What Are Irregular Periods (Oligomenorrhea)? What Causes Irregular Periods?

Oligomenorrhea is a medical term which generally refers to irregular or infrequent menstrual periods with intervals of more than 35 days - however, the duration may vary.

A period, or menstruation, is the shedding of the endometrium - the lining of the uterus. Menstruation is also called menses. All female humans, as well as a number of other female mammals, have regular periods during their reproductive age. Menstruation, which includes bleeding from the vagina, occurs mainly among humans and similar animals, such as primates. In many mammals, the endometrium is reabsorbed.

As far as humans are concerned a period is a bleed from the womb (uterus) that is released through the vagina. Human females have a period about every 28 days - most women have between 11 and 13 menstrual periods each year. However, some women may have a 24-day cycle while other may have a 35-day one. A period is part of the female's menstrual cycle.

Periods usually start between the ages of 10 and 16 (during puberty), and continue until the menopause, when woman is 45 to 55 years old. Periods can take up to two years to occur in a regular cycle. After puberty, the majority of females have a regular menstrual cycle (the length of time between each period is similar).

Menstrual bleeding usually lasts for about five days, but can vary from two to seven days.

Some women have irregular periods - the time between periods, as well as the amount of blood shed varies considerably. This may have several possible causes, including a change in contraception method, a hormone imbalance, hormonal changes in perimenopause, and endurance exercises.

Treatments for irregular periods during puberty and around the menopause are not usually necessary, as they are quite common.

A large European study found that hay fever and asthma were linked to a higher risk of irregular periods.

Women with delayed sleep phase syndrome are more likely to report irregular menstrual cycles and premenstrual symptoms, according to scientists at Northwestern University in Chicago, USA.

According to Medilexicon's medical dictionary:

Oligomenorrhea means "Scanty menstruation."

What are the causes of irregular periods?

There are two main reasons for irregular periods:

• A change in the contraception method
• An estrogen and/or progesterone imbalance (hormones which regulate the menstrual cycle)

Examples include:

• Polycystic ovarian syndrome (polycystic ovary system) - also known as PCOS, or the Stein-Leventhal Syndrome. Many cysts (small, fluid filled sacs) develop in the ovaries. It is a condition characterized by irregular or no periods, obesity, acne, and excess hair growth.
  
  Women with PCOS have a disorder of chronically abnormal ovarian function and abnormally high levels of androgen (hyperandrogenism). Androgen is a male sex hormone - the major androgen is testosterone.
  
  According to the CDC (Centers for Disease Control and Prevention), USA, approximately 5% to 10% of women of reproductive age are affected by PCOS.
  
  A woman with PCOS does not release an egg every month (she does not ovulate). Patients with PCOS have a considerably higher risk of hypertension (high blood pressure), diabetes, heart disease and endometrial cancer (cancer of the uterus). Experts say that in many cases weight loss and exercise can eliminate much of the risk.
• A woman's imbalance of hormones, which may lead to irregular periods, may also be caused by:
  
  
  • Extreme weight loss. Low body weight is a common cause of irregular or missed periods.
  • Extreme weight gain. Obesity may sometimes cause menstrual problems.
  • Emotional stress
  • Eating disorders, such as anorexia or bulimia can lead to hormone imbalances, resulting in irregular or missed periods.
  • Endurance exercises - endurance athletes, such as those that compete in marathons, may have irregular or missed periods.
• Age
  
  
  • Puberty - irregular periods for a few years after puberty are common, and not considered unusual. It may take a few years for the hormones that control menstruation - estrogen and progesterone - to reach a balance.
  • Before the menopause - as the menopause approaches women commonly have irregular periods. The amount of blood shed may also vary. Menopause occurs when it has been 12 months since the woman has had a menstrual period.
• Breast feeding - most women do not start having periods again until they stop breastfeeding.
• Thyroid disorder - irregular periods may be caused by a thyroid disorder. The thyroid gland produces hormones that affect our bodies' metabolism.
• Contraceptives - an IUD (intrauterine device) may cause heavy bleeding, while the contraceptive pill can cause spotting between periods. Initially, when using the contraceptive pill for the first time, it is not uncommon for the woman to experience breakthrough bleeds (small bleeds). Breakthrough bleeds are generally shorter and lighter than normal periods - they usually go away after a few months.
• Cancer - bleeding between periods may be caused by cervical cancer or uterine cancer (cancer of the uterus/womb). These cancers may also cause the woman to bleed during sex. Bleeding caused by these cancers is rare.
• Emdometriosis - this is a condition in which cells that are normally found inside the uterus (endometrial cells) are found growing outside it. That is, the lining of the inside of the uterus is found outside of it. Endometrial cells are the cells that shed every month during menstruation, and so endometriosis is most likely to affect women during their childbearing years. The cellular growth is not cancerous, but benign. Though there are not always symptoms, it can be painful and lead to other problems.
  
  Problems may occur if released blood gets stuck in surrounding tissue and damage it, causing severe pain, irregular periods and infertility.
• Pelvic inflammatory disease - an infection of the female reproductive system. It is the most common and serious complication of sexually transmitted diseases, apart from AIDS, among women. If detected early it can be treated with antibiotics. However, if it spreads and damages the fallopian tubes and uterus it can result in chronic episodes of pain (in medicine "chronic" means long-term, for life). Of the many symptoms are included bleeding between periods and after sex.

What are the treatment options for irregular periods?

If the irregular periods occur during puberty or as the woman approaches the menopause, treatment is not usually necessary.

• Contraception - any patient who has been fitted with an IUD (intrauterine device) and has been having irregular bleeding that does not go away after a few months should talk to a health care professional and discuss alternative contraception options.
  
  Women who are on a new contraceptive pill that is causing irregular bleeding for more than a couple of months will probably be advised to switch to another pill.
• PCOS (polycystic ovarian syndrome) - if the woman is overweight/obese and has PCOS, as well as irregular periods, losing weight may help resolve the irregular periods. On losing weight the body does not need to produce so much insulin, resulting in lower testosterone levels and a better chance of ovulating.
  
  If the woman is not trying to become pregnant, the doctor may prescribe low-dose birth control pills that contain a combination of estrogen and progesterone (synthetic). They lower androgen (male hormone) production and give the body a rest from the effect of non-stop estrogen, lowering the risk of endometrial cancer, as well as correcting abnormal bleeding.
  
  Alternatively, the woman may take progesterone for about 10 to 14 days each month - this is likely to regulate the periods, as well as offering protection against endometrial cancer (does not improve androgen levels).
  
  The doctor may prescribe metformin (Glucophage, Glucophage XR) - this is an insulin-lowering oral drug for type 2 diabetes, resulting in more probable ovulation and regular periods. The medication also slows down the progression of type 2 diabetes if the patient already has pre-diabetes and subsequently loses weight.
• Thyroid problems - treatment may involve:
  
  
  • Prescribing medication that slows down the production of thyroid hormones.
  • Radioactive iodine therapy - radioiodine treatment is a kind of radiotherapy that targets tissue in the thyroid gland, resulting in a reduction in the amount of thyroid hormone the thyroid gland produces.
  • Partial thyroidectomy - part of the thyroid gland is surgically removed.
• Psychological therapy - if emotional stress or sudden weight loss are diagnosed as a cause of irregular periods, the doctor may advise counseling or stress management. This may include relaxation techniques, stress management, and talking to a therapist.

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What Is Lichen Planus? What Causes Lichen Planus?

Lichen planus is an inflammatory skin condition, characterized by an itchy, non-infectious rash of small, polygonal (many sided) flat-topped pink or purple lesions (bumps) on the arms and legs. Other parts of the body may also be affected, including the mouth, nails, scalp, vulva, vagina, and penis. Involvement in the scalp can result in hair loss - sometimes permanent.

Nobody knows what the exact causes of lichen planus are. We know it can be triggered by taking certain medications, including thiazide diuretics, antimalarials and phenothiazines (a group of tranquilizing drugs with antipsychotic actions). A significant number of skin specialist doctors (dermatologists) believe it might be classified as an autoimmune disease. A higher-than-normal percentage of people with hepatitis C and some other liver diseases have lichen planus.

According to the National Institutes of Health (NIH), USA, lichen planus affects between 1% and 2% of the American population. According to the National Health Service (NHS), UK, around 1 in every 50 people is affected by lichen planus.

Oral lichen planus is more common in women than in men. Skin lichen planus affects both sexes equally. It typically occurs in people over 30 years of age. About half of all affected people have oral lichen planus (symptoms in the inner surface of the mouth). Oral lichen planus typically occurs inside the cheeks, but may also affect the lips, gums and tongue.

