It’s the latest wrinkle in acne treatments -- an at-home kit that uses LED light therapy by exposing the skin to various wavelengths of colored light in an attempt to clear up blemishes.

LED treatments aren’t just favored by dermatologists and facialists, but by high-profile celebs like Carla Bruni, Sienna Miller and Natalie Imbruglia, reports The Daily Mail. In salons, a light treatment could cost well over $100 and take more than six sessions.

But a hand-held device for home use actually mimics the treatments that the pros pay top dollar for, at a much smaller price.

The Tanda Light Therapy Skincare System, created in Canada, is a minimachine for home use that has two separate devices. One, the Tanda Clear, employs blue LED light to zap bacteria that cause acne. Red LED light is used in the Tanda Regenerate, said to enliven collagen-producing cells, with the goal of fewer wrinkles and firmer skin. Studies found that users experienced a "significant" reduction in pimples, reports The Daily Mail.

So is a device like this safe for those who like the idea of a do-it-yourself acne treatment?

"It appears to be safe, but I would be skeptical of the findings of any of these studies," says Dr. David Avram, a dermatologist at Long Island College Hospital. "They are not doubleblinded studies that meet the criteria for good scientific studies."

Those who use the at-home LED system may discover that it "will probably help on inflamed lesions," Avram says. "It will wipe away acne on the surface of the skin. It works very superficially on very mild cases, but in significant acne, it really does not have much of a role."

Adds Dr. Maria Tsoukas, a dermatologist at the University of Chicago, "The LED lights have been shown to be effective in acne therapy, but you have to be careful. Anytime someone uses something like this they should carefully follow the instructions."

Dr. Doris Day, dermatologist and an attending physician at Lenox Hill Hospital, predicts that more products like the Tanda will make their way onto the market. But, she says, people should think of at-home acne treatments as an adjunct to the treatment they receive from a physician.

There is no true "cure" for acne, she explains, and it can be scarring. "The earlier and more appropriately you treat it, the greater chance that you will be able to clear the acne without leaving marks behind," Day explains. "Systems like these are okay as part of a treatment, because very often a combination of treatments is needed for acne. In any case, they should be used under the guidance of your dermatologist."

Avram says of the at-home treatments, "They are not dangerous, but people who use them should be realistic. People probably will just see a limited improvement. For those with more significant acne, it may just be a waste of their time."


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VALLEJO, CA - AUGUST 11: Touro University medical student Shamis Fallah (R) prepares a Tdap vaccination during the Solano County health fair August 11, 2010 in Vallejo, California. California medical officials are urging California residents to get booster shots for whooping cough as the state is in the midst of the largest outbreak in over fifty years. Close to 1,500 cases of whooping cough have been reported this year, including six cases that resulted in deaths of children under three years old.

U.S. doctors increasingly are ditching pen and paper and sending prescriptions to pharmacies electronically, lured by up to $27 billion in government funds aimed at speeding the switch to electronic medical records.

There are now 200,000 doctors who use e-prescribing, or roughly one in three office-based doctors. That compares with 156,000 at the end of last year, and 74,000 at the end of 2008, according to new data released on Tuesday by Surescripts, which operates the largest U.S. electronic prescribing network. They said 47 states more than doubled their use of electronic prescribing last year.

In Massachusetts, one in three prescriptions is now written electronically, and 57 percent of doctors are sending prescriptions electronically. Doctors in Michigan, a state that has been hit hard by a slowdown in the automotive industry, make the most use of features that allow them to see if a patient's health plan covers certain drugs.

President Barack Obama has made using information technology a central plank in his plan to cut costs out of a U.S. healthcare system that consistently ranks lower in quality measures than other rich countries.

PENALTIES LOOM

In 2009, Congress authorized funding to promote electronic health records as part of the economic stimulus package. Incentives will be paid out over five years, and by 2015 providers will face penalties if they don't adopt the new technology. As a result, many more doctors are expected to switch to electronic prescriptions, which promise to prevent medical errors caused by poor handwriting and harmful drug interactions.

Dr. Edward Lisberg, an asthma and allergy specialist based in River Forest, Illinois, made the switch to e-prescribing and electronic medical records nine months ago. He said moving to e-prescribing was much easier than the transition he made to electronic medical records, which involves transferring years of patient medical histories into a digital form.

Lisberg said in a telephone interview his practice does not have enough Medicare patients required to qualify for up to $44,000 offered by the government to cover the cost of converting from paper to digital health records. And he sees e-prescribing largely as a convenience to patients, although it does offer a bit of improvement on his admittedly messy handwriting.

"It's a time-saver for patients, but not much for doctors," Lisberg said. That's because he may have to create new templates if he wants to customize a prescription. But it does mean patients don't lose their prescriptions anymore, he said.

Health information technology companies include Cerner Corp, McKesson Corp and Quality Systems Inc, as well as larger technology companies such as General Electric's GE Healthcare unit, Siemens, Microsoft Corp and Google Inc.

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Tyra Banks hot photos

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Transmission of the AIDS virus seems to be "out of control" among gay men in France despite an overall fall in the number of new HIV cases in the country, according to a study published on Thursday.

Scientists from the French National Institute for Public Health Surveillance found that nearly half of the 7,000 people newly infected with HIV in the country in 2008 were gay men, and the incidence among homosexual men is 200 times higher than in the heterosexual population.

Experts said the findings showed that French authorities needed to revise and renew prevention strategies and ensure they were properly targeted at groups most at risk of HIV infection.

The human immunodeficiency virus that causes AIDS infects 33.4 million people globally. In sub-Saharan Africa, 22.4 million people have it, and Eastern Europe currently has the fastest growing HIV epidemic in the world.

Thursday's study, published in The Lancet Infectious Diseases journal, found that HIV in France fell significantly from 8,930 new infections in 2003 to 6,940 in 2008.

But the number of new infections among gay men was stable despite a decline in other groups, and accounted for 48 percent of new cases in France in 2008.

Non-French-nationals living in France accounted for around 23 percent of all new infections in 2008 and for 45 percent of the infections transmitted heterosexually. Most were immigrants from sub-Saharan Africa, the researchers said.

The number of new infections among injecting drug users — a group in which HIV epidemics are spreading rapidly in other parts of Europe — was low and stable in France over the 5-year study period, accounting for only 1 or 2 percent of new infections every year.

"Our results provide a new perspective on the HIV epidemic in France," said Stephane le Vu, who led the research.

"HIV transmission disproportionately affects certain risk groups and seems to be out of control in the MSM population," he said, using an acronym for men who have sex with men.

Since AIDS emerged in the 1980s, 60 million people have been infected with virus that causes it and 25 million have died. HIV is spread in blood, during sex and in breast milk. Drug users can spread it by sharing needles with infected people.

In a commentary on the findings, Robert Hogg from the British Colombia Center for Excellence in HIV/AIDS in Vancouver, Canada, said the French data reflected an "unacceptably high" number of new infections among gay men worldwide.

He said authorities should seek to tackle the problem with a combined prevention approach which would include promoting prevention measures such as condom use among gay men and expanding access to AIDS drugs for all eligible HIV patients.

Recent studies have shown that treating HIV patients early in their disease and with potent cocktails of AIDS drugs not only helps them live longer but also significantly reduces the spread of the virus to others.

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The specialist: Dr. Steven Gruenstein on hematologic malignancies.

An associate clinical professor at Mount Sinai Hospital, Dr. Steven Gruenstein splits his practice treating hematology and oncology problems. Over the past 20 years, Gruenstein has seen thousands of patients with hematologic malignancies like myeloma, chronic myeloid leukemias and lymphomas.

