The Diabetes UK Media Relations Team was a proud finalist for the Third Sector Excellence Awards in the category of Communications Team.

The other finalists competing for one of the sectors most prestigious awards were the Childrens Society (the winner), Crimestoppers Trust, EveryChild and Macmillan Cancer Support.

Winners were announced at an awards ceremony on 24 September at the Grosvenor House Hotel in London.

Fantastic achievement

“Its fantastic to have made it through to the final stages of such a prestigious award,” said Paul McDonald, Head of Media at Diabetes UK.

A recently published study determined that women who make poor shoe choices early in life suffer with foot pain in later years. Research shows that men do not experience the same foot pain as women, due to type of shoes they wear. Details of this study appear in the October issue of Arthritis Care & Research, a journal published by WileyBlackwell on behalf of the American College of Rheumatology.

National data reveal that foot and toe symptoms are among the top 20 reasons patients ages 6574 visit their physician. In the U.S., foot pain is considered a very common musculoskeletal symptom and occurs in such conditions as rheumatoid arthritis, diabetes, and gout, or with sprains, muscle strains, bruises, and fractures. Previous studies have determined a correlation between improper footwear and foot pain, but this research focused on small patient samples or disease specific studies.

Researchers from Boston University School of Public Health and the Institute for Aging Research at Hebrew SeniorLife enrolled 3,372 participants in the Framingham Foot Study. Participants were derived from 2 large populationbased samples of residents from Framingham, Massachusetts. The first group was part of the Framingham Study Original Cohort (formed in 1948) and the Framingham Offspring Cohort (formed in 1972) that were originally studied for heart disease risk factors. The second group was a new population sample derived from census data and included subjects who were at least 50 years old and ambulatory who were added to increase participation by minority persons.

The Framingham Foot Study assessed 1,472 men and 1,900 women between 2002 and 2008. Subjects were asked if they experienced pain, aching, or stiffness in either or both feet. Data on specific areas of foot pain was identified in the nails, forefoot, hindfoot, heel, arch of the foot, and ball of the foot. Participants provided information on current and past shoewear across five age groups 2029 years, 3044 years, 4564 years, 6574 years, and 75+ years. Shoewear was classified as good (low risk shoes including athletic and casual sneakers), average (mid risk shoes such as hard or rubbersoled shoes, special shoes and work boots), and poor shoes (highrisk shoewear that lack support and sound structure, including highheeled shoes, sandals, and slippers).

According to the study 25% of participants reported generalized foot pain on most days with 19% of men and 29% of women falling into this subtype. “In women, we found an increased risk between hindfoot pain and shoewear,” said the authors. The study revealed that only a small percentage (< 2%) of men wore poor shoes, thus shoe type is not a major factor for developing foot pain in men. "While more research is needed, young women should make careful choices regarding their shoe type to avoid hindfoot pain later in life, or perform stretching exercises to alleviate the effect of high heels on foot pain," recommended researchers.

Citation
“Foot Pain Is Current or Past Shoewear a Factor?”
Alyssa B. Dufour, Kerry E. Broe, Anne H. Walker, Erin Kivell, UyenSa D.T. Nguyen, Marian T. Hannan, David R. Gagnon, Howard J. Hillstrom.
Arthritis Care & Research; Published Online September 29, 2009 (DOI 10.1002/art.24733); Print Issue Date October 2009.

Additional countries are expected to soon announce they will follow in the footsteps of nine developed countries who recently said they would donate H1N1 (swine flu) vaccine supplies to poorer nations, David Nabarro, of the U.N. said Friday, Reuters reports.

“It is most likely that there will be other countries donating 10 percent of their H1N1 vaccine stocks,” Nabarro said. Nabarro declined to name who the new donors would be, according to Reuters. A report released last week concluded “85 developing countries would have to rely entirely on donations for vaccine supplies,” the news service writes (Evans, 9/25).

VOA News reports the WHO also continues to solicit vaccine donations and reduced prices on H1N1 vaccines from pharmaceutical companies (Schlein, 9/25). In related news, Daily Nation/allAfrica.com reports Kenya will soon receive four million doses of H1N1 vaccine from the WHO (9/25).

H1N1Related Deaths Near 4,000
Also on Friday, the WHO reported that over 3,900 people have died from H1N1 “a jump of 431 deaths compared to a week ago,” according to Agence FrancePresse/the Australian. “The Americas region continued to post the highest number of fatal cases, at 2948,” the news service writes (9/25).

H1N1 Moves Through South Africa, Zimbabwe, Mexico

In South Africa, the number of H1N1related deaths climbed to 59, according to a spokesperson from the National Institute of Communicable Diseases, BuaNews reports (9/25). ZimOnline examines the rising number of H1N1 cases in Zimbabwe, “where health facilities have collapsed after a decade of economic recession” (Nyamhangambiri, 9/26).

The Associated Press/Detroit Free Press reports on the “next wave” of H1N1 in Mexico. Despite “[d]aily diagnoses reach[ing] higher levels in September than the H1N1 peak in April, with 483 new cases in just one day this month alone,” the news service writes, “Its unlikely there will be largescale closings of schools and stadiums … because health officials know the virus is benign if treated early” (9/27).