Lichen planus symptoms on the skin can take up to two years to go away. However, once gone they hardly ever return. Oral lichen planus can take much longer to go away.

Lichen planus:

• Does not appear to be an hereditary condition - you cannot pass it on to your children
• Is not an infectious condition - you cannot catch it from somebody with the condition
• Is not a form of cancer
• Occurrence does not seem to be linked to nutrition. However, spicy foods, citrus juices, and tomato products may aggravate symptoms if there are open sores in the mouth.

The word lichen refers to the lichen plant which grows on rocks or trees, while the word planus in Latin means "flat".

According to Medilexicon's medical dictionary:

Lichen planus is an "eruption of flat-topped, shiny, violaceous papules on flexor surfaces, male genitalia, and buccal mucosa of unknown cause; may form linear groups; microscopically characterized by a bandlike subepidermal lymphocytic infiltrate. Spontaneous resolution is common after months to years."

What are the signs and symptoms of lichen planus?

A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign. Lichen planus of the skin:

• The rash appears abruptly, and usually lasts for several months
• There are clumps or patterns of shiny, raised, red/pink/purple, flat-topped papules (bumps)
• Papules are approximately 3mm to 5mm in diameter
• Sometimes there may be white streaks on the papules, called Wickham's striae
• Intense itching, especially at night
• Most affected areas are the wrists, elbows, ankles, and lower back. However, other parts of the body may be affected. The shins may be affected by hypertrophic (thickened) lichen planus, while the armpits may have annular (ring-shaped) lichen planus.

The first attack may continue for weeks, and even months, while recurrences can go on for years - recurrences are more common in cases of oral lichen planus. When symptoms are gone there may be dark brown or gray spots on the skin, which are more noticeable if the patient has dark skin.

Oral lichen planus (affects the mouth):

• White streaks on the inside of the cheeks. The gums, tongue and lips may also be affected.
• The streaks are not usually painful or itchy
• The white streaks are persistent (they do not go away)
• Possible redness and blistering of the gums
• Sore mouth ulcers can develop, and recur (erosive lichen planus)
• The patient's sense of taste may become blunted. Some experience a metallic taste
• Dry mouth
• Spicy foods, crispy foods, and tomato products can exacerbate symptoms

Penile lichen planus (lichen planus of the penis):

• Purple/white ring-shaped patches appear around the glans (head of the penis)
• They are not usually itchy
• Symptoms are similar to thrush, and often mistaken for thrush

Lichen planus of the vagina and vulva:

• Vulva - white streaks develop, similar to those that appear in the mouth. They are usually not itchy or painful. The skin may be red. Erosive lichen planus may affect the inner lips (labia minora) and the entrance to the vagina (introitus) - the affected mucous membrane is bright red and raw. The labia minora may shrink and stick to each other or to the labia majora (outer lips).
• Vagina - may be red. Scar tissue may distort the shape of the vagina. Lichen planus may affect deeper within the vagina, causing desquamative vaginitis. A mucky discharge appears when the surface cells in the vagina peel off. The eroded vagina may easily bleed when touched. Sexual intercourse may become difficult or impossible.

Lichen planus follicaris (lichen planopilaris) - this affects hairy areas, such as the scalp. There may be redness and irritation. Sometimes there is hair loss, which may be permanent.

Other areas - lichen planus of the anus, ear canal, eyelids and esophagus (all extremely rare).

(Erosive lichen planus is a chronic, painful condition which affects mucous membranes - mainly the mouth and the genitals.)

What are the risk factors for lichen planus?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

Lichen planus can affect humans of any age or race. However, it is more common among:

• Middle-aged adults
• Females (oral lichen planus)
• Patients with liver diseases, such as hepatitis C or cirrhosis

What are the causes of lichen planus?

Experts are not sure what the exact causes of lichen planus are. Many believe it is linked to an immune system disorder, where the person's white blood cells - which defend us from bad bacteria, viruses and other germs - mistakenly attack healthy tissues of the skin, mucous membranes, and hair.

Medications - sometimes lichen planus may occur as a reaction to some medicines, such as:

• Beta-blockers - medications that relieve stress on the heart, slow the heart beat, lessen the force of heart muscle contractions, and reduce blood vessel contraction in the heart, brain, and throughout the body.
• Anti-inflammatory medications
• Gold injections - for the treatment of arthritis
• Antimalarials
• Thiazide diuretics
• Phenothiazines (a group of tranquilizing drugs with antipsychotic actions)

Some substances - there is a link between contact with some chemicals used on color photographic development and lichen planus risk.

Mercury tooth fillings - some studies have found a link between lichen planus type changes in the mouth as a result of allergy to mercury tooth fillings. Signs and symptoms go away after the fillings are replaced with non-mercury ones.

Lichen planus can be part of Grinspan's syndrome - a syndrome characterized by hypertension, diabetes and oral lichen planus.

Diagnosing lichen planus

After examining the skin and identifying the characteristic rash, a GP (general practitioner, primary care physician) may be able to diagnose lichen planus.

Punch biopsy - the doctor uses a circular tool to extract a small sample of the skin's deeper layers. Often stitches are required to close the wound. The sample is examined under a microscope to confirm a lichen planus diagnosis.

If the GP is still unsure, the patient may be referred to a doctor who specializes in skin conditions (a dermatologist).

Oral lichen planus - a dentist or oral specialist usually diagnoses oral lichen planus by taking a biopsy.

What are the treatment options for lichen planus?

Lichen planus is not a curable condition. However, when it affects the skin it usually clears within several months (sometimes this may take up to two years). Treatment focuses on easing symptoms until the rash clears. Other types of lichen planus may last much longer.

Mild cases require no treatment by the doctor, except for periodic observations.

Treatment for more severe cases may include:

• Antihistamines - usually taken at night to reduce itching.
• Phototherapy with ultraviolet light
• Topical medications (applied onto the skin):
  
  
  • Steroid creams or ointments - these can be very effective in reducing inflammation and redness. The medication is applied to the itchy spots. When the spots change color to brown or gray treatment should stop.
  • Immunosuppressants - sometimes creams or ointments may contain a steroid-sparing immune-modulating medication (drugs to reduce the immune system).
• Oral corticosteroids (steroid tablets) - for more severe cases, or when creams and ointments are not effective enough.
• Ciclosporin capsules or acetretin tablets - these lower the immune system and may sometimes help. Only used in extreme cases.
• Oral symptoms (symptoms in the mouth) - the doctor may prescribe steroid lozenges or mouth washes if mouth ulcer symptoms are uncomfortable. The tablets are dissolved in water and the patient swills the solution in his/her mouth for a few minutes, four to five times a day. Fortunately, oral lichen planus causes minimal problems and treatment is not usually required. Oral hygiene is sometimes poor among patients with pain inside their mouths, increasing the risk of gum diseases and tooth decay - it is important to maintain good oral hygiene. Talk to your doctor or dentist about this, and make sure you go to your scheduled dental visits.
• Lichen planus of the mucous membranes - treatment is difficult to get right and may take years. The doctor may prescribe oral corticosteroids as well as topical corticosteroids.

What are the possible complications of lichen planus?

After the rash has gone there may be permanent brown or grey marks on the skin - the darker the patient's skin is the more noticeable they will be.

Persistent skin lesions and mouth ulcers may slightly raise the risk of developing cancer (rare).

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California Has 4,017 Cases Of Whooping Cough (pertussis) And 9 Deaths

The California Department of Public Health announced that there have been 4,017 confirmed, probable and suspect cases of whooping cough (pertussis) reported in the state so far this year, up to September 14 - a state rate of 10.3 cases per 100,000 people. The number of weekly reported cases has dropped slightly recently, with 183 new cases this week and 234 cases the week before.

The last time so many cases were reported was in 1955, with 4,949 cases. The current incidence of whopping cough is the highest since 1962, when it reached 10.9 cases per 100,000 people. The previous peak in total reported cases was in 2005 (3,182 cases).

Of the reported cases, health authorities say 65% are confirmed, 20% are probable and 15% are suspect.

Authorities say 11.2% of infected patients have been hospitalized. 57% of those hospitalized were infants (vey young babies).

Of the 9 deaths reported so far:

• 8 were Hispanic infants
• 8 were infants aged less than two months at the time of disease onset
• None of the 8 infants less than two months old had received any doses of pertussis-containing vaccine
• 1 was an ex-28 week premature baby who was 2 months old at the onset of the disease who had received the first dose of DTaP 15 days before becoming ill.

