clinically important because they imply that collection of first morning voids, which is clearly more convenient than collecting a 24-hour urine, can be used for assessment of proteinuria."

Limitations of this study include inability to directly apply the results to individuals without diabetes or nephropathy. In addition, total protein concentrations were not measured in a first-morning void urine sample, precluding comparison between protein-to-creatinine ratios and ACRs derived from a first-morning void.

In an accompanying editorial, Bryan Kestenbaum, MD, and Ian de Boer, MD, from the University of Washington in Seattle, discuss the implications of this study for clinical practice and for clinical research.

"Given data from this study and the considerable patient effort required for a 24-hour urine collection, we agree with the authors that the first morning albumin:creatinine ratio is in general the logical choice for quantifying proteinuria in clinical practice," they write. "First, urine ACR represents more than simply proteinuria, and associations of urine ACR with disease outcomes should be interpreted in the context of dual contributions of urine albumin excretion and urine creatinine. Second, this study [begs] the questions, 'Why is low urine creatinine excretion associated with adverse kidney and cardiovascular disease outcomes independent of standard measures of body composition?' 'Does a low urine creatinine concentration reflect low muscle mass, low muscle quality, or both?' 'Is a low urine creatinine concentration a modifiable therapeutic target?'"

The RENAAL study was sponsored by Merck & Co, Inc. One of the study authors is an employee of Merck, and 4 other study authors are members of the RENAAL Steering Committee and have received grants from Merck. The editorialists have disclosed no relevant financial relationships.

J Am Soc Nephrol. Published online July 15, 2010.

Mobiles may increase risk of tinnitus, study suggests

Regularly using a mobile phone may increase the risk of tinnitus, which involves constant ringing or buzzing in the ear, a small study suggests.

Austrian researchers recruited 100 people with the condition and 100 without, and compared mobile phone use.

They found tinnitus was over 70% more likely in those averaging 10 minutes' daily phone use, reported Occupational and Environmental Medicine journal.

But the British Tinnitus Association said a link was unproven.

While intense noise, head trauma and certain drugs are all known to increase the risk of the ear condition, in many cases the reasons are unknown.

Researchers from the Medical University of Vienna said the evidence so far linking mobiles with tinnitus was anecdotal, but that their small study suggested at the very least it warranted further investigation.

Because of the widespread use of the devices, even a slightly increased risk would be of "public health importance", they wrote, particularly given that the condition can in some cases profoundly interfere with daily life.

It is thought about 10% of the population have some form of tinnitus, but it is unclear whether the condition is becoming more prevalent.

Ear energy

As well as the 70% increased risk from using a phone for more than 10 minutes a day, they found that having used a phone for more than 160 hours cumulatively was associated with a 60% increased risk.

But their study did throw up statistical anomalies, finding a lower risk among those who had made 4,000 calls or more than those who had made fewer.

The team acknowledged that asking people to recall their use was problematic, leading to both over-estimation and underestimation.

But lead author Dr Hans Peter Hutter said there were biological mechanisms by which mobiles could cause ear problems.

The cochlea, the spiral-shaped organ that translates sounds into electrical impulses the brain can understand, and the auditory pathway "are located in an anatomical region where a considerable amount of the power emitted by mobile phones are absorbed".

It is also possible that prolonged, constrained posture using a phone while walking and talking could affect blood flow in that side of the head.

These reasons are more likely than simply the sound of speech on the other end of the line.

Veronica Kennedy, a consultant and adviser to the British Tinnitus Association, said: "The association between tinnitus and electromagnetic fields is not a new idea with electromagnetic fields being put forward both as a cause and treatment for tinnitus.

"Some people have attributed their tinnitus to the sounds generated by electromagnetic fields within modern electrical wiring or power plants. Electromagnetic therapy has also been used to treat tinnitus. This is an interesting study but there are a number of complex factors underlying tinnitus which have not been addressed in the study.

"The link between mobile phone use remains unproven with further work still needed."

Bisphosphonates for Osteoporosis Reduce Risk for Breast Cancer

July 20, 2010 — Two retrospective studies suggesting that postmenopausal women who take oral bisphosphonates for osteoporosis have a reduced risk for breast cancer were published online June 21 in the Journal of Clinical Oncology.

Both studies were presented at the San Antonio Breast Cancer Symposium last year, as reported by Medscape Medical News at the time.