Who’s at risk

Hematology is the field of medicine that studies blood and blood diseases. Hematologic malignancies are cancers of the blood, bone marrow and lymph nodes. "Normally all our blood is produced in a broadly similar way, in which progenitor cells produce many types of cells," says Gruenstein. "A malignancy, or cancer, is when a cell mutates and develops clones that are not under normal controls."

A common result of hematologic malignancies is too much or too little blood. Individual hematologic malignancies are not very common in the general population, though some disorders appear more frequently than others. "For instance, non-Hodgkin’s lymphoma is fairly common, but Hodgkin’s disease is not," says Gruenstein. "As yet, we’re not sure if some groups are more at risk than others." The Leukemia and Lymphoma Society reports that hematologic malignancies account for 9% of all newly diagnosed cancers in the country.

Doctors consider hematologic malignancies to be idiopathic, which means they arise spontaneously or from an unknown cause." There aren’t really risk factors," says Gruenstein. "Some patients have it in the family, but that’s only a small fraction."

Environmental exposure to toxins like benzene also can cause hematologic malignancies.

"There are different pathways — a lot of times a genetic mechanism leads to a change in an enzyme or protein that forms a malignant population of cells," says Gruenstein.

Signs and symptoms

Patients often go undiagnosed for years because hematologic malignancies can be chronic diseases that progress slowly. "Usually, the symptoms are noticed by the internist at the annual physical," says Gruenstein. "After speaking to the patient and performing a physical exam, the doctor makes the diagnosis with a blood test, which is sometimes followed by a radiographic exam or a biopsy of the bone marrow or lymph node."

When bone marrow cells are the ones altered, the symptoms are usually related to too much or too little of certain cells like platelets or hemoglobin or white blood cells. Common red flags are anemia, high hemoglobin or thrombosis accompanied by fatigue, bleeding, night sweats, abdominal pain or pain in general.

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Do middle-aged people need sex ed?

The number of forty- and fiftysomethings in the U.K diagnosed with a sexually transmitted disease last year was double the number in 2000, according to data reported in the Daily Mail.

Nearly 13,000 middle-aged men and women were diagnosed in 2009 with an STD, according to data analyzed by the Family Planning Association.

The incidence of the STD chlamydia among women above the age of 45 rose 95% in the past nine years, and the FPA is seeing a 30% increase in the number of calls to its helpline from older citizens concerned about sexually transmitted diseases.

To draw attention to the issue, the FPA is launching a campaign, The Middle-age Spread, that targets Brits over 50.

Individuals who are leaving long-term relationships now use social networking to start dating again, but may be "apparently oblivious to the need for safer sex and the importance of condoms," according to the FPA, as reported by the Daily Mail.

FPA chief executive Julie Bentley says people in this age group may find it hard to discuss issues surrounding sex.

"We celebrate the positive and fulfilling sexuality of the over-50s, but we also have to get the message across that STIs (sexually transmitted infections) don’t care about graying hair and a few wrinkles," she said. "This is a concerning situation which unless we take action now is only going to get worse."

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Overworked and sleep deprived, doctors are making more medical mistakes than ever before. Who's most at risk? Young women—because they're assumed healthy and they're less likely to question a diagnosis. Here's how to be your own health advocate so you can help your M.D. help you. Your life could depend on it.

So, a woman walks into a doctor's office. She's 25, and her cramps are out of control; her period is irregular at best. What's more, she's packed on 50 pounds in 18 months. Her general practitioner suspects and tests her thyroid. Normal. She's shuffled to a gynecologist, who orders a raft of blood work. Normal again. She's prescribed Advil for the pain and birth-control pills to regulate her cycle. Back home, she takes to the Web, searching for answers. And at a followup visit with her gyno, she timidly offers a diagnosis of her own: polycystic ovary syndrome (PCOS), a hormonal disorder that plagues some 5 million young women. "Doubtful," says her doc. "You don't fit the profile." Though the classic PCOS patient is overweight, sufferers also have unnaturally high testosterone levels, something that's missing here. Besides, before her recent weight gain, she'd been slim and healthy, so she's likely just going through a normal postadolescent metabolic slowdown, says her M.D. She'll bounce back soon enough. Except that she doesn't—and two years later, after constant pain and countless more appointments, procedures, and tests, Alexa Stevenson of St. Paul, Minnesota, is finally correctly diagnosed by a reproductive endocrinologist with PCOS, the most common cause of infertility. What, were you expecting a punch line? Alexa's experience is no joke—in fact, it's alarmingly common. Tens of thousands of patients are misdiagnosed every year, according to the Institute of Medicine. In fact, medical mistakes are the eighth leading cause of death—higher than car accidents or even breast cancer. Alexa's diagnosis was fumbled because her birthcontrol pills lowered her testosterone level—something her gynecologist arguably should have deduced since she's the doctor who prescribed them in the first place, before checking her hormone levels. But Alexa is just one of the roughly 49 million Americans (many of them young women) who walk into their doctor's office with a problem and leave with a solution to something else.

Behind the Mistakes

For many women, "the good old days of putting yourself in the capable hands of a doctor who knows you are over," says Peter J. Weiss, M.D., author of More Health, Less Care: How to Take Charge of Your Medical Care and Write Your Own Personal Prescription for Lifelong Health. Today's inundated clinics and vexing HMOs mean physicians are swamped—not to mention drowning in paperwork—and are more likely to pass patients around, especially in big private practices. Not seeing the same practitioner each time you visit raises your risk for a misdiagnosis; without background knowledge, says Weiss, it's much harder for a doc to nail what ails you. And if you happen to be a female in your twenties or thirties, your chance jumps even higher.

It sounds strange, but young women's general good health can work against them. When dealing with a typically strong, fit demographic, doctors are less likely to look toward serious diagnoses. Take, for example, what happened to Emily Willingham of Austin, Texas. When she first saw a gastroenterologist for her relentless stomachaches at age 35, she was sent home with ibuprofen. Four years later, another M.D. discovered a precancerous three-inch-wide intestinal polyp. "That first G.I. doc thought I was too young and too female to have colon problems," she remembers. "But without treatment, I would have died of colon cancer."

Also contributing to misdiagnoses is that lots of young women use their gyno as their primary doctor, relying on a singlesubject- trained physician to diagnose all sorts of bodily woes, says gynecologist Shari Brasner, M.D., an assistant clinical professor at the Mount Sinai School of Medicine in New York City. "If a woman wakes up with ear pain, a gyno is not the right person to see." Janet Taylor, M.D., a psychiatrist and health strategist in Manhattan, echoes that statement: "Specialists are specialists for a reason; they focus on one area of the body. Even if you have a terrific relationship with your gynecologist, you should still seek out a general practitioner."

Of course, scheduling multiple appointments with multiple docs can be maddening (think: infuriating hold times). We don't have time to get sick, much less tend to our symptoms. As a result, when we finally find ourselves in an exam room, we're inclined to accept the first diagnosis that comes along so we can get out, get better, and get on with our lives. "This mind-set really causes problems," says Taylor.

Fortunately, there is a fix. What follows is crucial information on how to increase your chances of being correctly diagnosed off the bat and advice on the best ways to stay informed throughout your treatment.


Demystify Your Doc

Something about a white coat renders even brave, bossy types meek and compliant. Women often hesitate to ask questions, says Weiss, especially when we're already feeling sick and vulnerable. Plus, we're shivering in skimpy paper gowns, and we address our docs with their professional titles (Dr. So-and-So), while they call us by our first names. "All too often there is a parent-child relationship between doctors and patients, as opposed to an adult-adult interaction," explains Andrew Cook, M.D., of the Vital

Health Institute in Los Gatos, California. And young women might succumb to an extra insecurity: We want our doctors to treat us kindly and give us optimal care, so we're inclined to be obedient, says Taylor. We're also more likely to lie about our health and feel embarrassed about discussing "private" physical symptoms (hello, itchy vaginal rash!), so we often keep mum to avoid being judged.