Health authorities inform that of the babies who have caught whooping cough, the majority are infants aged three months or less.

The incidence of whooping cough (pertussis) is highest among babies aged up to six months - 184 cases per 100,000; in children aged 7-9 years - 33 cases per 100,000; and adolescents aged 10-18 - 24 cases per 100,000.

Most adolescent cases are aged 10 or 11 years.

What is whooping cough (pertussis)?

Pertussis, also known as whooping cough is an extremely contagious respiratory disease, caused by the bacterium Bordetella pertussis. The patient typically has an uncontrollable and violent cough, which may cause breathing difficulties.

After fits of several coughs, the whooping cough patient will often need to take deep breaths which can make a whooping sound. Pertussis coughing fits can last for up to 10 weeks or more; hence its nickname, the 100 day cough.

Infants and young children are especially susceptible to complications of whooping cough. Very young babies are more vulnerable to the fatal complications of the diseases.

The best way to protect yourself form pertussis is to take the vaccination. There are vaccines for children, teens and adults. The childhood vaccine is called DTaP, while the booster vaccine for adolescents and adults is called Tdap.

According to the CDC (Centers for Disease Control and Prevention), there are 30-50 million cases of pertussis and about 300,000 deaths per year worldwide.

Since the 1980s, the number of reported cases of pertussis in the USA has been increasing, especially among 10-19 year olds and infants aged less than 6 months.

Over 50% of babies less than 1 year old who become infected need to be hospitalized.

According to Medilexicon's medical dictionary:

Pertussis is An acute infectious inflammation of the larynx, trachea, and bronchi caused by Bordetella pertussis; characterized by recurrent bouts of spasmodic coughing that continues until the breath is exhausted, then ending in a noisy inspiratory stridor (the "whoop") caused by laryngeal spasm.

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What Are Vitamins? What Vitamins Do I Need?

Vitamins are organic compounds which are needed in small quantities to sustain life. We get vitamins from food, because the human body either does not produce enough of them, or none at all. An organic compound contains carbon. When an organism (living thing) cannot produce enough of an organic chemical compound that it needs in tiny amounts, and has to get it from food, it is called a vitamin.

Sometimes the compound is a vitamin for a human but not for some other animals. For example, vitamin C (ascorbic acid) is a vitamin for humans but not for dogs, because dogs can produce (synthesize) enough for their own needs, while humans cannot.

Put simply, a vitamin is both:

• An organic compound (contains carbon).
• An essential nutrient the body cannot produce enough of on its own, so it has to get it (tiny amounts) from food.

There are currently 13 recognized vitamins.

According to Medilexicon's medical dictionary:

A vitamin is One of a group of organic substances, present in minute amounts in natural foodstuffs, that are essential to normal metabolism; insufficient amounts in the diet may cause deficiency diseases.

Fat soluble and water soluble vitamins

There are fat-soluble and water-soluble vitamins. Fat-soluble vitamins are stored in the fat tissues of our bodies, as well as the liver. Fat-soluble vitamins are easier to store than water-soluble ones, and can stay in the body as reserves for days, some of them for months.

Water-soluble vitamins do not get stored in the body for long - they soon get expelled through urine.

Water-soluble vitamins need to be replaced more often than fat-soluble ones.

Vitamins A, D, E and K are fat-soluble.

Vitamins C and all the B vitamins are water-soluble.

Fat-soluble vitamins are absorbed through the intestinal tract with the help of fats (lipids).

List of vitamins

• Vitamin A.
  Chemical names (vitaminer) - retinol, retinal, and four carotenoids (including beta carotene).
  Fat soluble.
  Deficiency may cause night-blindness and keratomalacia (eye disorder that results in a dry cornea)
  Good sources - liver, cod liver oil, carrot, broccoli, sweet potato, butter, kale, spinach, pumpkin, collard greens, some cheeses, egg, apricot, cantaloupe melon, milk.
• Vitamin B₁.
  Chemical name (vitaminer) - thiamine
  Water soluble.
  Deficiency may cause beriberi, Wernicke-Korsakoffsyndrome
  Good sources - yeast, pork, cereal grains, sunflower seeds, brown rice, whole grain rye, asparagus, kale, cauliflower, potatoes, oranges, liver, and eggs.
• Vitamin B₂.
  Chemical name (vitaminer) - riboflavin
  Water soluble.
  Deficiency may cause ariboflavinosis
  Good sources - asparagus, bananas, persimmons, okra, chard, cottage cheese, milk, yogurt, meat, eggs, fish, and green beans.
• Vitamin B₃.
  Chemical names (vitaminer) - niacin, niacinamide Water soluble. Deficiency may cause pellagra
  Good sources - liver, heart, kidney, chicken, beef, fish (tuna, salmon), milk, eggs, avocados, dates, tomatoes, leafy vegetables, broccoli, carrots, sweet potatoes, asparagus, nuts, whole grains, legumes, mushrooms, and brewer's yeast.
• Vitamin B₅.
  Chemical name (vitaminer) - pantothenic acid
  Water soluble.
  Deficiency may cause paresthesia
  Good sources - meats, whole grains (milling may remove it), broccoli, avocados, royal jelly, fish ovaries.
• Vitamin B₆.
  Chemical names (vitaminer) - pyridoxine, pyridoxamine, pyridoxal
  Water soluble.
  Deficiency may cause anemia, peripheral neuropathy
  Good sources - meats, bananas, whole grains, vegetables, and nuts. When milk is dried it loses about half of its B₆. Freezing and canning can also reduce content.
• Vitamin B₇.
  Chemical name (vitaminer) - biotin
  Water soluble.
  Deficiency may cause dermatitis, enteritis
  Good sources - egg yolk, liver, some vegetables.
• Vitamin B₉.
  Chemical names (vitaminer) - folic acid, folinic acid
  Water soluble.
  Deficiency may cause pregnancy deficiency linked to birth defects
  Good sources - leafy vegetables, legumes, liver, baker's yeast, some fortified grain products, sunflower seeds. Several fruits have moderate amounts, as does beer.
• Vitamin B₁₂.
  Chemical names (vitaminer) - cyanocobalamin, hydroxycobalamin, methylcobalamin
  Water soluble.
  Deficiency may cause megaloblastic anemia
  Good sources - fish, shellfish, meat, poultry, eggs, milk, and dairy products. Some fortified cereals and soy products, as well as fortified nutritional yeast.
• Vitamin C.
  Chemical names (vitaminer) - ascorbic acid
  Water soluble.
  Deficiency may cause megaloblastic anemia
  Good sources - fruit and vegetables. The Kakadu plum and the camu camu fruit have the highest vitamin C contents of all foods. Liver also has vitamin C.
• Vitamin D.
  Chemical names (vitaminer) - ergocalciferol, cholecalciferol
  Fat soluble.
  Deficiency may cause rickets, osteomalacia
  Good sources - produced in the skin after exposure to ultraviolet B light from the sun or artificial sources. Found in fatty fish, eggs, beef liver, and mushrooms.
• Vitamin E.
  Chemical names (vitaminer) - tocopherols, tocotrienols
  Fat soluble.
  Deficiency is uncommon. May cause mild hemolytic anemia in newborns
  Good sources - kiwi fruit, almonds, avocado, eggs, milk, nuts, leafy green vegetables, unheated vegetable oils, wheat germ, and wholegrains.
• Vitamin K.
  Chemical names (vitaminer) - phylloquinone, menaquinones
  Fat soluble.
  Deficiency may cause bleeding diathesis
  Good sources - leafy green vegetables, avocado, kiwi fruit. Parsley contain a lot of vitamin K.

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What Is An Umbilical Hernia? What Causes An Umbilical Hernia?

An umbilical hernia occurs when part of the bowel or fatty tissue pokes through an area near the belly button (navel, umbilicus), pushing through a weak spot in the surrounding abdominal wall. Approximately 1 in every 10 infants is affected by an umbilical hernia - they are common in premature babies.

While the developing fetus is in the uterus (womb), the umbilical cord passes through an opening in the abdominal wall, which should close before the baby is born, or soon after. However, sometimes the muscles do not completely seal, leaving a weak spot through which an umbilical hernia can develop. The hernia looks like a lump in the navel, which may become more evident when the baby is laughing, crying, heaving (going to the toilet), or coughing. When the child is lying down or relaxed the lump may shrink. It is not usually painful.

In the majority of cases an infant's umbilical hernia closes on its own by the age of 12 months. If the hernia is still there by the time the child is 4 years old, the doctor may recommend surgery.