A third similar study was published earlier this year in the British Journal of Cancer.

Interestingly, all 3 studies show that bisphosphonate use reduces the relative risk for breast cancer by approximately 30%, writes Michael Gnant, MD, from the Medical University of Vienna, Austria, in an accompanying editorial.

However, because these were all retrospective studies, with confounders that might not have been controlled, these findings should "be viewed as hypothesis generating and not practice changing at this time," he writes.

"At this point, it would be premature to recommend the use of oral bisphosphonates to prevent breast cancer in all postmenopausal women," Dr. Gnant says.

"However, it is not unreasonable to consider the potential anticancer benefits of bisphosphonate therapy, in addition to its bone-protecting effects, when evaluating treatment options in women with postmenopausal osteoporosis, especially considering that bisphosphonates are well tolerated in this population," he concludes.

Data from the WHI Study

The largest of the studies, by Rowan Chlebowski, MD, PhD, from the University of California, Los Angeles, and colleagues, evaluated data from the Women's Health Initiative (WHI). Of the 154,768 participants, 2,816 postmenopausal women were taking oral bisphosphonates when they entered the study (90% were taking alendronate, 10% etidronate).

In carrying out their analysis, the researchers controlled for bone mineral density (BMD); low BMD is an indication for bisphosphonate use and is associated with a lower incidence of breast cancer.

After a mean of 7.8 years of follow-up, there was a significant reduction in the incidence of invasive breast cancer in women who had taken oral bisphosphonates (32% reduction; P < .01), and in the incidence of estrogen-receptor (ER)-positive invasive cancers (30% reduction; P = .02). A similar but nonsignificant trend was seen in ER-negative breast cancer.

"The findings are consistent with a direct effect of bisphosphonates on slowing or inhibiting growth of preclinical but already established breast cancers," Dr. Chlebowski and colleagues write.

However, there was a significant increase in the incidence of ductal carcinoma in situ (DCIS) in women taking oral bisphosphonates.

"The clinical significance of this finding is uncertain, as much DCIS either does not develop into invasive breast cancer or does so with such delay to question clinical relevance," the researchers note.

"In any event, if bisphosphonates prevent in situ cancers from progressing to an invasive stage or influence only invasive cancer, a relative increase in in situ cancers could occur," they speculate. They add that a similar observation came out of the Study of Tamoxifen and Raloxifene (STAR) in breast cancer prevention; although there was a significant decrease in invasive breast cancer with both drugs, there was a strong trend toward an increase in in situ cancers with raloxifene.

"As oral bisphosphonates are in widespread and increasing use in clinical practice, these findings have public health implications," Dr. Chlebowski and colleagues conclude.

Similar Findings From 2 Other Studies

The second study comes from Gad Rennert MD, PhD, from the Clalit Health Services National Cancer Control Center in Haifa, Israel, and colleagues.

They analyzed the pharmacy records of 4039 postmenopausal women, 1832 of whom were diagnosed with breast cancer; the remainder acted as control subjects. They found that 10.5% of patients and 14.8% of control subjects had used oral bisphosphonates, most commonly alendronate.

Dr. Rennert and colleagues calculated that taking bisphosphonates for a year or more reduced the risk for breast cancer by 28%.

In addition, the tumors detected in bisphosphonate users were different from those in nonusers; they had better prognostic markers, and there were significantly more ER-positive tumors and significantly fewer poorly differentiated tumors.

"The data support a possible significant protective effect of the use of bisphosphonates against breast cancer development," Dr. Rennert and colleagues conclude.

The study did not control for low BMD, which is known to be associated with a lower risk for breast cancer. But the finding that bisphosphonates need to be taken for a year before a preventive effect on breast cancer is seen "supports the notion that the effect seen is a reflection of the drug itself, and not the underlying condition of low bone density or osteoporosis," they note.

The third study, published earlier this year in the British Journal of Cancer (2010;102:799-802), comes from Polly Newcomb, PhD, MPH, and colleagues from the University of Wisconsin in Madison. They analyzed data for 2936 women with breast cancer and 2975 control subjects, and found a 33% reduction in the risk for breast cancer among current bisphosphonate users.

"Although this is a smaller study, this represents an additional independent report of the correlation between bisphosphonate use and decreased cancer risk," Dr. Gnant notes in his editorial.