But here's the thing: This isn't a scenario of us versus them. Women and their doctors are on the same team, so why shouldn't we be as vigilant when it comes to our health as we are at work or at home?

Before you even get into that paper gown, comparison shop. Suss out a practice in advance by reading reviews at sites like AngiesList.com. If the docs are booked till Christmas, ask to see a nurse practitioner instead—they are a good first step into a medical group, can prescribe meds, and are often more available than the physicians.

While in research mode, don't let concern about ruffling anyone's feathers keep you from your homework. "Arrogance and ego are real problems in the medical profession," but good docs welcome involved patients, says Richard Klein, M.D., author of Surviving Your Doctors: Why the Medical System Is Dangerous to Your Health and How to Get Through It Alive.

In addition to asking lots of questions, keep close track of your medical history by filing away copies of your records and transferring them whenever you change docs. But even if you have charts dating back to childhood, don't assume your physician has digested everything. "There really isn't enough time," says Adam Dickler, M.D., a radiation oncologist in Evergreen, Illinois. If your doctor flips open your file while entering the exam room, it may be the first time she's looking at it, so be ready with a recap. A full recap. "The issue isn't always that doctors aren't looking at your info," says Taylor, "it's that patients aren't giving enough information." (Case in point: Emily Willingham didn't know to tell her first doc about her family's history of colon polyps.) "Anyone who's ever seen an episode of House knows the importance patient history plays in a diagnosis," says PCOS sufferer Alexa Stevenson. "And when it comes to how you've felt in the past, you are the only real expert."

Double-Check Your Diagnosis

There are thousands of medical diagnoses. But most doctors see only about 250 of them in the course of their career, leaving lots of room for error, says patient advocate Jason Maude, founder of Isabel Healthcare, which runs a diagnosis computer program for medical pros. Docs are taught that the obvious culprit is usually the right one— and it often is. But after diagnosing dozens of patients, it's tempting to jump to easy conclusions. Just imagine a physician has seen 10 cases of strep throat in the past 10 days. If you walk in with a sore throat, guess what's at the front of her mind?

That preliminary diagnosis is critical— and tough to shake. Once your symptoms are given a name, the label tends to stick until overwhelming evidence (or your own persistence) compels alternate theories. Cook, for example, recently saw a patient in her twenties with excruciating pelvic pain that other docs believed was a psychological result of her history of sexual abuse. In reality, he says, she was suffering from endometriosis.

Cutting-edge in-office online diagnosis aids like Isabel and UpToDate are starting to help doctors think outside their familiar 250 cases. But even with the best tools and the most open-minded physician, "diagnosis is still a question of playing the odds," says Weiss. "Even if I'm 99 percent sure you have a certain condition, there's always that 1 percent chance I'm wrong."

Tip the odds all the way by doing research before your appointment (remember, you're researching, not diagnosing) and reminding your M.D. that other possibilities could still exist. When you walk in with that sore throat, remember to ask, "So you think I have strep, but what else could it be?"

Most important, don't think twice about getting a second opinion. Many Americans shy away from having their diagnoses double-checked; that's especially bad news for women, since female-specific illnesses like ovarian cancer are frequently misdiagnosed. A smart doctor should never feel offended or threatened by a backup opinion, particularly if it's from a specialist, says Dickler. "Many women have a fear of insulting their doctors," he says, "but getting a second opinion is a patient's right."

Still feeling bashful? Start thinking of your health as your most important investment. "We spend so much money on health care that we're entitled to get the correct diagnosis," says Taylor. "You owe it to yourself to get a second opinion."

Be an Empowered Patient

Once the diagnostic process is over, you may be tempted to just sit back and swallow your meds. But one-size-fits-all solutions don't always apply in medicine. Every young woman reacts differently to her treatment, so make sure you get the lowdown on possible side effects and continue to monitor your body closely. If prescription pills aren't helping, ask for a list of alternatives. "Many traditions are related to health and healing," says Weiss. "But doctors come from just one tradition—medical school— so they might automatically prescribe drugs instead of, say, massage or acupuncture."

If your treatment is over but you still feel lousy, schedule another appointment... stat. Your M.D. won't know you're still sick if you don't tell her. "I always remind my patients that the follow-up is essential," says Napoleon Knight, M.D., vice president and associate medical director of the Carle Foundation Hospital in Urbana, Illinois. "If you're not getting better, it's your responsibility to come back in." Because although it's a doc's job to solve your medical problems, no one really cares more about your health than you do.


5 COMMONLY MISDIAGNOSED CONDITIONS

Thousands of patients are misdiagnosed each year, thanks to a host of diseases that can pre sent sketchy symptoms and be tricky to identify. A few of the most perplexing cases that affect young women:

1. Hormonal Imbalances Thyroid disease hits about one in eight women, but it is often mistaken for depression, as is polycystic ovary syndrome. Both also have symptoms such as mood swings and weight gain that can be misattributed to lack of exercise or poor diet. Docs sometimes neglect to ask female patients when their worst symptoms occur, thereby missing out on important hormonal cues.

2. Ovarian Cancer Regular Pap exams screen for cervical cancer, but tests are still in development for the ovarian kind, which can cause bloating and irregular bleeding-symptoms many doctors interpret as stomach-related issue like irritable bowel syndrome. As a result, more than 50 percent of ovarian cancer cases are already advanced when finally diagnosed.

3. Autoimmune Diseases Symptoms of illnesses like lupus and fibromyalgia— both more common among young women than men—are often chalked up to the results of excess stress. Fatigue and achy bones can also be hallmarks of anxiety or depression, which many auto-immunedisease sufferers are told they have.

4. Heart Disease Approximately 25,000 women under the age of 45 die of heart disease each year, but many old-school docs still wrongly think of coronary sickness as a "man's disease." Physicians often interpret cardiac-illness warning signs (a racing heart, difficulty breathing, chest pressure) as just heartburn or possible symptoms of anxiety disorders.

5. Endometriosis The average patient waits seven years for a proper diagnosis. The illness can cause crippling cramps and eventual infertility, but it's frequently diagnosed as an irregular menstrual cycle. Because surgery is the only concrete way to diagnose endometriosis, many docs treat other potential culprits first (and often find the real thing accidentally, such as during a C-section).

Take Charge of Your Checkup

1. Make a list. Writing down your symptoms, queries, and any meds you're taking helps avoid what Napoleon Knight, M.D., calls the "excuse-me moment," when your doc is about to leave and you say, "Excuse me! I forgot to mention....

2. Tell the whole truth. Total honesty about things like drug use and sex is nonnegotiable. "Your doc is there to treat you, not judge you," says Janet Taylor, M.D. "And if he does act like he's offended, he's not the doctor you wan

3. Get a translation. "Doctors some-times don't realize we're talking in our own language," says Richard Klein, M.D. If the medical mumbo jumbo isn't making sense, speak up. Ask your physician to slow down and give you layman's terms.

4. Take notes. It's hard to retain lots of new info, especially if you've just been handed upsetting news. Jot down your doc's thoughts on causes, treatments, and cures. Then use that crib sheet to do follow-up research when you get home.

5. Know your testing options. Not all medical tests are created equal: Some are notoriously inaccurate, others give vague results. Understand the risks behind each test, including any false positive or negative outcomes.