Umbilical hernias may also develop in adults, especially if they are very overweight, lifting heavy objects, or have a persistent cough. Women who have had multiple pregnancies have a higher risk of developing an umbilical hernia.

In adults, hernias are much more common in females. Among infants, the risk is about the same for boys and girls.

According to Medilexicon's medical dictionary:

an umbilical hernia is

a hernia in which bowel or omentum protrudes through the abdominal wall under the skin at the umbilicus.

What are the signs and symptoms of an umbilical hernia?

A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign.

There may be a soft bulge/swelling near the umbilicus (navel), ranging from about 1 to 5 cms in diameter (0.5 to 2 inches). The bulge is usually more noticeable if the baby cries, laughs, coughs or strains.

Pain - in children and infants umbilical hernias are not usually painful. Adults may feel pain or discomfort.

When to see a doctor:

• If you see a bulge and would like to know what it is
• The bulge becomes painful
• The infant/adult vomits (and there is a bulge)
• The bulge swells up more
• The bulge becomes discolored

What are the risk factors for umbilical hernias?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

Age - infants, especially those born prematurely, have a higher risk of having an umbilical hernia than older humans.

Being obese - obese children and adults have a significantly higher risk of developing an umbilical hernia, compared to individuals of normal weight for their height and age.

Coughing - prolonged periods of coughing increase the risk of hernias.

Multiple pregnancies - when the pregnant mother is carrying more than one baby inside her. The risk of an umbilical hernia is higher if the woman has a multiple pregnancy.

What causes an umbilical hernia?

Babies - as the fetus develops in the mother's uterus (womb), there is a small opening in the abdominal muscles allowing the umbilical cord to pass through - this connects the mother to the baby.

Around the time of birth, or shortly afterwards, this opening in the abdominal muscles should close. When this does not happen - if the opening does not close completely, fatty tissue or part of the bowel can protrude (poke through), causing an umbilical hernia.

Adults - if there is too much pressure on the abdominal wall, fatty tissue or a part of the bowel can poke through a weak part of the abdominal muscle. Individuals at high risk (see Risk Factors) are more likely to have higher-than-normal pressure in areas where fatty tissue or parts of the gut can protrude.

How is an umbilical hernia diagnosed?

A doctor will be able to diagnose an umbilical hernia during a physical examination. He/she may also be able to determine what is protruding; what is caught in the hernia sac.

If the doctor wants to screen for complications, an abdominal ultrasound, X-ray or blood tests may be ordered.

What are the treatment options for umbilical hernia?

Babies and children - in the majority of cases the hernia closes on its own by the age of 12 months. Sometimes the doctor may be able to push the lump back into the abdomen (it is important that only the doctor do this).

Surgery may be ordered if:

• The hernia grows after the child is one or two years old
• The bulge is still there by the age of four years
• If the hernia blocks the intestines
• If the hernia becomes trapped

Adults - surgery is usually recommended, to prevent potential complications, especially if the hernia grows or starts to hurt.

Surgery - this is a small, quick operation to push the bulge back into place and to make the abdominal wall stronger. In most cases the child (patient) will be able to go home on the same day.

The surgeon makes an incision at the base of the belly button and pushes either the fatty lump or bowel back into the abdomen. Muscle layers are stitched over the weak area in the abdomen wall, effectively strengthening it. Dissolvable stitches or a special glue are used to close the wound. Sometimes the surgeon will place a pressure dressing, which remains there for four to five days.

An umbilical hernia operation usually takes about 20 or 30 minutes.

What are the possible complications of an umbilical hernia?

Umbilical hernia complications are very rare in children. If the protrusion becomes incarcerated (trapped) and cannot be pushed back into the abdominal cavity it may lose some of its blood supply and become damaged. If the blood supply is completely cut off there is a risk of gangrene, and life-threatening infection.

Incarceration is also rare in adults, but more common than in children.

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Statins Work As Well On Females As Males

Statins given to female patients are as effective in preventing the occurrence of cardiovascular events as they are for men, researchers from Boston and New York reported in the Journal of the American College of Cardiology. Cardiovascular events include stroke, heart attack, and angina.

William J. Kostis, Ph.D., M.D., from Harvard Medical School, and team set out to determine what impact statins might have on reducing cardiovascular event risk in male and female patients. They gathered and analyzed data on 18 clinical trials which had gender-specific outcomes. A total of 141,235 patients were involved in all the studies, of which 40,275 were female - there were a total of 21,468 cardiovascular events.

They found that those who were prescribed (randomly) statins had a considerably lower risk of a cardiovascular event compared to those on a placebo, usual care, or low-dose statin therapy. Females Odds Ratio were similar to men's - Odds Ratio: 0.81, 95% CI: 0.75 to 0.89; p < 0.0001, and Odds Ratio: 0.77, 95% CI: 0.71 to 0.83, p < 0.0001, respectively.

The authors explained that the benefits of statins, regardless of the baseline risk, or type of control, were similar for males and females. All cause mortality was also considerably lower for both the male and female patients who were on statin therapy.

In the same journal, the authors concluded in an Abstract:

"Statin therapy is associated with significant decreases in cardiovascular events and in all-cause mortality in women and men. Statin therapy should be used in appropriate patients without regard to sex."

What are statins?

Statins, also known as HMG-CoA reductase inhibitors, belong to a class of medications that are commonly prescribed to reduce cholesterol levels. They can block the chemical action that occurs in the liver for making cholesterol.

Our bodies need cholesterol in order to function properly. However, very high levels can raise the risk of developing atherosclerosis - cholesterol-containing plaques accumulate in the arteries and undermine blood flow. Statins can reduce cholesterol levels, and consequently lower the chances of developing angina (chest pain), stroke and heart attack.

Examples of statins include:

• atorvastatin (the most potent, along with rosuvastatin)
• cerivastatin
• fluvastatin (the least potent)
• lovastatin
• mevastatin
• pitavastatin
• pravastatin
• rosuvastatin (the most potent, along with atorvastatin)
• simvastatin

Statins inhibit HMG-CoA reductase, an enzyme which controls the production of cholesterol in the liver. Statins act to replace the HMG-CoA in the liver, thus slowing down the process of cholesterol production. Liver enzymes sense that cholesterol production has gone down and create a protein which triggers the production of low density lipoprotein (LDL, or bad cholesterol) receptors, which relocate to the liver cell membranes - in short, the LDL is eventually taken into the liver and digested.

Statins may be prescribed for patients with atherosclerosis, some types of heart diseases, diabetes, and those with a family history of heart attacks, among others.

Although statins are prescribed mainly for those with high cholesterol levels, they may also be used to lower the risk of heart diseases by preventing atherosclerosis. Even though heart attacks can occur in patients whose blood cholesterol levels are not high, in the majority of cases heart attacks start with atherosclerosis plaque accumulation. Plaques resulting from atherosclerosis can form even when blood cholesterol levels are not high. Therefore, statins may be prescribed to treat patients whose blood cholesterol is not high, but have a higher risk of atherosclerosis (or have atherosclerosis).

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New Drug For Advanced Colorectal Cancer Shows Promise In Trial

An experimental drug for advanced colorectal cancer that available treatments have failed to halt, has shown promise in a clinical trial, says Bayer HealthCare, the company that makes it. The results of the phase III trial show that compared to placebo, regorafenib slowed tumor growth and extended survival.

In a statement released yesterday, Bayer announced that the Phase III CORRECT (Colorectal cancer treated with regorafenib or placebo after failure of standard therapy) trial "met its primary endpoint, showing statistically significant improvement in overall survival ... in patients with metastatic colorectal cancer (mCRC) whose disease had progressed after approved standard therapies".

The statement goes on to add that the trial also shows that regorafenib showed statistically significant improvement in progression-free survival and improvement in disease control rate in the patients who received the drug compared to those who received placebo.

The trial results show that more of the side effects commonly or occasionally seen with chemotherapy occurred with the drug than with placebo, including fatigue, hand-foot skin reaction, diarrhea, anorexia, high blood pressure, oral mucositis (inflammation of the lining of the mouth) and rash/skin peeling.

The trial was "unblinded" late in 2011 after an independent data monitoring committee said the drug was showing significant improvement in overall survival and patients receiving placebo should be offered the option to take it.

It was conducted in North America, Europe, China, Japan and Australia and enrolled 760 patients.

Bayer said they will be seeking Food and Drug Administration (FDA) approval for regorafenib within the next 12 months. If approved, it will be the first new treatment for colorectal cancer in over five years.

