Postings # 704, 707, 711, 714, 715.

This abstract from a recent J. Emerg Med cautions us to think about acute diverticulitis when faced with a person under 40 years of age with atypical belly pain.  The incidence of such a disease entity is growing in the younger population.  The ones at most risk are males and those who have a pants size as large as Madagascar.  25% may have their pain localized to the RLQ.  CT should make the diagnosis for you.
http://omniphysicians.com/2008/03/23/diverticulitis-in-the-young/

This article is for Dr. L., a cheese gourmand par excellance!  Reports indicate that some of the mozzarella in the Naples is contaminated with dioxin.  The toxicity first came to light when Italians suddenly began talking like Marlon Brando in The Godfather.
http://omniphysicians.com/2008/03/23/malignant-mozzarella/

The FDA is cautioning the public about not buying cantaloupes coming from Honduras (Really!  No joke).  Seems that a batch contained salmonella and some Americans and Canadians have taken ill.  The salmonella actually have been arrested as illegal aliens (That’s a joke!).
http://omniphysicians.com/2008/03/23/cantaloupes-come-out-with-your-hands-up/

PRES refers to Posterior Reversible Encephalopathy Syndrome.  It’s rare, it’s reversible if caught and treated early, and it’s most common in pre-eclamptic and eclamptic women.  This abstract from J Emerg Med will give you an idea about it. 
http://omniphysicians.com/2008/03/23/pres/

Today’s NY Times reports that the life-expectancy gap is widening between the “haves” and “have-nots.”  It’s not true that The Times also reported that based on these findings, Dr Mohler should live to 126!
http://omniphysicians.com/2008/03/23/me-rich-me-live-long-me-poor-me-die-quick/

Reversible posterior leukoencephalopathy syndrome is a clinicoradiologic entity characterized by headaches, altered mental status, seizures, and visual loss and is associated with white matter vasogenic edema predominantly affecting the posterior occipital and parietal lobes of the brain.^[1] There has been some controversy about what the proper term should be for this entity because MRI has shown that lesions can occur in both gray and white matter. Therefore, a new name, posterior reversible encephalopathy syndrome (PRES), has been coined.^[2] Most cases of PRES occur with hypertension or immunosuppression, but it can occur with many diverse clinical entities.^[1,3] Since PRES is often unsuspected by clinicians, recognition of the characteristic imaging findings by radiologists is key to diagnosing this syndrome and should prevent deleterious work-ups or therapies.

The pathophysiology of PRES is under debate, but it is related to disordered cerebral autoregulation. Two pathophysiologic mechanisms have been proposed regarding cerebral autoregulation—cerebral vasospasm, which results in cytotoxic edema,^[4] and vasodilatation, which results in vasogenic edema.^[5] The latter is more favored by most experimental and clinical data.^[6,7] The pathophysiology of PRES also implicates endothelial dysfunction, especially in cases without severe hypertension, such as pre-eclampsia or cytotoxic therapies.^[1]

The most characteristic imaging pattern in PRES is the presence of edema involving the white matter of the posterior portions of both cerebral hemispheres, especially the parieto-occipital regions, in a relatively symmetric pattern that spares the calcarine and paramedian parts of the occipital lobes.^[1] However, other structures (such as the brain stem, cerebellum, and frontal and temporal lobes) may also be involved, and although the abnormality primarily affects the subcortical white matter, the cortex and the basal ganglia may also be involved.^[8] Although they are rare, gyriform signal enhancement or parenchymal hemorrhage can occur in complicated cases.^[9] Recently, studies with diffusion-weighted sequences^[6] and diffusion-tensor sequences^[7] have shown increased apparent diffusion coefficients (ADCs) in the involved regions accompanied by anisotropy loss, which suggests reversible vasogenic edema as an underlying pathophysiology. Therefore, early diagnosis and treatment is essential for the patients’ prognosis.

Conclusion

Posterior reversible leukoencephalopathy syndrome is a clinicoradiologic entity associated with hypertension, immunosuppression, or many diverse clinical entities. Since PRES is often unsuspected by clinicians, recognition of the characteristic imaging findings by radiologists is key to diagnosing this syndrome and should prevent deleterious work-ups or therapies.

References

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Intro:  Posterior reversible encephalopathy syndrome (PRES) refers to a clinicoradiological entity characterized by headache, confusion, visual disturbances, seizures and posterior transient changes on neuroimaging.  Here is an abstract of a case report involving an eclamptic patient with PRES.