6. Follow up. Don't assume your tests came back OK just because you haven't heard from your doctor. "Samples can be mislabeled or, worse, lost," says Klein. Call the office yourself and always request all the hard numbers.

Symptoms You Should Never Ignore

1. Killer Cramps or Vaginal Bleeding If your flow is heavier than normal, don't assume it's just a one-time fluke. Ditto for harsher cramps, unexpected spotting, or a later-than-usual period. Changes in your cycle can be no big deal, but they could also be signs of a serious infection or even cancer. Let your doc do the decoding.

2. Blurred Vision Before you self-diagnose a migraine—and borrow your coworker's headache meds—dial up your M.D. Wooziness or blurry eyesight could indicate a neurological problem like a blood clot or a tumor. It could also be an early sign of multiple sclerosis, which affects many more young women than men.

3. Excessive Sweating and Difficulty Breathing You're having a scary but fleeting panic attack, right? Maybe not. Per the American Heart Association, young women do have heart attacks (to the tune of more than 10,000 a year). They often ignore heart-attack symptoms, thinking they're not old enough for coronary ills.

4. Persistent Down-There Itching If your "yeast infection" just won't quit, all the OTC aids you're taking aren't helping (in fact, they're probably hurting) because you most likely don't have a yeast infection. See your ob-gyn ASAP, and ask her about bacterial vaginosis and ST D testing.

5. A Bulging Stomach Bloated and constipated? Stop saying "I have to eat better" and schedule a doctor's appointment. Chronic abdominal unrest could spell anything from easily treatable lactose intolerance to more dire problems like Crohn's disease or an ovarian tumor.

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Americans love their butts: one in five people still smokes cigarettes on a regular basis, according to the Centers for Disease Control and Prevention, and, after four decades of declining smoking rates, the rate’s been stable for the last five years, according to the Los Angeles Times.

And cigarettes aren’t just hurting smokers. Nearly all the kids who live with a smoker have toxic chemicals in their bloodstream that may put them at risk for cancer, heart disease and other illnesses, and more than half of all American children are exposed to poisonous second-hand smoke.

"If you smoke and have children, don’t kid yourself," said CDC director Dr. Thomas R. Frieden at a news conference reported by the Los Angeles Times. "Your smoke is harming your children."

While many may think tobacco products marketed as not as harmful are less likely to sicken them, they’re equally hazardous, Frieden said. "All cigarettes kill equally, and we know that light and low-tar cigarettes are no less likely to kill you."

Smoking is still the leading cause of preventable deaths in this country, even though there’s been a reduction in smoking over the past 40 years. Some 446,000 Americans die from smoking-related illnesses annually. Of all the states, West Virginia and Kentucky have the highest smoking rates: about 26% of adults in those states smoke regularly. Utah has the lowest rate (10%) and California comes in second lowest (just below 13%).

Frieden says that if other states had similar cancer prevention programs to Utah’s and California’s, there would be 5 million fewer smokers in the nation. The tobacco industry has become more skilled at getting around efforts by the government to keep people from smoking. For instance, the industry targets price discounts to get kids to start smoking, and introduced flavored lozenges to circumvent the ban on flavored cigarettes.

The CDC study found that sex, race and educational level all affect whether a person smokes or not.

Some 24% of men smoke, versus 18% of women, and 31% of smokers live below the poverty level. Close to 50% of people with a GED and 25% of those who did not graduate from high school smoke, while only 6% of college graduates smoke.

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Federal health regulators have issued warnings to the makers of Canada Dry ginger ale and Lipton tea for making unsubstantiated nutritional claims about their green tea-flavored beverages.

In a warning letter issued Aug. 30, the Food and Drug Administration takes issue with the labeling of Canada Dry Sparkling Green Tea Ginger Ale. The agency issued a similar letter Aug. 23 to Unilever Inc., over website and product labeling for its Lipton Green Tea.

Food processors increasingly have been adding vitamins and nutrients to their products to make them more appealing to health-conscious consumers. But the FDA letter to Dr. Pepper Snapple Group, which makes Canada Dry, states that the agency "does not consider it appropriate to fortify snack foods such as carbonated beverages." Furthermore, the agency states that the soft drink does not meet federal requirements to carry the claim that the drink is "enhanced with 200 mg of antioxidants from green tea and vitamin C." According to FDA regulations, the ingredients in Canada Dry's product "are not nutrients with recognized antioxidant activity."

The FDA letter to Unilever takes issue with a company website that mentions four studies that showed a cholesterol-lowering effect with tea. According to the agency, the labeling is misleading because it suggests Lipton tea is designed to treat or prevent disease. The agency also cites antioxidant labeling claims on the company's Lipton Green Tea, which do not follow federal guidelines.

The agency asks executives from both companies to respond to the citations within 15 days and to outline their plans for addressing the problems.

Calls to Plano, Texas-based Dr. Pepper Snapple Group were not immediately returned Tuesday. Calls placed to Unilever's Englewood Cliffs, N.J.-based offices were also not immediately returned. The company is headquartered in London and Rotterdam, Netherlands.

Once a niche market, nutrient-enriched beverages have grown into a multibillion dollar business that includes everything from calcium-enhanced orange juice to energy drinks containing ginseng, ginkgo and other organic products.

In recent years, the FDA has begun cracking down on food companies that overstate the benefits of their products.

The FDA generally endorses health claims on foods only after government researchers have verified that the products help prevent actual disease. Food containing oats, for example, can carry the FDA-approved claim, "may reduce risk of heart disease."

The FDA regularly issues warning letters to companies that do not follow regulations for manufacturing and marketing. The letters are not legally binding, but the agency can take companies to court if they are ignored.

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Definition

Dry eyes are caused by a lack of tears. Tears are necessary for the normal lubrication of your eyes and to wash away particles and foreign bodies.

Alternative Names

Tearing - decreased; Eyes - dry

Considerations

If you have dry eyes, you will feel a burning, scratching, or stinging sensation. You may also have strained or tired eyes after reading, even for short periods of time. If you wear contacts, they will likely feel uncomfortable. Having dry eyes for a while can lead to tiny abrasions on the surface of your eyes.

Common Causes

Common causes of dry eyes include:

• Aging
• Dry environment or workplace (wind, air conditioning)
• Sun exposure
• Smoking or second-hand smoke exposure
• Cold or allergy medicines
• An eye injury or other problem with your eyes or eyelids (like a drooping eyelid or bulging eyes)
• Sjogren's syndrome -- includes dry eyes, mouth, and mucus membranes, and often rheumatoid arthritis or other joint disorder
• Previous eye surgery

Home Care

The following steps may help:

• Try artificial tears, available as either drops or ointment. Ointments last longer, but are thicker and can cause blurry vision.
• Don't smoke. Avoid second-hand smoke, direct wind, and air conditioning.
• Use a humidifier, especially in the winter.
• Purposefully blink more often. Rest your eyes.

Call your health care provider if

Call your health care provider if:

• You have red or painful eyes.
• You have flaking, discharge, or a lesion on your eye or eyelid.
• You have had trauma to your eye, or you have a bulging eye or a drooping eyelid.
• You have joint pain, swelling, or stiffness.
• You also have a dry mouth.
• Your dry eyes do not respond to self-care measures within a few days

What to expect at your health care provider's office

Your health care provider will take a medical history and perform a physical examination, including a careful eye examination.