Dr Axel Grothey, MD, Professor of Oncology at the Mayo Clinic is a co-principal investigator on the trial.

He is presenting the trial results at the 2012 Gastrointestinal Cancers Symposium of the American Society of Clinical Oncology (ASCO-GI), in San Francisco later this week.

The oral abstract presentation (LBA number 385) is set to take place at 14:30 h PT on 21 January in the Level 3 Ballroom, Moscone Center West.

Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer death in the US, in both men and women.

About half of patients diagnosed with the disease have the advanced form (metastases, usually to the liver), either at the time of diagnosis or due to recurrent disease.

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Oral HPV Rates Higher In Men Than Women

A study published in JAMA reveals that among men and women between the ages 14 to 69 years in the U.S., the overall prevalence of oral human papillomavirus (HPV) infection is around 7%. In addition, the researchers found that the prevalence of HPV is higher among men than women.

The study is being published early online in order to accompany its presentation at the Multidisciplinary Head and Neck Cancer Symposium.

The researchers explain:

"Oral HPV infection is the cause of a subset of oropharyngeal [relating to the mouth and pharynx] squamous cell carcinomas (OSCC). Human papillomavirus - positive OSCC are associated with sexual behavior in contrast to HPV-negative OSCC that are associated with chronic tobacco and alcohol use.

At least 90 percent of HPV-positive OSCC are caused by high-risk (or oncogenic) HPV type 16 (HPV-16), and oral infection confers an approximate 50-fold increase in risk for HPV-positive OSCC. The incidence of OSCC has significantly increased over the last 3 decades in several countries, and HPV has been directly implicated as the underlying cause.

Although oral HPV infection is the cause of a cancer that is increasing in incidence in the United States, little is known regarding the epidemiology of infection."

In order to analyze the prevalence of oral HPV in the U.S., Maura L. Gillison, M.D., Ph.D., of the Ohio State University Comprehensive Cancer Center, Columbus, and colleagues examined data from a cross-sectional study as part of the National Health and Nutrition Examination Survey (NHANES) 2009-2010, a statistically representative sample of the U.S. population.

The 5,579 participants, aged between 14 to 69 years old, provided a 30-second oral rinse and gargle with mouthwash. In order to detect HPV types, the researchers assessed DNA purified from oral exfoliated cells through testing methods.

Results revealed that the most prevalent HPV type detected was HPV-16 (1.0%) and the overall prevalence of oral HPV infection was 6.9%. The researchers discovered peaks in the prevalence of oral HPV infection in different age ranges:

• The first peak was found among participants aged between 30 to 34 years old (7.3%).
• The second among participants aged between 60 to 64 years old (11.4%).

The overall prevalence of oral HPV infection was considerably lower among women (3.6%) than men (10.1%). The prevalence was also higher among cigarette smokers, former and current marijuana users, and heavy alcohol drinkers.

In addition, the team discovered that the prevalence of oral HPV was linked to numerous measures of sexual behavior. They found that the prevalence was higher among participants who reported ever having sex (7.5%) than those who did not (0.9%).

Lifetime or recent number of sexual partners for any kind of sex, oral or vaginal, increased the prevalence of HPV.

In analysis inclusive of people aged 14 to 69 years, the researchers found that sex, lifetime number of sexual partners, as well as current number of cigarettes smoked per day, were factors independently linked to prevalent oral HPV.

According to the researchers, their data provide evidence that oral HPV infection is primarily sexually transmitted. "Taken together, these data indicate that transmission by casual, nonsexual contact is likely to be unusual." The researchers explain:

"Our results have important research as well as public health implications. Natural history studies of cervical HPV infection were essential for the development of public health interventions, such as HPV vaccination to prevent and HPV detection to screen for cervical cancer. Natural history studies of oral HPV infection are therefore necessary to understand the effects of age, sex, and modifiable risk factors (e.g., smoking and sexual behavior) on the incidence and duration of oral HPV infection."

They conclude:

"...vaccine efficacy against oral HPV infection is unknown, and therefore vaccination cannot currently be recommended for the primary prevention of oropharyngeal cancer. Given an analysis of U.S. cancer registry data recently projected that the number of HPV-positive oropharyngeal cancers diagnosed each year will surpass that of invasive cervical cancers by the year 2020, perhaps such vaccine trials are warranted. Such trials could inform ongoing discussions regarding the benefits of HPV vaccination for males, given the higher prevalence of oral HPV infection demonstrated here as well as higher incidence of HPV-positive OSCC among men."

In an associated report, Hans P. Schlecht, M.D., M.M.Sc., of the Drexel University College of Medicine, Philadelphia, explains:

"Future research will need to identify the natural history of HPV-related oropharyngeal dysplastic lesions and evaluate potential screening methods to detect oropharyngeal dysplasia prior to invasion. Successful screening measures such as a Papanicolaou test, HPV polymerase chain reaction testing, or both may be daunting to achieve, but there is meaningful hope that prevention efforts will ameliorate the effects of HPV-related oropharyngeal cancer."

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US Cancer Screening Below National Targets

The percentage of people screened for cancer in the US remains below national targets for 2020, with rates lower among Asian and Hispanic Americans than other groups, according to a new report by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI) released on Friday.

The report shows that in 2010, the screening rate for breast cancer was 72.4%, compared to the 2020 national target of 81%, for cervical cancer it was 83%, compared to a target of 93%, and for colorectal it was 58.6% percent, compared to a target of 70.5%.

The US Preventive Services Task Force (USPSTF), an independent panel of health professionals, recommends screening tests for breast, cervical and colorectal cancers. As part of its Healthy People 2020, the US Department of Health and Human Services has set 10-year national targets for such recommended tests, and identifies the National Health Interview Survey (NHIS) as the way to measure progress.

For breast, cervical and colorectal cancer screening, the USPSTF recommends that:

• Women aged 50 to 74 years have a mammogram every two years,
• Women who have been sexually active or aged 21 to 65 years have a Pap test at least every three years, and
• Average-risk men and women aged 50 - 75 years, should either (1) do a high-sensitivity fecal occult blood test (FOBT) at home every year; (2) undergo sigmoidoscopy every five years with FOBT every three years; or (3) undergo colonoscopy every 10 years.

Data from the NHIS allows researchers to assess people's use of currently recommended screening tests by age, race, ethnicity, education, how long they have lived in the US, and who funds the screening.

The ethnic groups are: Chinese, Filipino, or other Asian and Hispanics as Puerto Rican, Mexican, Mexican-American, Central or South American, or other Hispanic.

The data for 2010 shows that screening rates for all three cancers were significantly lower among Asians: 64.1% breast cancer, 75.4% for cervical, and 46.9% for colorectal), and that non-Hispanics were more likely to be screened for cervical and colorectal cancer (83.8% and 59.9% respectively) than Hispanics (78.7% and 46.5%).

Other key findings include:

• Screening rates for breast cancer haven't changed much in the last 10 years (varied by 3% between 2000 and 2010).


• However, screening rates for colorectal cancer have risen markedly for men and women in the last ten years, with rates for women rising a bit faster, such that by 2010 they were on a par (58.5% for men and 58.8% for women in 2010).


• There was a small but significant 3.3% reduction in rate of women receiving a Pap test in the last three years.


• Rates of screening for all three cancers were significantly lower among those without the usual source of health care or health insurance.

Report lead author Dr Sallyann Coleman King, an epidemic intelligence service officer in the Division of Cancer Prevention and Control at the CDC, told the press she and her colleagues were troubled that not all Americans were getting the recommended cancer screening and that disparities across groups persist:

"Screening can find breast, cervical, and colorectal cancers at an early stage when treatment is more effective. We must continue to monitor cancer screening rates to improve the health of all Americans," she urged.

The authors conclude the findings reinforce the importance of continuing to monitor disparities across groups, and suggest there is a need for new ways to identify people eligible for cancer screening and more effort needs to go into encouraging its use.

They also note that the Affordable Care Act is expected to improve access to screening by expanding insurance coverage.

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Fake Antimalarial Medications Undermine Africa Malaria Drive

Fraudulent and substandard antimalarial drugs could be wrecking the chances of winning the war against malaria in Africa, researchers from the Wellcome Trust-Mahosot Hospital-Oxford University Tropical Medicine Research Collaboration reported in the Malaria Journal. The authors add that millions of lives could be lost over the next twelve months unless urgent action is taken both within the African continent and elsewhere in the world.