Journal of Emergency Medicine
Volume 33, Issue 4, November 2007, Pages 377-379

Posterior Reversible Encephalopathy Syndrome (PRES) in a Thirty-Six-Week Gestation Eclamptic

Emilie S. Powell MD, MBA and Mitchell J. Goldman DO

Christopher D. Cole MD and Allan B. Wolfson MD

From the 3/11/08 San Francisco Chronicle:  Legislation to create uniform standards for homeless shelters is expected to be enacted soon by San Francisco’s board of supervisors and mayor. “I think we will definitely see a healthier and more positive environment for people who have to use the shelters,” said City Supervisor Tom Ammiano, who introduced the legislation after years of complaints about the shelters’ sanitary conditions. Under the pending law, shelters must provide soap, toilet paper, clean drinking water, and bath towels to people who stay there, as well as telephone access and a secure place to store belongings and medicine. Staff at the shelters would be required to undergo training on how to interact positively with people who have mental illness or abuse drugs and alcohol, and how to interact with gay, lesbian, bisexual or transgender populations and people with disabilities. “This makes it very clear to anyone contracting with the city that these are the rules and these are the standards,” said Dariush Kayhan, the Mayor’s homeless-policy director. “Our goal right now is to decrease street homelessness,” Kayhan said, adding that the legislation is intended to change the idea among the homeless that shelters are a refuge of last resort. The city has also agreed to cover the additional expenses, which total about $135,000 per year and a one-time expenditure of $108,000 for laundry machines. The Board of Supervisors is expected to approve the legislation this week. 

CNN, 3/22/08:  Makers of Italy’s prized buffalo mozzarella took out full-page ads in Italian newspapers Friday assuring consumers the cheese was safe after high levels of dioxin were found in some samples of buffalo milk.

The tainted products came from a few buffalo dairies in the southern Campania region, whose reputation as a top agricultural producer already has been tarnished by the months-old garbage crisis that has fueled fears of food contamination.

Dioxin, a chemical environmental pollutant, can be hazardous even in small amounts. When it accumulates in the body, it can be linked to cancer, birth defects and organ failure.

Over the past week, Italian authorities have searched dozens of buffalo dairies and seized milk samples for tests after higher-than-permitted levels of dioxin were discovered in products from 29 mozzarella makers, news reports said.

Prosecutors in Naples have placed 109 people under investigation in connection with the probe, on suspicion of fraud and food poisoning, the ANSA news agency reported.

On Friday, the consortium of buffalo mozzarella makers in Campania took out full-page ads in Corriere della Sera and other national newspapers outlining the system of controls that are in place for its top-branded mozzarella, which carries the designation DOP, meaning it has certain protection and quality guarantees.

Health officials, police, agricultural and cheese authorities all guarantee the safe production of DOP mozzarella, the ad said, adding that the dairies involved in the police seizures were not members of the consortium.

“Considering these norms, buffalo milk — before being transformed — is placed under the most stringent health and chemical controls which guarantee the safety and quality of Campania’s DOP buffalo mozzarella,” the ad said.

The Italian agricultural lobby Coldiretti called for a speedy investigation to determine which dairies were to blame, since buffalo mozzarella is such an important brand domestically and internationally.

The soft and subtly flavored mozzarella is a key ingredient in pizza, but also is eaten uncooked, often alongside prosciutto or with sliced tomatoes and basil.

Coldiretti said 33,000 tons, worth €300 million ($462.69 million), of DOP mozzarella is produced annually, employing some 20,000 people. Most DOP mozzarella is consumed in Italy, but 16 percent is exported, mostly to European countries but also to Japan and Russia, Coldiretti said.

It was not clear what, if any, role Campania’s garbage crisis has had on the mozzarella contamination. However, earlier this year Naples health authorities began screening residents for dioxin contamination amid accusations that toxic garbage was being dumped illegally by the mafia-controlled garbage industry in the area.

Naples and its surrounding area have been plagued by garbage crises over the past dozen years. Dumps close after filling up, and residents — afraid that toxic garbage is being dumped — block efforts to open new ones.

A recent study by the World Health Organization found that people living in Campania were not as healthy as residents in the rest of Italy. Mortality rates, particularly from some forms of cancer, are higher in the areas around Naples where the garbage crisis peaked.

Still, Renato Pizzuti, a regional epidemiologist, said a direct link to garbage contamination cannot be made.

“For sure, the population of the Campania region is suffering from some negative health factors, both in terms of mortality, above all, and for some pathologies in terms of morbidity.” But in a recent interview with AP Television News, he stressed, “This cannot be directly linked to garbage.”