To help better understand your dry eyes, your health care provider may ask the following:

• How long have you had dry eyes? Does it involve one or both eyes?
• Do you have it all of the time or does it only occur at certain times, with certain activities, or in certain places?
• Does the dryness seem related to wind, dust, chemicals, sun, or light exposure?
• Does it affect your vision?
• Does it cause pain?
• Do your eyelids close easily?
• Have you noticed any drainage from your eyes?
• Does anything make your dry eyes worse?
• Does anything make your dry eyes better?
• Have you tried artificial tears? Do they help?
• Are you taking any medications? Which ones?
• Have you had surgery or an injury to your eyes or nose?
• Do you have allergies?
• Have you been using any new cosmetics?
• Do you have any other symptoms like dry mouth or joint discomfort?

Your health care provider may perform tearing tests that can help diagnose dry eyes. Artificial tears may be prescribed.

References

yahoo.net

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Definition

Acne is a skin condition that causes whiteheads, blackheads, and inflamed red lesions (papules, pustules, and cysts) to form. These growths are commonly called pimples or "zits."
Alternative Names

Acne vulgaris; Cystic acne; Pimples; Zits
Causes, incidence, and risk factors

Acne occurs when tiny holes on the surface of the skin, called pores, become clogged. Each pore is an opening to a canal called a follicle, which contains a hair and an oil gland. Normally, the oil glands help keep the skin lubricated and help remove old skin cells. When glands produce too much oil, the pores can become blocked, accumulating dirt, debris, and bacteria. The blockage is called a plug or comedone.

The top of the plug may be white (whitehead) or dark (blackhead). If it ruptures, the material inside, including oil and bacteria, can spread to the surrounding area and cause an inflammatory reaction. If the inflammation is deep in your skin, the pimples may enlarge to form firm, painful cysts.

Acne commonly appears on the face and shoulders, but may also occur on the trunk, arms, legs, and buttocks.

Acne is most common in teenagers, but it can happen at any age, even as an infant. Three out of four teenagers have acne to some extent, probably caused by hormonal changes that stimulate oil production. However, people in their 30s and 40s may also have acne.

Acne tends to run in families and can be triggered by:

* Hormonal changes related to menstrual periods, pregnancy, birth control pills, or stress
* Greasy or oily cosmetic and hair products
* Certain drugs (such as steroids, testosterone, estrogen, and phenytoin)
* High levels of humidity and sweating

Despite the popular belief that chocolate, nuts, and other foods cause acne, research does not confirm this idea.
Symptoms

* Blackheads
* Crusting of skin eruptions
* Cysts
* Pustules
* Redness around the skin eruptions
* Scarring of the skin
* Whiteheads

Signs and tests

Your doctor can diagnose acne based on the appearance of the skin. Testing is usually not required.
Treatment

Take the following self-care steps to lessen the effects of acne:

* Clean your skin gently with a mild, non-drying soap (such as Dove, Neutrogena, or Basics). Remove all dirt or make-up. Wash once or twice a day, including after exercising. However, avoid excessive or repeated skin washing.
* Shampoo your hair daily, especially if it's oily. Comb or pull your hair back to keep the hair out of your face. Avoid tight headbands.
* Try not to squeeze, scratch, pick, or rub the pimples. Although it might be tempting to do this, it can lead to skin infections and scarring.
* Avoid touching your face with your hands or fingers.
* Avoid greasy cosmetics or creams. Look for water-based or "non-comedogenic" formulas. Take make-up off at night. Non-comedogenic products have been tested and proven not to clog pores and cause acne.

If these steps do not clear up the blemishes to an acceptable level, try over-the-counter acne medications. These products are applied directly to the skin. They may contain benzoyl peroxide, sulfur, resorcinol, or salicylic acid. They work by killing bacteria, drying up the oil, and causing the top layer of your skin to peel. They may cause redness or peeling of the skin.

If pimples are still a problem, a dermatologist can prescribe stronger medications and discuss other options with you.

Prescription medicines include:

* Oral antibiotics (taken by mouth) such as minocycline, doxycycline, tetracycline, erythromycin, and amoxicillin
* Topical antibiotics (applied to the skin) such as clindamycin, erythromycinm or dapsone
* Retinoic acid cream or gel (Retin-A) and isotretinoin pills (Accutane) -- pregnant women and sexually active adolescent females should NOT take Accutane, as it causes severe birth defects. Women taking Accutane must use two forms of birth control before starting the drug and enroll in the iPledge program.
* Prescription formulas of benzoyl peroxide, sulfur, resorcinol, salicylic acid
* A pill called spironolactone may help women with hormonally controlled acne.
* A laser procedure called photodynamic therapy may also be helpful.

Birth control pills can sometimes help clear up acne. (In some cases, though, they may make it worse.)

Your doctor may also suggest chemical skin peeling, removal of scars by dermabrasion, or removal, drainage, or injection of cysts.

A small amount of sun exposure may improve acne. However, excessive exposure to sunlight or ultraviolet rays is not recommended because it increases the risk of skin cancer.
Expectations (prognosis)

Acne usually subsides after adolescence, but may last into middle age. The condition generally responds well to treatment after 6 - 8 weeks, but may flare up from time to time. Scarring may occur if severe acne is not treated. Some people, especially teenagers, can become significantly depressed if acne is not treated.
Complications

Possible complications include:

* Changes in skin color
* Cysts
* Damage to self-esteem, confidence, personality, and social life
* Permanent facial scars
* Side effects of Accutane (including very dry skin and mucus membranes, high triglyceride levels, liver damage, and birth defects in an unborn baby; call your doctor right away if you become pregnant while taking this drug)
* Side effects of other medications

Calling your health care provider
Call your doctor or a dermatologist if:

* Self-care measures and over-the-counter medicine have not helped after several months
* Your acne is severe (for example, you have lots of redness around the pimples or you have cysts) or getting worse
* You develop scars as your acne clears up

Call your pediatrician if your baby has acne that does not clear up on its own within 3 months.
References

Acne, rosacea, and related disorders. In: Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 7.

Adam.

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Salma Hayek Hot Photos

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Amrita Rao Hot Photos

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Chemicals used to waterproof fabrics and make non-stick cookware coatings have been linked to high cholesterol levels in kids, according to research reported by Reuters.

For the study, which appeared in the Archives of Pediatrics & Adolescent Medicine, scientists focused on two compounds: perfluorooctanoic acid (PFOA) and perfluorooctanesulfonate (PFOS). They found that kids with the highest levels of two chemicals had higher cholesterol levels than children with lower blood levels of the substances.

Both the total cholesterol and the LDL, or so-called "bad" cholesterol, were higher in the children with higher levels of PFOA and PFOS. While the research does not prove that being exposed to the chemicals causes higher cholesterol levels, they do suggest a link and point to a need for further study, West Virginia University’s Stephanie Frisbee and her colleagues wrote.

PFOA and PFOS get into a person’s bloodstream through drinking water, microwave popcorn, dust, food packaging, occupational exposure and air, according to the scientists.

Frisbee and her co-workers looked at the cholesterol levels of more than 12,000 children who had PFOA in their drinking water. The children lived in the mid-Ohio River Valley, and had higher-than-average PFOA levels. Their PFOS concentration was around the same as the national average.

Those kids with the highest PFOA levels had total cholesterol levels that were 4.6 points higher and LDL cholesterol levels that were 3.8 points higher than kids who had the lowest PFOA levels.

More research is needed, said the team, to prove that exposure to chemicals could cause higher cholesterol levels.

nydailynews.com

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Fashionistas who check into the Cleveland Clinic are in for a sartorial treat: designer duds made by Diane von Furstenberg.

And while the new hospital gowns may not look like the iconic wrap dresses the designer became famous for, they’re certainly a sight for sick eyes: they feature a bold graphic print (along with the Cleveland Clinic logo) and side ties, which get rid of the open-back look, according to the Associated Press.