Fake medications are coming onto the scene as a result of deliberate criminal activity, while substandard drugs are becoming more common because of poor manufacturing practice. Not only are scores of patients being inadequately treated, but the presence of these undesirable and illegal medications significantly raises the risk of drug resistance among the malaria parasites.

Approximately 781,000 people are thought to have died from malaria in 2009, says the World Malaria Report 2010.

Artemisinin derivatives are the best antimalarials, experts say. They work faster than other medications, such as chloroquine and mefloquine, and also have fewer side-effects. These drugs can be used on their own to treat malaria, but are more commonly administered alongside other medications, mainly because of the rising problem of drug resistance. WHO (World Health Organization) recommends that for uncomplicated falciparum malaria, combination therapies be used.

The researchers set out to determine how prevalent counterfeit and substandard antimalarials were in Africa. They gathered data from 11 nations in Africa between 2002 and 2010.

They found that some fake drugs contained a combination of erroneous active ingredients, many of which only treated malaria signs and symptoms, but did not cure the disease itself. These unsuitable active ingredients were also found to cause potentially serious side-effects, especially when administered in combination with other medications, such as those used to treat HIV.

Some of the fake drugs had small quantities of artemisinin derivatives - experts believe this was so that they could be passed off as authentic medications during authenticity tests. They contain such small quantities of artemisinin derivatives that there are useless in ridding the body of malaria parasites, and highly likely to promote their resistance to artemisinin. Put simply, the patient derives no benefit, and the parasite becomes more difficult to eliminate.

Scientists managed to trace some of the pollen found in the fake medicines to eastern Asia. In 2001, authorities in Guangshou, China, arrested Chinese and Nigerian men who were accused of producing fake halofantrine, an antimalarial. Investigators say that there is no pollen evidence of fake drug production occurring in Africa. Packaging materials for counterfeit antimalarial medications have been confiscated in Nigeria.

Research leader, Dr Paul Newton, said:

"Public health organizations must take urgent, coordinated action to prevent the circulation of counterfeit and substandard medicines and improve the quality of the medicines that patients receive. We must move finally away from the use of single drugs and towards the exclusive use of combination therapies.

The enormous investment in the development, evaluation and deployment of antimalarials is wasted if the medicines that patients actually take are, due to criminality or carelessness, of poor quality and do not cure. Malaria can be readily treated with the right drugs of good quality, but poor-quality medicines - as well as increasing mortality and morbidity - risk exacerbating the economic and social impact of malaria on societies that are already poor.

Worse still, they encourage drug resistance, potentially resulting in the failure of artemisinin treatments, with profound consequences for public health in Africa. Failure to take action will put at risk the lives of millions of people, particularly children and pregnant women."

Dr. Newton says regulatory authorities in Africa need increased investment, so that quality control can be more closely monitored. For the fight against malaria to be effective, people need access to top-quality and affordable artemisinin combination therapies.

Dr Jimmy Whitworth, Head of International Activities at the Wellcome Trust, commented:

"This research is very worrying and should act as an early warning. We have already begun to see the emergence of drug-resistant malaria parasites in South-east Asia; substandard and counterfeit antimalarials and the availability of artemisinin monotherapies threaten to lead to the spread of drug resistance in Africa. If this happens, the effect could be devastating on efforts to control malaria in Africa."

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Lower Limb Amputation Rates Associated With Diabetes Drop, US

An investigation by the Centers for Disease Control and Prevention, found that between 1996 and 2008, the number of leg and foot amputations among U.S. individuals, aged 40+ with diagnosed diabetes, decreased by 65%.

The study, entitled "Declining Rates of Hospitalization for Non-traumatic Lower-Extremity Amputation in the Diabetic Population Aged 40 years or Older: U.S., 1988-2008," is published online in the current issue of Diabetes Care.

In 1996, the age-adjusted rate of leg and foot amputations was 11.2 per 1,000 individuals with diabetes. However, in 2008 this rate fell to 3.9 per 1,000.

Non-traumatic, lower-limb amputations, refers to amputations caused by circulatory problems, rather than those caused by injuries. Circulatory problems are a prevalent adverse effect in individuals suffering with diabetes.

Furthermore, results from the study revealed that in 2008:

• Women had lower age-adjusted rates of lower-limb amputations (1.9 per 1,000) than men (6 per 1,000)
• Individuals aged 75+ had the highest rate (6.2 per 1,000) than people in other age groups
• Rates were higher among blacks (4.9 per 1,000) than whites (2.9 per 1,000)

According to the researchers, the decrease in lower-limb amputations among individuals with diabetes may partially be due to factors such as: declines in heart disease, improvements in blood sugar control, as well as foot care and diabetes management.

Nilka Ríos Burrows, M.P.H., an epidemiologist with CDC's Division of Diabetes Translation, explained:

"The significant drop in rates of non-traumatic lower-limb amputations among U.S. adults with diagnosed diabetes is certainly encouraging, but more work is needed to reduce the disparities among certain populations.

We must continue to increase awareness of the devastating health complications of diabetes. Diabetes is the leading cause of lower-limb amputations in the United States."

After examining data from the National Hospital Discharge Survey on non-traumatic lower-limb amputations from the National Health Interview Survey on the prevalence of diagnosed diabetes from 1988-2008, the researchers discovered that the decrease in rates was higher among individuals with diagnosed diabetes than people without the disease. Although, in 2008, the rate was still approximately 8 times higher among those with the disease than those without diabetes.

Diabetes is the leading cause of non-traumatic, lower-limb amputations, kidney failure, and blindness among adults. In addition, the disease is the 7th leading cause of mortality in the U.S.. Diabetes also increases the risk of strokes, hypertension, and heart attacks.

CDC's Division of Diabetes Translation supports prevention and control programs in all 50 states, seven U.S. territories and island jurisdictions, and the District of Columbia.

The National Diabetes Education Program provides education to enhance treatment for individuals with the disease, promote early diagnosis and prevent or delay type 2 diabetes from developing. The program is co-sponsored by CDC and the National Institutes of Health.

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Guilt In Depression Has Different Brain Response, Suggesting Freud Was Right

The brains of people with depression, even in remission, respond differently to feelings of guilt, suggesting Freud was right, said researchers from the University of Manchester in the UK who compared magnetic resonance imaging (fMRI) scans of people with a history of depression to those of people who had never had it. If further tests prove successful, they suggest the finding could lead to the first brain scan marker for future risk of depression.

The new study, part-funded by the Medical Research Council was published on 4 June in an online-first issue of the Archives of General Psychiatry.

It is the first piece of research to show there is a brain mechanism behind Freud's classical idea that depression differs from normal sadness by proneness to exaggerated feelings of guilt or self-blame.

Dr Roland Zahn, from the University's School of Psychological Sciences, told the press:

"For the first time, we chart the regions of the brain that interact to link detailed knowledge about socially appropriate behavior - the anterior temporal lobe - with feelings of guilt - the subgenual region of the brain - in people who are prone to depression."

For their study, Zahn and colleagues took fMRI scans of people while they imagined themselves or their best friend acting badly (eg in a mean, tactless or bossy way) towards others, and said what they felt, for instance, guilt, shame, contempt, or disgust, and whether this was toward self or another.

The participants were 25 people who had been in remission from depression for over a year (16 of whom were not currently taking anti-depressants), and 22 healthy volunteers with no history of depression who served as controls.

Previous studies have suggested that the subgenual cingulate cortex and adjacent septal region (SCSR) become active when we feel guilty, and in healthy people with a low risk of depression, this effect is "selective relative to equally unpleasant feelings associated with blaming others (indignation/anger)", write the researchers.

The anterior temporal lobe (ATL) has also been consistently implicated in moral feelings such as guilt, but unlike the SCSR, this part of the brain is "activated irrespective of the type of moral feeling, whether it is guilt or indignation", they note.

There is also evidence to suggest the right superior ATL is important for constructing social concepts that help us make different judgements (eg such as distinguishing merely critical from fault-finding behavior). This in turn protects us against over-generalization and self-blame (eg my pointing out a typing error in a colleague's piece of writing means "I am critical" as opposed to "I am unlikable").

So, prior to this latest study, it had already been proposed, but not shown, that a coupling between these two brain areas, or "ATL-SCSR functional coupling", helps people with low risk of depression blame themselves in an "adaptive" way, without damaging their self-worth or hating themselves.

Zahn and colleagues found the fMRI scans showed the coupling between these brain regions was weaker in the group with a history of depression than in the healthy controls with no history of depression.