"These significant correlations are profound and intriguing," he points out. "They suggest that bisphosphonate-induced changes to the microenvironment surrounding potential cancer cells can be exploited in preventing breast cancer."

Effect Also Seen in Breast Cancer Patients

Dr. Gnant points out that the potential anticancer effects of bisphosphonates have also been reported in several studies of women who already have breast cancer, including one by his team. In that study, the Austrian Breast and Colorectal Cancer Study Group trial (n = 1803), and in ZO-FAST (Zometa-Femara Adjuvant Synergy Trial; n = 1065), the intravenous bisphosphonate zolendronic acid reduced cancer recurrence in bone and nonbone sites, including contralateral breast cancer, he notes.

There were also 2 previous studies of the oral bisphosphonate clodronate in women with breast cancer (total n = 1371) that showed a delay in the development of bone metastases and an improvement in disease-free and overall survival.

In addition, laboratory studies suggest that bisphosphonates have both direct and indirect anticancer effects, including effects on cancer cell apoptosis, inhibition of cancer cell adhesion and extravasation, inhibition of angiogenesis, and activation of immune cells with anticancer activity.

It is possible that these are a class effect of the bisphosphonates, Dr. Gnant writes.

All of these researchers and the editorialist urge further study in this field, because, as Dr. Gnant writes, "the potential implications would be far-reaching."

Dr. Gnant reports acting as a consultant/advisor, and/or receiving honoraria and/or research funding from AstraZeneca, Novartis, Pfizer, Roche, and Sanofi-Aventis. Dr. Chlebowski reports acting as a consultant/advisor for AstraZeneca, Novartis, Pfizer, Amgen, and Eli Lilly, and receiving honoraria from AstraZeneca, Novartis, and Amgen. Several coauthors report links with Novartis and Merck, and one coauthor holds stock in Merck. Dr. Rennert, Dr. Newcomb, and their colleagues have disclosed no relevant financial relationships.

J Clin Oncol. Published online June 21, 2010. Abstract, Abstract, Abstract

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Authors and Disclosures
Journalist
Zosia Chustecka
Zosia Chustecka is news editor for Medscape Hematology-Oncology and prior news editor of jointandbone.org, a Web site acquired by WebMD. A veteran medical journalist based in London, UK, she has won a prize from the British Medical Journalists Association and is a pharmacology graduate. She has written for a wide variety of publications aimed at the medical and related health professions. She can be contacted at ZChustecka@webmd.net.

Zosia Chustecka has disclosed no relevant financial relationships.

Lung Cancer Often Recurs More Than 5 Years After Resection

NEW YORK (Reuters Health) Jul 16 - Patients with non-small-cell lung cancer (NSCLC) who don't have recurrence for 5 years after resection may not yet be free and clear. Some patients with certain tumor characteristics are at significant risk for a late recurrence, a Japanese team reports in the July issue of Chest.

Dr. Junji Yoshida and colleagues with the National Cancer Center Hospital East in Chiba analyzed data on 1358 patients who had complete resection of NSCLC with systematic lymph node dissection; 819 of them were free of recurrence for 5 years.

Subsequently, 87 of these patients (11%) had a late recurrence.

"Five years is not enough." Dr. Yoshida commented in an email to Reuters Health. "This is both for patient follow-up and for outcome evaluation. Five years has been the standard for both in lung cancer, but we showed there were a significant percentage of NSCLC patients developing recurrence beyond 5 years after surgical resection."

On multivariate analysis, the team found that factors disposing to recurrence more than 5 years after resection were intratumoral vascular invasion and nodal involvement.

Specifically, they report, "The 5-year recurrence-free probabilities from the point of 5 years after primary tumor resection were 81% for patients with intratumoral vascular invasion (p<0.001), and 89%, 84%, and 65% for patients with N0, N1, and N2 cancers, respectively (p<0.001)."

"Patients with vascular invasion positive tumors are at almost a 2-fold risk and those with nodal involvement tumors are at a 4-fold risk of a late recurrence," Dr. Yoshida stated.

Summing up, he said, "Similarly to colorectal cancer, we need to follow lung cancer patients beyond 5 years and to evaluate treatment outcome based on 10-year follow-up."

In their paper, Dr. Yoshida and his colleagues add, "This has implications for whether scheduled long-term follow-up beyond 5 years is warranted, or whether patients should simply be counseled on symptom recognition."