The fabric, which according to the Plain Dealer was picked to coddle patients who complain of being too warm in the hospital, is lightweight, yet hardy enough to withstand multiple washings and dryings – and having all manner of monitors and drains attached to it.

Patient feedback? Women seem to love the gowns, though some of the guys have protested that the outfit is overly feminine. Thus the design team may come up with an alternate print.

No word yet on whether other masculine touches are planned to cater to fashion-conscious male patients.

nydailynews.com

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Don't waste your money at the Dentist! Read this special report and find out what Dentists DON'T want you to know about teeth whitening options online!
Emily and her sweet daughter

Samantha, a Ho Chi Minh City, 20 teacher and full time mother isn't one to let a tight budget keep her from getting what she wants. About 16 months ago she began looking for deals online and managed to find great items for as much as 75% off the retail price (like an authentic Coach pocketbook for $55). She was determined to seek out other great offers on the internet and just recently she discovered her best find. Samantha found a clever way of combining two different teeth whitening offers from two different companies - BriteWhite Smile and Idol White - to get results similar to that of a professional whitening done by a dentist. Rather then spending $500 at her local dentist to attain a sexy smile, she was able to do so for less than $5 by using free trial offers she found online.

Samantha: "Yellow teeth are embarrassing. I hated the way my teeth looked and avoided smiling at all costs. I tried some of the products you can find at the drug store and got nothing but wasted time and money. I priced out some whitening procedures at the dentist and ran for the hills - we're talking hundreds of dollars that I just don't have because of the crappy economy.

So what are you going to do? Fight the urge to smile for the rest of your life, or just accept your embarrassing teeth? After all, they do say that beauty is only skin deep right? Well, I tried that for a while and it just didn't work for me."

How long have you felt insecure about the color of your teeth?

"It's been a while now; your teeth get yellow as you age even if you're not a smoker. You think that your teeth are okay, but then you put on lipstick and the yellowness really shows. It doesn't help that so many of our favorite drinks like coffee, tea and wine are responsible for changing our 'pearly whites' into 'dingy yellows'. I wasn't ready to accept the way my teeth looked, so I kept looking for the answer and I found it online.

While searching the Web I found a few online teeth whitening companies giving away free trials* where you only had to pay a few dollars for shipping. I ordered two products, BriteWhite Smile and Idol White, both of which had 9/10 ratings and positive feedback from all users. After using the first product the results were noticeable, but after following with the second product I had a celebrity white smile. I'm far from a medical expert, but it appears that each product focused on DIFFERENT parts of the problem and that the second one put the whitening effect into overdrive. By using them both in a row I had absolutely unbelievable results. I can't believe companies are practically giving these products away!

What prompted Samantha to try out two products at the same time?

"I wanted fast results and didn't want to wait or risk one of them not working. It's a little embarrassing to say, but I had a high school reunion coming up and I just wanted to look my best! Luckily, it turned out that using both products together is the way to get the best results and I would never have discovered it if I wasn't so anxious about getting ready for that reunion."

Can you describe the process for the readers?

"It was a lot easier than finding those bargains online, all I had to do was sign up for the free trial for both BriteWhite Smile and Idol White and I had both products within a week, you do have to pay for the shipping but it is next to nothing compared to what you have to pay a dentist to get the same results.

While it's true that you can't put a price on the way you look, times are tight these days. All I know is when I look at my smile in the mirror - I like what I see. I'm confident in any social situation and feel much better about myself. It's amazing that whitening your smile by a few shades can make this much difference in your life but it does - I'd recommend anyone to try this out and see for themselves."

CNN reported recently that the number one request from patients is tooth whitening products, is there anyone that you feel wouldn't benefit from your secret?

"Who doesn't want a whiter smile? Unless your teeth are perfect or you have the money to pay $350 or more to your local dentist, you owe it to yourself to try my secret out. Just remember that you have to order both products and use them together to achieve the same results."

Just because money is tight doesn't mean that you have to settle for not looking your best. Just about the first thing that anyone notices about you - whether it's on a first date or an important job interview - is your smile. A bright white and healthy smile looks clean, attractive and professional - what does your smile say about you?"

Consumer News 12 would like to thank Samantha for sharing this fantastic teeth whitening method with our readers. If you're interested in getting fast results like she did, we've obtained special links and a coupon code for additional discounts straight from the manufacturer - but they're for a limited time only. Make sure to get your free* trials today.

consumernewsdaily.net

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Just looking for the basics about what you need to know about the 2010 egg recall? Here are quick links that'll help answer your questions about the latest recall and salmonella outbreak.

What’s going on?

About half a billion eggs have been recalled because of a salmonella outbreak. While this recall involves hundreds of millions of eggs, they represent less than 1 percent of the 80 billion eggs produced in the United States each year, according to the Egg Safety Center, a trade association entity.

Egg producer Hillandale Farms of Iowa recalled some 170.4 million eggs distributed to stores and companies and another company, Wright County Egg of Galt, Iowa, has recalled 380 million eggs.

Which eggs are affected?

The Egg Safety Center has a complete list of recalled eggs, their expiration dates, and brands. If you happen to have any of these don’t eat them – get rid of them or return them for a refund.

How many people have been affected?

About 1,300 cases of salmonella have been linked to eggs from Wright County Eggs and Hillandale Farms of Iowa, forcing a recall of their products in at least 17 states, according to the Food and Drug Administration and the Centers for Disease Control and Prevention.

What is salmonella?

CNN’s Dr. Sanjay Gupta explains that chickens can pass salmonella enteritidis, the bacteria at the center of the outbreak, without getting sick. Symptoms for humans can be mild to severe, but most people will have some gastrointestinal signs.

How did salmonella get into the eggs?

Laying hens can be infected either by contact with human workers who have not followed proper sanitary procedures, or, more frequently, by consuming feed that has come into contact with rodent feces. Affected hens can transmit the bacteria from their ovaries or oviducts before the shell even forms around an egg, thus making the egg's tainted status undetectable, Eatocracy’s Kat Kinsman explains.

What’s the background on the egg companies?

Congress has asked the two Iowa-based egg producers for details on the contamination of their egg products. The companies, Wright County Egg and Hillandale Farms were supplied by another company, Quality Egg, which provided feed and young birds. Both Wright County and Quality Egg are owned by the DeCoster family, which has a string of agribusiness interests in the Midwest and Northeast.

Could this have been prevented?

The latest outbreak raises serious questions about the U.S. food supply and safety. New regulations went into effect July 9, requiring egg producers with more than 3,000 hens to take measures designed to prevent the spread of salmonella. But the current outbreak began in May, according to the FDA.

I love eating eggs. Do I have to give them up?

Avoid the recalled products and here are some additional safety tips.

Will I be safer if I eat cage-free or organic eggs?

Regardless of methodology, none of it ensures that the eggs are completely safe from salmonella, Eatocracy explains.

CNN

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When meat smells funky or fruit gets moldy, you know it's time to toss it. But new science is showing that even "nonperishables" such as tea, olive oil, dried herbs, and grains can lose valuable nutrients during months in your pantry. We surveyed a dozen experts to find out what's at risk—and learned some tips for prolonging your food's nutritional shelf life.

Green Tea

Antioxidants decrease an average of 32% after 6 months on the shelf, according to a 2009 study in the Journal of Food Science. These antioxidants, known as catechins, may decrease your risk of several types of cancer, but they are sensitive to both oxygen and light. Sadly, tea, unlike wine, does not improve with age.