"We corroborated the prediction of a guilt-selective reduction in ATL-SCSR coupling in MDD [major depressive disorder] vs controls ... and revealed additional medial frontopolar, right hippocampal, and lateral hypothalamic areas of decoupling while controlling for medication status and intensity of negative emotions," they write.

They also found that lower levels of ATL-SCSR coupling were linked with higher scores on a validated measure of overgeneralized self-blame.

"Interestingly, this 'decoupling' only occurs when people prone to depression feel guilty or blame themselves, but not when they feel angry or blame others," explained Zahn.

"This could reflect a lack of access to details about what exactly was inappropriate about their behaviour when feeling guilty, thereby extending guilt to things they are not responsible for and feeling guilty for everything," he suggested.

Zahn and colleagues suggest the finding is important because it shows there are brain mechanisms that may explain why some people respond to stress with depression rather than aggression.

The team is now testing whether these findings can predict the risk of depression following remission. If they succeed, this could lead to the first fMRI marker for risk of future depression.

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Fake, Poor Quality Malaria Drugs Threaten Progress

Up to 42% of anti-malaria drugs available across Southeast Asia and sub-Saharan Africa are poor quality or fake, resulting in drug resistance and inadequate treatment that threatens vulnerable populations and to undermine the huge progress made in recent years, according to a new study published online in The Lancet Infectious Diseases this week.

The study was funded by the Fogarty International Center at the US National Institutes of Health in Bethesda, Maryland, where co-author Dr Joel Breman is Senior Scientist Emeritus. He told the press:

"Poor quality antimalarial drugs are very likely to jeopardize the unprecedented progress and investments in control and elimination of malaria made in the past decade."

The emergence of malaria strains that are now resistant to artemisinin drugs on the border between Thailand and Cambodia border means it is imperative that we improve the drug supply to these regions, say Breman and colleagues.

Drugs based on artemisinin are currently the most effective treatment against the malaria parasite, and any reports that it is developing resistance to them will cause great alarm. Analyses suggest that an important driver in the spread of drug resistance is underdosing of patients, such as through use of poor quality or fake drugs.

For the study, Breman and colleagues examined data from published and unpublished studies reporting chemical analyses and assessments of packaging of antimalarial drugs available across Southeast Asia and sub-Saharan Africa.

They found that between 20 and 42% of the drugs were either poor quality or fake.

Poor quality samples include: falsified drugs that are fraudulently manufactured with fake packaging and usually contain no active ingredient or the wrong one; substandard products that are poorly manufactured with either not enough or too much active ingredient; and degraded supplies which start out as good quality but then deteriorate because of poor storage and handling.

From seven countries in Southeast Asia, the resarchers found of 1,437 samples of drugs in five classes: "497 (35%) failed chemical analysis, 423 (46%) of 919 failed packaging analysis, and 450 (36%) of 1260 were classified as falsified".

From 21 countries in sub-Saharan Africa, they found in 21 surveys of drugs from six classes: "796 (35%) of 2,297 failed chemical analysis, 28 (36%) of 77 failed packaging analysis, and 79 (20%) of 389 were classified as falsified".

"Data were insufficient to identify the frequency of substandard (products resulting from poor manufacturing) antimalarial drugs, and packaging analysis data were scarce," write the researchers.

They also note that in regions where malaria is common, antimalaria drugs are widely available, and often self-prescribed, either wrongly or correctly. And, the facilities for monitoring the quality of drugs is poor, and there is low awareness among consumers and healthworkers about the treatments.

Plus there is no regulatory oversight of manufacturing and counterfeiters aren't punished, they add, concluding that:

"Concurrent interventions and a multifaceted approach are needed to define and eliminate criminal production, distribution, and poor manufacturing of antimalarial drugs. Empowering of national medicine regulatory authorities to protect the global drug supply is more important than ever."

Breman and colleagues also point out that it is difficult to assess the size of the problem worldwide because there are no reliable global estimates and no internationally accepted criteria for what constitutes inadequate drugs. There are no standard protocols for testing them or specifying their content, and there are no international scientific and technical meetings to give oversight.

"These findings are a wakeup call demanding a series of interventions to better define and eliminate both criminal production and poor manufacturing of antimalarial drugs," said Breman.

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Dysentery May Be Treatable With Cheap Arthritis Drug

US researchers have discovered that an already approved arthritis drug may offer a cheap, low-dose treatment for the amoebic infections that cause dysentery in humans worldwide. So far they have only tested the drug in lab and animal studies, but they have applied for approval to start clinical trials to test it as a treatment for both amebiasis and the parasite Giardia in humans.

The researchers, from University of California - San Diego (UCSD), and University of California - San Francisco (UCSF), write about their findings in the 20 May online issue of Nature Medicine.

The antirheumatic drug is called auranofin, marketed as ridaura, and is a form of the precious metal gold.

The researchers were screening already approved drugs to find new treatments for the developing world when they made their discovery.

Co-senior author James McKerrow is a professor of pathology at UCSF's Sandler Center for Drug Discovery. He told the press:

"When we're looking for new treatments for the developing world, we start with drugs that have already been approved."

Using a high-throughput drug screen he and his colleagues found that auranofin was 10 times more potent against the parasite Entamoeba histolytica than the current treatment metronidazole.

They said their study illustrates the importance of screening existing drugs for new purposes, especially for neglected diseases.

McKerrow said that the combination of an off-patent drug and decades of clinical safety data means we may have a global lower-cost solution, with fewer side effects or risks of bacterial resistance, than the current therapy.

Every year, 50 million people around the world, most in developing countries, contract amebiasis, a gastrointestinal infection by the parasite Entamoeba histolytica that causes symptoms ranging from mild diarrhea to dysentery with blood and mucus in the stool.

The infection spreads through contaminated food and water, and kills around 70,000 people a year, with children being the ones most likely to become severely ill.

The parasite Giardia also infects 6-8% of all children in developing countries, causing diarrhea, abdominal cramps and dehydration.

The current treatment for both amebiasis and giardiasis is the antibiotic metronidazole, whose side effects include nausea, vomiting, dizziness and headache.

Auranofin has been used as a twice-daily tablet for adults with rheumatoid arthritis since 1985, and has been shown to be safe at that dosage.

Because the study's lab and animal test findings show auranofin is 10 times more potent that the current therapy, they suggest it could be effective at a low dose, perhaps even on a one-time or limited basis.

First author Anjan Debnath is a postdoctoral fellow at UCSF. He said:

"This is a drug that you can find in every country. Based on the dosage we're seeing in the lab, this treatment could be sold at about $2.50 per dose, or lower. That cost savings could make a big difference to the people who need it the most."

Debnath is a member of McKerrow's team at UCSF. They focus on infectious diseases in the developing world that are not research priorities for pharmaceutical companies.

The team set out to create a screen to find small molecule drugs that would kill amoebas safely. One key breakthrough came when Debnath developed a high-throughput screen that could test the molecules in an oxygen-free, or anaerobic, environment, to mimic the amoeba's natural environment.

Another key breakthrough was from a company going out of business. Iconix Biosciences, of Menlo, California, offered the team its screening library of 900 approved compounds, each in its own vial.

After testing auranofin in the lab, the researchers then tested it in two animal studies. One test was in a mouse model of amebiasis in the colon, which is where the parasite first takes hold, and the other was in a hamster model that shows the impact of infection in the liver.

In both animal studies, the team said auranofin was the most effective drug they had ever seen. At very low doses it markedly reduced the number of parasites, inflammation damage and the size of liver abscesses.

Armed with this "proof of principle", Debnath has applied to the US Food and Drug Administration (FDA) to grant auranofin Orphan Drug Status. This is a way of fast-tracking new drugs that show promise in treating a neglected or orphan disease (ie one that affects fewer than 200,000 people in the US, or one that is not expected to recover the development and marketing cost).

Co-senior author Sharon L Reed, professor in the UCSD Departments of Pathology and Medicine, said:

"Because auranofin has already been approved by the FDA for use in humans, we can save years of expensive development."

"This new use of an old drug represents a promising therapy for a major health threat, and highlights how research funded by the National Institutes of Health can benefit people around the world," she added.

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Lung Cancer CT Screening Guidelines Revised

Older, current and former heavy smokers should receive annual, low-dose CT screening, according to revised guidelines published in the Journal of the American Medical Association on Sunday. The revised guidelines follow, and in the JAMA paper are accompanied by, a systematic review of evidence on the role of CT screening for individuals at higher risk of lung cancer.

CT (computerised tomography) or CAT scans are a type of x-ray that can detect early signs of lung cancer, but they can give false-positive results. They use a computer to create detailed images of the inside of the body.