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NY Times, 3/23/08:  New government research has found “large and growing” disparities in life expectancy for richer and poorer Americans, paralleling the growth of income inequality in the last two decades.

Life expectancy for the nation as a whole has increased, the researchers said, but affluent people have experienced greater gains, and this, in turn, has caused a widening gap.

One of the researchers, Gopal K. Singh, a demographer at the Department of Health and Human Services, said “the growing inequalities in life expectancy” mirrored trends in infant mortality and in death from heart disease and certain cancers.

The gaps have been increasing despite efforts by the federal government to reduce them. One of the top goals of “Healthy People 2010,” an official statement of national health objectives issued in 2000, is to “eliminate health disparities among different segments of the population,” including higher- and lower-income groups and people of different racial and ethnic background.

Dr. Singh said last week that federal officials had found “widening socioeconomic inequalities in life expectancy” at birth and at every age level.

He and another researcher, Mohammad Siahpush, a professor at the University of Nebraska Medical Center in Omaha, developed an index to measure social and economic conditions in every county, using census data on education, income, poverty, housing and other factors. Counties were then classified into 10 groups of equal population size.

In 1980-82, Dr. Singh said, people in the most affluent group could expect to live 2.8 years longer than people in the most deprived group (75.8 versus 73 years). By 1998-2000, the difference in life expectancy had increased to 4.5 years (79.2 versus 74.7 years), and it continues to grow, he said.

After 20 years, the lowest socioeconomic group lagged further behind the most affluent, Dr. Singh said, noting that “life expectancy was higher for the most affluent in 1980 than for the most deprived group in 2000.”

“If you look at the extremes in 2000,” Dr. Singh said, “men in the most deprived counties had 10 years’ shorter life expectancy than women in the most affluent counties (71.5 years versus 81.3 years).” The difference between poor black men and affluent white women was more than 14 years (66.9 years vs. 81.1 years).

The Democratic candidates for president, Senators Hillary Rodham Clinton of New York and Barack Obama of Illinois, have championed legislation to reduce such disparities, as have some Republicans, like Senator Thad Cochran of Mississippi.

Peter R. Orszag, director of the Congressional Budget Office, said: “We have heard a lot about growing income inequality. There has been much less attention paid to growing inequality in life expectancy, which is really quite dramatic.”

Life expectancy is the average number of years of life remaining for people who have attained a given age.

While researchers do not agree on an explanation for the widening gap, they have suggested many reasons, including these:

¶Doctors can detect and treat many forms of cancer and heart disease because of advances in medical science and technology. People who are affluent and better educated are more likely to take advantage of these discoveries.

¶Smoking has declined more rapidly among people with greater education and income.

¶Lower-income people are more likely to live in unsafe neighborhoods, to engage in risky or unhealthy behavior and to eat unhealthy food.

¶Lower-income people are less likely to have health insurance, so they are less likely to receive checkups, screenings, diagnostic tests, prescription drugs and other types of care.

Even among people who have insurance, many studies have documented racial disparities.

In a recent report, the Department of Veterans Affairs found that black patients “tend to receive less aggressive medical care than whites” at its hospitals and clinics, in part because doctors provide them with less information and see them as “less appropriate candidates” for some types of surgery.

Some health economists contend that the disparities between rich and poor inevitably widen as doctors make gains in treating the major causes of death.

Nancy Krieger, a professor at the Harvard School of Public Health, rejected that idea. Professor Krieger investigated changes in the rate of premature mortality (dying before the age of 65) and infant death from 1960 to 2002. She found that inequities shrank from 1966 to 1980, but then widened.

“The recent trend of growing disparities in health status is not inevitable,” she said. “From 1966 to 1980, socioeconomic disparities declined in tandem with a decline in mortality rates.”

The creation of Medicaid and Medicare, community health centers, the “war on poverty” and the Civil Rights Act of 1964 all probably contributed to the earlier narrowing of health disparities, Professor Krieger said.

Robert E. Moffit, director of the Center for Health Policy Studies at the conservative Heritage Foundation, said one reason for the growing disparities might be “a very significant gap in health literacy” — what people know about diet, exercise and healthy lifestyles. Middle-class and upper-income people have greater access to the huge amounts of health information on the Internet, Mr. Moffit said.

Thomas P. Miller, a health economist at the American Enterprise Institute, agreed.