SOURCE: http://link.reuters.com/dyh97m

Scientists say vaginal gel cuts HIV-infections by half

The gel, containing the Aids drug tenofovir, cut infection rates by 50% after one year of use, and by 39% after two and a half years, researchers said.

If the results are confirmed it would be the first time that a microbicidal gel has been shown to be effective.

Such a gel could be a defence for women whose partners refuse to wear condoms.

New ways of curbing the spread of HIV are badly needed, particularly in sub-Saharan Africa, where nearly 60% of those infected with the virus are women.

Many women are often forced to take part in unsafe sex, and are biologically more vulnerable to HIV infection than men, making a gel they apply an attractive option.

Welcoming the results, UN agencies said they would convene an expert consultation in South Africa next month to discuss the next steps with the product.

'Just pennies'

The results of the three-year study, which was completed by the Centre for the Aids Programme of Research in South Africa (Caprisa), are being presented at an international aids conference in Vienna and were published on Monday by the US magazine Science.

The gel was found to be both safe and acceptable when used once in the 12 hours before sex and once in the 12 hours after sex by women aged 18 to 40 years.

Salim Abdool Karim, one of the two leading co-researchers, told reporters in Vienna that the 889 women involved in the trial, conducted in the coastal city of Durban and a remote rural village, had largely used the gel as directed.

They were also given condoms and advice about sexually transmitted diseases, and tested for HIV once a month.

After 30 months, 98 women became infected with HIV - 38 in the group that got tenofovir in the gel and 60 in the group that got placebos.

"We showed a 39% lower incidence of HIV in the tenofovir group," Dr Karim said.

Tenofovir, he added, lowered the risk of infection by 50% at 12 months but then the efficacy declined.

Women who used the gel more consistently were much less likely to be infected, he said.

He added that he did not know how much each dose would cost but said the applicators and gel cost "just pennies".

"Boy, have we been doing the happy dance," Dr Karim, from the University of KwaZulu-Natal in Durban, said.

'Hope for women'

"It's the first time we've ever seen any microbicide give a positive result that you could say was statistically significant," said Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

The researchers say women who used the gel also showed a significant reduction in genital herpes, a common sexually transmitted infection, which itself increases the risk of HIV infection.

The UN's HIV/Aids agency noted that nearly 20 years of research had gone into microbicides that can be controlled by a woman, independent of her partner.

"We are giving hope to women," said Mr Michel Sidibe, executive director of UNAids.

"For the first time we have seen results for a woman-initiated and controlled HIV prevention option."

A microbicide, he said, would be a "powerful option for the prevention revolution and help us break the trajectory of the Aids epidemic".

Dr Margaret Chan, director-general of the World Health Organization, welcomed Caprisa's findings.

"We look forward in seeing these results confirmed," she said.

"Once they have been shown to be safe and effective, WHO will work with countries and partners to accelerate access to these products."

US Scientists Engineer Malaria-Proof Mosquito

American scientists have created genetically altered mosquitoes that cannot infect humans with malaria.

The scientists from the University of Arizona introduced a gene that affects the insect's gut, rendering it incapable of sustaining the malaria parasite.

The study appears in the journal Public Library of Science Pathogens.

The researchers hope to eventually introduce the genetically altered mosquitoes into the wild in hopes of wiping out the disease-carrying insects.

Nearly 250 million people worldwide are infected with malaria every year.

AIDS Tops List of Global Health Concerns

A new international opinion poll shows AIDS tops the list of health concerns among people in countries in all regions of the world. The poll was conducted by UNAIDS and Zogby International before a major AIDS conference next week in Vienna.

Nearly 30 years into the AIDS epidemic, the first of its kind poll on HIV finds people everywhere rank AIDS high on the list of the most important issues facing the world.

UNAIDS Executive Director Michel Sidibe said about half the 12,000 poll respondents are optimistic that the spread of HIV can be stopped by 2015.

"However, half of all the people surveyed say a lack of funding is an obstacle," said Sidibe. "And, more than 70 percent say resources should go to HIV-prevention. This highlights the importance of stopping new infections."

The AIDS pandemic appears to have stabilized in most regions, although Eastern Europe and central Asia continue to have high rates of new HIV infections. UNAIDS officials say 57 percent of new infections in these regions are occurring among people injecting drugs.