Make It Last: "Buy tea in airtight packages such as tins, rather than cellophane wraps, which air can penetrate," advises Rona Tison of ITO EN, the world's largest supplier of green tea. Store your tea bags in sealed, opaque canisters in a cool spot. "Green tea is more sensitive to heat than black tea , so place your sealed container in the refrigerator to keep the leaves fresh and healthy for as long as possible," she says.

Is your kitchen making you sick?

Tomato Products

Canned tomato juice loses 50% of its lycopene after 3 months in the refrigerator—even when it's unopened, says a study in Food Chemistry. Similarly, scientists in Spain have found that the lycopene in ketchup deteriorates over time. That's a shame, because it's a potent antioxidant that may fight many forms of cancer and heart disease and even strengthen bones.

Make It Last: Skip the premade tomato sauce and make your own using boxed whole or diced tomatoes rather than pureed. Whole and diced tomatoes contain more solids, which provide added protection for the lycopene, says B. H. Chen, PhD, a food scientist at Fu Jen University in Taiwan who analyzes the stability of carotenoids. If ketchup sits in your fridge for months, buy smaller bottles, says Christine Gerbstadt, M.D., RD. Fresh bottles tend to start off with higher levels of lycopene.

Potatoes

Vitamin C declined 40%, on average, after 8 months in proper storage (in a place that's cool, dark, and dry), according to researchers in Holland. You probably wouldn't keep potatoes that long. But farmers often store them up to 5 months before shipping them to market, says Peter Imle, a potato farmer and plant geneticist in northern Minnesota.

Make It Last: Look for smaller potatoes (often labeled new), which have a slightly higher vitamin C content to begin with, and buy only what you can eat in a few weeks. Imle also recommends keeping potatoes in paper sacks, rather than plastic grocery bags. "Paper keeps out excess light and oxygen. But it still allows the potatoes to breathe, without trapping in moisture like plastic can," he explains.

How to store food to make it last longer.

Olive Oil

The potency of antioxidants declined 40% after 6 months, according to a 2009 Italian study of bottled olive oil in the Journal of Food Science. Yet in many households, bottles can sit on the shelf for much longer than that.

Make It Last: Don't store oil near the stove or leave it uncapped for long, as it's sensitive to oxygen, heat, and light, says Doug Balentine, PhD, director of nutrition sciences at Bertolli, an olive oil producer. If you don't cook with it often, buy smaller bottles.

Berry Jams

The anthocyanins in blueberry jam decline by 23%, on average, after 2 months of storage at room temperature, say researchers at the University of Arkansas. Similarly, strawberry jam loses up to 12% of its health-boosting flavonoids after 6 months in a dark cupboard. Experts believe the flavonoids (including anthocyanins) contribute to the antiinflammatory, memory-preserving, antioxidant effects of berries.

Make It Last: Store jams in the fridge before opening to retain about 15% more of the anthocyanins and their antiaging benefits. Or buy sugar-free blueberry jams. Researchers found that they maintain higher levels of anthocyanins over time.

6 Things that make your home unsafe.

Dried Herbs & Spices

The capsaicin in chili powder decreased continuously during 9 months of storage in one Chinese study. Capsaicin may contribute to weight loss and also help fight certain cancers. "Generally, spices that should be bright in color but have grown dull are also devoid of flavor and nutritional value," says Jay Bunting, owner of Wayzata Bay Spice Co.

Make It Last: Buy in glass jars whenever possible, says Bunting. (Air penetrates plastic.) Better yet, grind your own. Whole spices such as peppercorns retain health benefits and flavor much longer because the inside of each peppercorn is protected from light and air. Store herbs and spices out of direct light and away from the hot stove.

Grains & Dry Goods

The riboflavin in enriched macaroni plummeted 50% after being exposed to light for only a day, according to a Journal of Food Science study. Even dim light can degrade riboflavin by 80% after 3 months, according to another study. The folic acid in enriched flour is also sensitive to both light and oxygen.

Make It Last: Store grains in opaque ceramic containers, far from the stove's damaging heat. A dry cupboard is better than the fridge, except in the case of brown rice, which contains a small amount of oil and therefore spoils faster at room temperature.

Prevention

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The initial diagnosis of acute coronary syndrome (ACS) is based on history, risk factors, and, to a lesser extent, ECG findings. The symptoms are due to myocardial ischemia, the underlying cause of which is an imbalance between supply and demand of myocardial oxygen.

Patients with ACS include those whose clinical presentations cover the following range of diagnoses: unstable angina, non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). This ACS spectrum concept is a useful framework for developing therapeutic strategies.

A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of midsternal chest pain that began after eating a large meal. Pain is now present but is minimal. Aspirin is the single drug that will have the greatest potential impact on subsequent morbidity. In the setting of ongoing symptoms and ECG changes, nitrates titrated to 10% reduction in blood pressure and symptoms, beta-blockers, and heparin are all indicated. If the patient continues to have persistent signs and/or symptoms of ischemia, addition of a glycoprotein IIb/IIIa inhibitor should be considered.

[ CLOSE WINDOW ]

A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of midsternal chest pain that began after eating a large meal. Pain is now present but is minimal. Aspirin is the single drug that will have the greatest potential impact on subsequent morbidity. In the setting of ongoing symptoms and ECG changes, nitrates titrated to 10% reduction in blood pressure and symptoms, beta-blockers, and heparin are all indicated. If the patient continues to have persistent signs and/or symptoms of ischemia, addition of a glycoprotein IIb/IIIa inhibitor should be considered.

A 62-year-old woman with a history of chronic stable angina and a "valve problem" presents with new chest pain. She is symptomatic on arrival, complaining of shortness of breath and precordial chest tightness. Her initial vital signs are blood pressure 140/90 mm Hg and heart rate is 98. Her ECG is as shown. She is given nitroglycerin sublingually, and her pressure decreases to 80/palpation. Right ventricular ischemia should be considered in this patient.

[ CLOSE WINDOW ]

A 62-year-old woman with a history of chronic stable angina and a "valve problem" presents with new chest pain. She is symptomatic on arrival, complaining of shortness of breath and precordial chest tightness. Her initial vital signs are blood pressure 140/90 mm Hg and heart rate is 98. Her ECG is as shown. She is given nitroglycerin sublingually, and her pressure decreases to 80/palpation. Right ventricular ischemia should be considered in this patient.

Pathophysiology

Myocardial ischemia is most often due to atherosclerotic plaques, which reduce the blood supply to a portion of myocardium. Initially, the plaques allow sufficient blood flow to match myocardial demand. When myocardial demand increases, the areas of narrowing may become clinically significant and precipitate angina. Angina that is reproduced by exercise, eating, and/or stress and is subsequently relieved with rest, and without recent change in frequency or severity of activity that produce symptoms, is called chronic stable angina. Over time, the plaques may thicken and rupture, exposing a thrombogenic surface upon which platelets aggregate and thrombus forms. The patient may note a change in symptoms of cardiac ischemia with a change in severity or of duration of symptoms. This condition is referred to as unstable angina.

Patients with STEMI have a high likelihood of a coronary thrombus occluding the infarct artery. Angiographic evidence of coronary thrombus formation may be seen in more than 90% of patients with STEMI but in only 1% of patients with stable angina and about 35-75% of patients with unstable angina or NSTEMI. However, not every STEMI evolves into a Q-wave MI; likewise, a patient with NSTEMI may develop Q waves.

The excessive mortality rate of coronary heart disease is primarily due to rupture and thrombosis of the atherosclerotic plaque. Inflammation plays a critical role in plaque destabilization and is widespread in the coronary and remote vascular beds. Systemic inflammatory, thrombotic, and hemodynamic factors are relevant to the outcome. Evidence indicates that platelets contribute to promoting plaque inflammation as well as thrombosis. A new theory of unbalanced cytokine-mediated inflammation is emerging, providing an opportunity for intervention.