“People with more education tend to have a longer time horizon,” Mr. Miller said. “They are more likely to look at the long-term consequences of their health behavior. They are more assertive in seeking out treatments and more likely to adhere to treatment advice from physicians.”

A recent study by Ellen R. Meara, a health economist at Harvard Medical School, found that in the 1980s and 1990s, “virtually all gains in life expectancy occurred among highly educated groups.”

Trends in smoking explain a large part of the widening gap, she said in an article this month in the journal Health Affairs.

Under federal law, officials must publish an annual report tracking health disparities. In the fifth annual report, issued this month, the Bush administration said, “Over all, disparities in quality and access for minority groups and poor populations have not been reduced” since the first report, in 2003.

The rate of new AIDS cases is still 10 times as high among blacks as among whites, it said, and the proportion of black children hospitalized for asthma is almost four times the rate for white children.

The Centers for Disease Control and Prevention reported last month that heart attack survivors with higher levels of education and income were much more likely to receive cardiac rehabilitation care, which lowers the risk of future heart problems. Likewise, it said, the odds of receiving tests for colon cancer increase with a person’s education and income.

Chicago Tribune, 3/23/08:  J.J. Jamison, a “borderline” diabetic who closely monitors his blood sugar, has been missing his sweets. So after reading about stevia and alternative sweeteners in a recent Q cover story, the 61-year-old DeKalb resident e-mailed asking, “What about agave?”

Agave’s naturally sweet sap, once strictly a famous source of tequila, is growing more popular among diabetics and others seeking natural sugar substitutes. The amber-colored nectar contains about 90 percent fructose, a natural sugar found in plants.

But agave, commercially produced as a sweetener in Mexico since the 1990s, is still something of a wild card. Registered dietitian Dave Grotto touts its low glycemic index and lists agave in his book “101 Foods That Could Save Your Life!” Others charge that agave is toxic, harmful to pregnant or lactating women and intentionally mislabeled.

“Agave is really chemically refined hydrolyzed high-fructose inulin syrup and not from the blue agave plant, organic or raw as claimed,” said Russ Bianchi, a food and beverage formulator.

The Food and Drug Administration says there is no evidence of safety concerns. But in the past, agave products may have been “economically adulterated or misbranded by adding corn syrup or high-fructose corn syrup [HFCS],” said FDA spokesman Michael Herndon. Chronic shortages of the plant make this a real concern, especially for products purchased over the Internet. But Whole Foods and Trader Joe’s carry agave nectar or syrup. And Madhava agave nectar is a popular option at the Wild Tree Cafe in Evanston, where owner Jaqi Boyer uses it in soups and baked goods for both diabetic and vegan customers.

Grotto likes agave because “it doesn’t impact blood glucose [glycemic] levels as dramatically as other sweeteners such as cane sugar,” he said. “And because it is sweeter than table sugar, you don’t need to use as much.”

Agave also contains a complex form of fructose called inulin, Grotto said. “Bifodobacteria, a type of friendly bacteria, digests inulin to produce short-chain fatty acids that have been shown to fight colon cancer,” he wrote. Agave’s sapogenins, meanwhile, have anti-inflammatory and anti-cancer properties, Grotto said. But others dismiss agave as “expensive fructose.”

“It’s almost all fructose, highly processed sugar with great marketing,” said Dr. Ingrid Kohlstadt, a fellow of the American College of Nutrition and an associate faculty member at Johns Hopkins School of Public Health. “Fructose has a low glycemic index so it doesn’t raise blood glucose.” But it raises blood fructose, which is worse.

“Fructose interferes with healthy metabolism when taken at higher doses,” she said. “Many people have fructose intolerance like lactose intolerance. They get acne or worse diabetes symptoms even though blood glucose is OK.”

Grotto disagreed, adding that there is no scientific evidence showing an association between sugar and acne. His bottom line is that “excess consumption of any sweetener is not wise. But honey and agave syrup are value-added sweeteners, if used moderately.”

If you use agave:

• Botulism spores can be found in bottled sweeteners originally derived from natural products. Treat it like honey; don’t give it to children under age 1.

• Avoid it if you’re pregnant; some believe it can cause miscarriages.

• Seek out an agave product that is organic and carries the official USDA seal.

• The FDA says there is no current need for regulatory action but would like to know if there is any literature or other information that shows agave causes adverse effects, Herndon said.

MarketWatch, 3/23/08:  The Food and Drug Administration warned that cantaloupes from a Honduran producer may be tainted with salmonella and it detained all shipments of cantaloupes by the company.

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