Regular chest x-rays produce less detailed images than CT scans and can also give false-positives. They are not recommended as a lung cancer screening test because there is no evidence they save lives.

Several groups collaborated in the systematic review, namely the American College of Chest Physicians (ACCP), the American Society of Clinical Oncology (ASCO), the American Cancer Society, and the National Comprehensive Cancer Network, with input from the American Thoracic Society (ATS).

The review concludes that:

"Low-dose computed tomography screening may benefit individuals at an increased risk for lung cancer, but uncertainty exists about the potential harms of screening and the generalizability of results."

The review forms the basis of clinical practice guidelines developed by the ACCP and ASCO and was endorsed by ATS.

The revised guidelines recommend that current and former smokers aged 55 to 74 who have smoked for 30 pack years or more, and either are still smoking or have quit in the past 15 years, should be offered low-dose CT screening over both annual screening with chest x-ray or no screening.

And, this offer should only be made in settings that can deliver the comprehensive care provided to National Lung Screening Trial participants, which essentially means only centers with specialist radiologists and surgeons.

The guidelines say CT screening should not be performed on current or former smokers who have not accumulated 30 pack years of smoking, or who are outside the 55 to 74 age range.

Sick people with limited life expectancy or whose illness is not likely to be cured should also be excluded.

The JAMA report has a full account of guideline remarks and explanations.

30 pack years is the equivalent of smoking one pack of 20 cigarettes a day for 30 years. For instance, two packs per day for 15 years is equivalent to 30 pack years.

The review included a large National Cancer Institute study involving more than 53,000 people with a 30 pack year history.

The study showed that CT screening prevented about 80 deaths from lung cancer over 6 years, but 16 participants died after CT screening, including 6 who did not have lung cancer.

Lung cancer is the leading cause of cancer death both globally and in the United States, where it causes as many deaths as the next 4 most deadly cancers combined: breast, prostate, colon, and pancreatic.

Although lung cancer deaths in the US have fallen slightly since 1990, the disease is likely to kill more than 160,000 Americans in 2012.

The survival rate for lung cancer is poor, the current 5-year survival rate stands at 16%, and most people diagnosed with the disease are at an advanced stage (40% at stage IV, 30% at stage III).

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Stroke Treatment Using Stem Cells Shows Early Promise In Controversial Trial

A controversial stem cell treatment for stroke is showing promising signs in the early results of a small safety trial. Speaking at an international conference last week, the researchers warn that it is still early days, but so far five of the six patients who have received doses of the stem cells have shown some improvement and there have been no side effects.

The hope is that the treatment, by repairing damaged brain tissue, will one day help stroke patients regain some movement and ability to speak. Even small improvements can make a big difference to a person who has been robbed of the ability to wash, dress and feed themselves.

The PISCES trial (Pilot Investigation of Stem Cells in Stroke) study, which is based in Scotland at the Institute of Neurological Sciences, Southern General Hospital, Greater Glasgow and Clyde NHS Board, is the first in the world to evaluate genetically engineered neural stem cells in people with disabling ischemic stroke.

The researchers presented the interim results at the 10th Annual Meeting of the International Society for Stem Cell Research (ISSR), which took place from 13 to 16 June 2012, in Yokohama, Japan.

The lead investigator of the trial is Professor Keith Muir, SINAPSE Professor of Clinical Imaging, Division of Clinical Neurosciences at the University of Glasgow. He told the press:

"We remain pleased and encouraged by the data emerging from the PISCES study to date."

The Phase I trial, which started towards the end of 2010, and follows five years of repeated regulatory rebuffs, is testing the safety of ReN001, a genetically engineered neural stem cell line made by UK biotech ReNeuron.

The trial is controversial because the stem cell line originated nearly ten years ago, from the tissue of a 12-week fetus.

ReN001 is a genetically engineered line of adult stem cells that are described as "committed, not pluripotent". That is they are not capable of turning into any type of cell in the body: they are already part way down the track of becoming neurons or brain cells.

The trial is testing four different doses of ReN001 in 12 patients, all men over the age of 60, with moderate to severe functional neurological impairments resulting from their stroke. So far only 6 patients, on the lower doses, have received the treatment. The other 6 patients will start receiving the higher doses, comprising around 20 million stem cells, in the coming months.

At the conference, the researchers reported the interim results on 5 of the 6 patients.

They said so far, no adverse side effects, neither from the stem cells nor from the immune system, have been reported. Some patients have experienced minor problems such as superficial scalp infection or minor bleeding where the stem cells were implanted.

Although the main aim of the trial is to evaluate the safety and tolerability of the ReN001 treatment, to help with the design of future clinical studies, the patients are also undergoing tests of movement and brain function that will show if there are any reductions in their disability.

One test, National Institutes of Health Stroke Scale (NIHSS), measures things like speech, eye movement, ability to move arms and legs, and sensation in limbs and face. A high NIHSS score means more disability. The researchers said the pre-treatment median score for the first 5 patients was 8 (ranging from 6 to 10), and at the three-month follow up, it was 4 (ranging from 3 to 9).

Brain imaging data from fMRI scans taken before and after treatment also show some changes consistent with these improvements.

Muir said:

"The data indicate that the ReN001 treatment has a good safety profile at the doses administered thus far. The preliminary signals of potential functional benefit, whilst intriguing, will require further investigation in a suitably designed Phase II efficacy study. The clinical team looks forward to dosing patients in the remaining higher dose cohorts in the PISCES study over the coming months."

Michael Hunt, Chief Executive Officer of ReNeuron, said we must be very cautious about interpreting these early results, because the aim of the study is to test the safety of the treatment.

"That said, we remain encouraged by the results seen in the study to date and we look forward to providing further updates on the study as the higher dose cohorts are treated and to progressing our planning for further clinical trials with ReN001," he added.

Should the early promise bear out, and subject to receiving the go-ahead from the Data Safety Monitoring Board, the company hope to apply for a Phase II clinical study (to test the effectiveness of the treatment) during 2013.

Stroke is the third largest cause of death and the single largest cause of disability in adults in the developed world.

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Pre-Diabetic Patients Respond To Agressive Glucose-Lowering Treatment

In 2011, the Centers for Disease Control and Prevention estimated that 79 million Americans have pre-diabetes. Each year 11% of individuals with the condition, which occurs when blood glucose concentrations are higher than normal, but not as high as seen in diabetes, develop diabetes.

Now, researchers have found that people with pre-diabetes are 56% less likely to develop diabetes 5 to 7 years later if they experience a period of normal glucose regulation.

The study, conducted by the Diabetes Prevention Program Research Group, USA, was presented at the American Diabetes Association 72nd Scientific Sessions on June 9th and published Online First in The Lancet.

The researchers examined data from the Diabetes Prevention Program Outcomes Study (DPPOS), which analyzes long-term outcomes in patients who participated in the Diabetes Prevention Program (DPP). The DPP involved more than 3,000 individuals with pre-diabetes who were at high risk of developing Type 2 diabetes.

Earlier examinations of the DPPOS and DPP data have demonstrated that drug treatment and lifestyle interventions can reduce the risk of people with pre-diabetes developing diabetes. However, in this study, the team set out to examine patients who not only did not develop diabetes, but actually reverted to normal glucose function at some point during the study period.

The team found that these patients were 56% less likely to develop diabetes during the 5 to 7 year follow-up period, regardless of how the reversion was achieved and even when it was only temporary. According to the researchers, these findings may be vital for planning diabetes reduction strategies.

Lead author Dr Leigh Perreault of the University of Colorado, USA, explained:

"Results from the present analysis would contend that the strategy is unimportant as long as the intervention is early (when someone has preddiabetes) and can restore normal glucose regulation, even if transiently... This analysis draws attention to the significant long-term reduction in diabetes risk when someone with prediabetes returns to normal glucose regulation, supporting a shift in the standard of care to early and aggressive glucose-lowering treatment in patients at higher risk."

In an associated comment, Dr Natalia Yakubovich of McMaster University, Canada, said: "Identification of regression to normal glucose regulation could be an important way to stratify people into those at higher and lower risk of progression to diabetes. Such stratification could therefore identify individuals for whom additional treatment might be needed to prevent diabetes or to slow down disease progression."

Dr. Yakubovich continued:

"Factors that predict regression to normal glucose regulation, what makes this regression temporary or sustained, and whether regression reduces long-term outcomes are all questions that need further research. The results of such research might substantially change the therapeutic strategy from diabetes prevention and lifelong glucose lowering treatment to induction of regression and monitoring for relapse."

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