A less common cause of angina is dynamic obstruction, which may be caused by intense focal spasm of a segment of an epicardial artery (Prinzmetal angina). Coronary vasospasm is a frequent complication in patients with connective tissue disease. Other causes include arterial inflammation and secondary unstable angina. Arterial inflammation may be caused by or related to infection. Secondary unstable angina occurs when the precipitating cause is extrinsic to the coronary arterial bed, such as fever, tachycardia, thyrotoxicosis, hypotension, anemia, or hypoxemia. Most patients who experience secondary unstable angina have chronic stable angina as a baseline medical condition.

Spontaneous and cocaine-related coronary artery dissection remains an unusual cause of ACS and should be included in the differential diagnosis, especially when a younger female or cocaine user is being evaluated. An early clinical suspicion of this disease is necessary for a good outcome. Cardiology consultation should be obtained for consideration for urgent percutaneous coronary intervention.

Although rare, pediatric and adult ACS may result from the following (see Myocardial Infarction in Childhood):

• ACS may occur with Marfan syndrome; Kawasaki disease; Takayasu arteritis; or cystic medial necrosis with aortic root dilatation, aneurysm formation, and dissection into the coronary artery.
• Anomalous origin of the left coronary artery from the pulmonary artery may occur as unexplained sudden death in a neonate.
• Coronary artery ostial stenosis may occur after repair of a transposition of the great arteries in the neonatal period.
• An aberrant left main coronary artery with its origin at the right sinus of Valsalva may cause ACS, especially with exertion.
• Traumatic myocardial infarction can occur in patients at any age.
• Accelerated atherosclerosis is known to occur in cardiac transplant recipients on immunosuppressive therapy.
• ACS may occur with progeria.

Irrespective of the cause of unstable angina, the result of persistent ischemia is myocardial infarction (MI).

Frequency

United States

Although the exact incidence of ACS is difficult to ascertain, hospital discharge data indicate that 1,680,000 unique discharges for ACS occurred in 2001.

International

In Britain, annual incidence rate of angina is estimated at 1.1 cases per 1000 males and 0.5 cases per 1000 females aged 31-70 years. In Sweden, chest pain of ischemic origin is thought to affect 5% of all males aged 50-57 years. In industrialized countries, annual incidence rate of unstable angina is approximately 6 cases per 10,000 people.

Mortality/Morbidity

When the only therapy for angina was nitroglycerin and limitation of activity, patients with newly diagnosed angina had a 40% incidence of MI and a 17% mortality rate within 3 months. A recent study shows that the 30-day mortality rate from ACS has decreased as treatment has improved, a statistically significant 47% relative decrease in 30-day mortality rate among newly diagnosed ACS from 1987-2000. This decrease in mortality rate is attributed to aspirin, glycoprotein (GP) IIb/IIIa blockers, and coronary revascularization via medical intervention or procedures.

Clinical characteristics associated with a poor prognosis include advanced age, male sex, prior MI, diabetes, hypertension, and multiple-vessel or left-mainstem disease.

Sex

Incidence is higher in males among all patients younger than 70 years. This is due to the cardioprotective effect of estrogen in females. At 15 years postmenopause, the incidence of angina occurs with equal frequency in both sexes. Evidence exists that women more often have coronary events without typical symptoms, which might explain the frequent failure to initially diagnose ACS in women.

Age

ACS becomes progressively more common with increasing age. In persons aged 40-70 years, ACS is diagnosed more often in men than in women. In persons older than 70 years, men and women are affected about equally.

Clinical

History

• Typically, angina is a symptom of myocardial ischemia that appears in circumstances of increased oxygen demand. It is usually described as a sensation of chest pressure or heaviness, which is reproduced by activities or conditions that increase myocardial oxygen demand.
• Not all patients experience chest pain. Some present with only neck, jaw, ear, arm, or epigastric discomfort.
• Other symptoms, such as shortness of breath or severe weakness, may represent anginal equivalents.
• A patient may present to the ED because of a change in pattern or severity of symptoms. A new case of angina is more difficult to diagnose because symptoms are often vague and similar to those caused by other conditions (eg, indigestion, anxiety).
• Patients may have no pain and may only complain of episodic shortness of breath, weakness, lightheadedness, diaphoresis, or nausea and vomiting.
• Patients may complain of the following:
  • Palpitations
  • Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm
  • Exertional dyspnea that resolves with pain or rest
  • Diaphoresis from sympathetic discharge
  • Nausea from vagal stimulation
  • Decreased exercise tolerance
  • Patients with diabetes and elderly patients are more likely to have atypical presentations and offer only vague complaints, such as weakness, dyspnea, lightheadedness, and nausea.
• Stable angina
  • Involves episodic pain lasting 5-15 minutes
  • Provoked by exertion
  • Relieved by rest or nitroglycerin
• Unstable angina: Patients have increased risk for adverse cardiac events, such as MI or death. Three clinically distinct forms exist, as follows:
  • New-onset exertional angina
  • Angina of increasing frequency or duration or refractory to nitroglycerin
  • Angina at rest
• Variant angina (Prinzmetal angina)
  • Occurs primarily at rest
  • Triggered by smoking
  • Thought to be due to coronary vasospasm
• Elderly persons and those with diabetes may have particularly subtle presentations and may complain of fatigue, syncope, or weakness. Elderly persons may also present with only altered mental status. Those with preexisting altered mental status or dementia may have no recollection of recent symptoms and may have no complaints whatsoever.
• As many as half of cases of ACS are clinically silent in that they do not cause the classic symptoms described above and consequently go unrecognized by the patient. Maintain a high index of suspicion for ACS especially when evaluating women, patients with diabetes, older patients, patients with dementia, and those with a history of heart failure.

Physical

• Physical examination results are frequently normal. If chest pain is ongoing, the patient will usually lie quietly in bed and may appear anxious, diaphoretic, and pale.
• Hypertension may precipitate angina or reflect elevated catecholamine levels due to either anxiety or exogenous sympathomimetic stimulation.
• Hypotension indicates ventricular dysfunction due to myocardial ischemia, infarction, or acute valvular dysfunction.
• Jugular venous distention
• Third heart sound (S₃) may be present.
• A new murmur may reflect papillary muscle dysfunction.
• Rales on pulmonary examination may suggest left ventricular (LV) dysfunction or mitral regurgitation.
• Presence of a fourth heart sound (S₄) is a common finding in patients with poor ventricular compliance due to preexisting ischemic heart disease or hypertension.

Causes

• Atherosclerotic plaque is the predominant cause. Coronary artery vasospasm is less common.
• Alternative causes of angina include the following:
  • Ventricular hypertrophy due to hypertension, valvular disease, or cardiomyopathy
  • Embolic occlusion of the coronary arteries
  • Hypoxia, as in carbon monoxide poisoning or acute pulmonary disorders
  • Cocaine and amphetamines, which increase myocardial oxygen demand and may cause coronary vasospasm
  • Underlying coronary artery disease, which may be unmasked by severe anemia
  • Inflammation of epicardial arteries
  • Coronary artery dissection
• Risk factors for ACS should be documented and include the following:
  • Male gender
  • Diabetes mellitus (DM)
  • Smoking history
  • Hypertension
  • Increased age
  • Hypercholesterolemia
  • Hyperlipidemia
  • Prior cerebrovascular accident (CVA) - These patients constitute 7.5% of patients with ACS and have high-risk features.
  • Inherited metabolic disorders
  • Methamphetamine use
  • Occupational stress
  • Connective tissue disease

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