Sub-Saharan Africa remains the most heavily affected region, accounting for 71 percent of all new HIV infections.

Sidibe said the worldwide response to AIDS is showing results, but the epidemic remains a serious problem. "We estimated that in 2008, there were 33.4 million people living with HIV around the world ... and two million people died of AIDS-related illnesses," said Sidibe.

The UNAIDS/Zogby opinion poll shows one in three people consider public awareness about AIDS to be the greatest achievement of the international efforts. This is followed by implementation of HIV prevention programs and the development of new anti-retroviral drugs.

More than half of those surveyed consider the availability of prevention services to be the most important obstacle. Stigma and discrimination are cited as other barriers.

In another significant finding, a new UNAIDS report shows HIV prevalence among young people is dropping in many key countries around the world, especially in parts of sub-Saharan Africa.

Sidibe says the report shows there has been a 25-percent reduction of HIV infections in young people in 15 of the most affected countries. They include Botswana, Ethiopia, Kenya, Malawi, Namibia, Tanzania, Zambia and Zimbabwe.

"These excellent results in this report have happened because young people are adopting safer behaviors, young people are choosing to have sex later, to have fewer partners and they are using condoms," said Sidibe.

Five million people living with HIV are receiving life-saving anti-retroviral treatment, but an additional 10 million are in need of treatment.

UNAIDS says a better, cheaper, easier to use pill could save their lives and prevent one-million new HIV infections.

Depression and Erectile Dysfunction Are Independent Risk Factors for Heart Disease

July 18, 2010 (Florence, Italy) — The presence of depressive symptoms increased the risk of cardiovascular events in men with erectile dysfunction, a new study has shown [1].

The study, published in the August 2010 issue of the Journal of Sexual Medicine, was conducted by a team led by Dr Elisa Bandini (University of Florence, Italy). Bandini commented to heartwire : "In a large sample of men with erectile dysfunction, after controlling for other risk factors, we found that those with severe depression had increased risk of cardiovascular events. We know that depression and erectile dysfunction are both risk factors for heart disease, but this study shows that these risk factors are independent of each other."

She added: "Our results show that when evaluating patients for sexual dysfunction, doctors should think about general health as well. Erectile dysfunction may be the first disease or depression may be first disease, but we should look beyond these initial conditions to look at secondary consequences such as increased cardiovascular risk. If we treat depression and sexual dysfunction, we may be able to improve cardiovascular outcomes, too."

What is important . . . is the broader concept of the sexual-medicine problem no longer being just about a man's performance in the bedroom, but about his psychological mood and his cardiovascular health.
Editor-in-chief of the Journal of Sexual Medicine, Dr Irwin Goldstein (Alvarado Hospital, San Diego, CA), added: "What is important about this study is the broader concept of the sexual-medicine problem no longer being just about a man's performance in the bedroom, but about his psychological mood and his cardiovascular health. This is a valid reason for a woman to encourage her partner to seek help for his erectile dysfunction."

In the study, 1687 patients with erectile dysfunction were screened for depression using the Middlesex Hospital Questionnaire. Those in the highest quintile of depression score were compared with the rest of the sample. Results showed a positive relationship between depression score and progressive erectile dysfunction, even after adjustment for confounding factors. During a mean follow up of 4.3 years, there were a total of 139 cardiovascular events, 15 of which were fatal. Unadjusted incidence of cardiovascular events was significantly associated with baseline depressive symptoms. And severe depressive symptomatology was independently associated with a higher incidence of cardiovascular events in a Cox regression model controlling for degree of erectile dysfunction, partner’s hypoactive sexual desire, age, chronic diseases score, and another measure of psychopathology.

Association Still There After Controlling for Obesity

Because obesity is an important risk factor for cardiovascular events in subjects with sexual dysfunction, the authors looked at whether the presence of obesity might explain the effect of depression on cardiovascular events in this study. But in an alternative Cox model, they showed that depressive symptoms retained an independent ability to predict cardiovascular events, although their effect was more evident in leaner subjects.

The need for a regular screening for cardiac morbidity in men with erectile dysfunction is even greater in those patients showing depressive symptoms.
While no study has yet evaluated the possible effect of treatment of depression on the incidence of cardiovascular events, Bandini et al say that their study suggests that recognizing depressive symptoms in erectile-dysfunction subjects is mandatory not only for improving their sexual life, but also for preventing heart disease.

They conclude: "Owing to the complex multidimensional relationships existing among erectile dysfunction, cardiovascular disease, and depression, clinicians involved in the management of sexual dysfunction should be aware that the presence of one component of this triad necessitates inquiry regarding the other two components."

They add: "The wellness of the body, of the couple, and of the mind independently affects the cardiovascular fate of men with erectile dysfunction," and "the need for a regular screening for cardiac morbidity in men with erectile dysfunction is even greater in those patients showing depressive symptoms."

Animal Study Shows Potential of Universal Influenza Vaccine

July 18, 2010 — A universal influenza vaccine tested on mice and ferrets successfully immunized the animals against a virus strain from 1934, according to scientists at the National Institute of Allergy and Infectious Diseases (NIAID).

The experimental vaccine, which consisted of a primer dose and a booster, generated antibodies in mice and ferrets against virus strains from 4 different decades — not only H1 subtypes of influenza virus A but also other subtypes such as H5N1, or avian influenza.

The research, led by NIAID scientist Gary Nabel, MD, PhD, appeared online July 15 in Science. The team also included scientists from the US Centers for Disease Control and Prevention and a private research company.

The animal study, which also included monkeys, comes at a time when scientists are conducting human trials of "prime-boost" influenza vaccines to test their safety and ability to trigger an immune response.

"We may be able to begin efficacy trials of a broadly protective flu vaccine in 3 to 5 years," Dr. Nabel said in a press release issued yesterday by the National Institutes of Health. He added that the research published in Science could help scientists select candidate vaccines for large-scale human studies.

In contrast to the experimental vaccine in the NIAID study, current influenza vaccines do not produce such broadly neutralizing antibodies and so must be reformulated each year to match the predominant virus strains in circulation.

The prime-boost combination could eliminate the need for annual influenza shots, said Dr. Nabel. Instead, influenza vaccination could resemble how people are inoculated against diseases such as hepatitis, "where we vaccinate early in life and then boost immunity through occasional, additional inoculations in adulthood."

Peculiarity of HA Surface Protein Key to Vaccine's Promising Results

Dr. Nabel and his team first primed the animals' immune systems with a vaccine made from DNA that encodes the hemagglutinin (HA) surface protein, a mushroom-shaped structure, from a 1999 H1N1 influenza strain appearing in the 2006 to 2007 seasonal vaccine. Mice and ferrets then received a booster dose of either the seasonal vaccine for 2006-2007 or one made from a weakened adenovirus that expresses the HA surface protein. The only booster shot for monkeys was the seasonal influenza vaccine.

The anatomy of the HA surface protein, which supplies the "H" in the nomenclature of virus strains such as H1N1, is key to the experimental vaccine's promising results (the "N" comes from the protein neuraminidase). The combination of a primer and booster triggered an immune response to the stem of the HA surface protein, as opposed to its head. Although the head of the protein mutates easily, thwarting the ability of antibodies to recognize the virus, the stem is largely the same from strain to strain.

In principle, said Dr. Nabel, antibodies generated against the stable stem of the HA surface protein should neutralize multiple strains of influenza. The results of the study supported his hypothesis. All the animals that had received the prime/boost vaccine produced antibodies against virus strains from 1986, 1995, 1999, and 2007. Mice and ferrets generated antibodies against strains from additional years, including 1934.

The ability of the prime-boost vaccine to elicit a wide range of antibodies is promising, but Dr. Nabel's team also wanted to know how well the vaccine would guard animals from influenza. So they exposed 20 mice to lethal levels of the 1934 virus 3 weeks after a booster dose was administered. Eighty percent of the mice survived. In contrast, all mice that received only the primer, only the seasonal flu vaccine, or a sham prime-boost combination died.

Similar results were achieved in challenge tests with ferrets using the 2 kinds of boosters after the primer. All 4 ferrets that received the seasonal influenza vaccine as a booster achieved protection from a 2007 virus strain, and all 6 ferrets receiving the adenovirus booster were likewise protected from the 1934 strain. The researchers noted that ferrets provide a good animal model for predicting how well influenza vaccines will work in humans.

Science. Published online July 15, 2010.

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Authors and Disclosures
Journalist
Robert Lowes
Freelance writer, St. Louis, Missouri

Disclosure: Robert L. Lowes has disclosed no relevant financial relationships.