No Major Changes In H1N1 Virus, U.S. Health Officials Say

HealthDay News/Atlanta JournalConstitution reports that U.S. health officials on Friday reported there were no major changes in the genetic composition of the H1N1 virus, “making the forthcoming vaccine a good match for the virus” and signifying the virus has not mutated into a deadlier form (9/25).

News Outlets Explore U.S. Efforts To Track Adverse Effects Of H1N1 Vaccine

AP examines the U.S. system to track H1N1 vaccinerelated side effects. The article includes information about several governmentfunded projects that will help stay on top of the outcomes of people who take the H1N1 vaccine (Neergaard, 9/27). The New York Times also features a piece on how the government is preparing to separate commonly occurring medical events from events that can be linked back to being a side effect of the H1N1 vaccine. The CDC “has compiled data on how many problems like heart attacks, strokes, miscarriages, seizures and sudden infant deaths normally occur” and “has broken those figures down for various highpriority vaccine groups, like pregnant women or children with asthma,” the newspaper writes, adding, “When vaccinations begin, it plans to gather reports from vaccine providers, hospitals and doctors, looking for signs of adverse events, so it can detect problems before rumors grow” (McNeil, 9/27).

This information was reprinted from globalhealth.kff.org with kind permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Global Health Policy Report, search the archives and sign up for email delivery at globalhealth.kff.org.

© Henry J. Kaiser Family Foundation. All rights reserved.

The U.S. Food and Drug Administration approved Stelara (ustekinumab), a biologic product for adults who have a moderate to severe form of psoriasis.

Plaque psoriasis is an immune system disorder that results in the rapid overproduction of skin cells. About 6 million people in the United States have plaque psoriasis which is characterized by thickened patches of inflamed, red skin, often covered with silvery scales.

“This approval provides an alternative treatment for people with plaque psoriasis, which can cause significant physical discomfort from pain and itching and result in poor selfimage for people who are selfconscious about their appearance,” said Julie Beitz, M.D., director, Office of Drug Evaluation III, in the FDAs Center for Drug Evaluation and Research.

Stelara is a monoclonal antibody, a laboratoryproduced molecule that mimics the bodys own antibodies that are produced as part of the immune system. The biologic treats psoriasis by blocking the action of two proteins which contribute to the overproduction of skin cells and inflammation.

Three studies of 2,266 patients evaluated the biologics safety and effectiveness.

Since Stelara reduces the immune systems ability to fight infections, the product poses a risk of infection. Serious infections have been reported in patients receiving the product and some of them have lead to hospitalization. These infections were caused by viruses, fungi, or bacteria that have spread throughout the body. There may also be an increased risk of developing cancer.

The FDA is requiring a risk evaluation and mitigation strategy or REMS for Stelara that includes a communication plan targeted to healthcare providers and a medication guide for patients.

Stelara is manufactured by Centocor Ortho Biotech Inc. of Horsham, Pa., a whollyowned subsidiary of Johnson & Johnson of New Brunswick, N.J.

Merck & Co., Inc., which operates in many countries as Merck Sharp & Dohme (MSD), has received a positive opinion from the European Medicines Agencys (EMEA) Committee for Medicinal Products for Human Use (CHMP) for JANUVIA® tablets and JANUMET® tablets recommending their use as addon to insulin for the treatment of type 2 diabetes. If adopted by the European Commission, sitagliptin will be the only diabetes treatment in the DPP4 inhibitor class to have an indication for use as addon to insulin in the European Union.

In the United States, JANUVIA is indicated, as an adjunct to diet and exercise, to improve glycemic control in adult patients with type 2 diabetes. JANUMET is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus when treatment with both sitagliptin and metformin is appropriate. JANUMET and JANUVIA should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. The labeling for both JANUVIA and JANUMET state that they have not been studied in combination with insulin.

In the United States, a supplemental New Drug Application (sNDA) that is similar to the European proposal concerning the use JANUVIA and JANUMET in combination with insulin has been accepted by the U.S. Food and Drug Administration (FDA) and is currently under review. The use of JANUVIA and JANUMET in combination with insulin is investigational in the U.S.

Sitagliptin is a selective, oncedaily DPP4 inhibitor that enhances a natural body system called the incretin system to help regulate blood sugar by increasing levels of active GLP1 and GIP hormones; it inhibits DPP4 over 24 hours. The fixeddose combination of sitagliptin and metformin targets all three key defects of diabetes insulin deficiency from pancreatic beta cells, hepatic insulin resistance, and overproduction of glucose by the liver. Sitagliptin is the first approved medicine in the DPP4 inhibitor class of oral treatments. It has been approved in more than 80 countries, and to date there have been more than 15 million prescriptions dispensed worldwide.

Selected cautionary information for JANUVIA

JANUVIA is contraindicated in patients with a history of a serious hypersensitivity reaction to sitagliptin, such as anaphylaxis and angioedema. As is typical with other antihyperglycemic agents used in combination with a sulfonylurea, when JANUVIA is used in combination with a sulfonylurea, a class of medications known to cause hypoglycemia, the incidence of hypoglycemia was increased over that of placebo. Therefore, a lower dose of sulfonylurea may be required to reduce the risk of hypoglycemia. Because JANUVIA is renally eliminated, and to achieve plasma concentrations of JANUVIA similar to those in patients with normal renal function, a dosage adjustment is recommended in patients with moderate renal insufficiency and in patients with severe renal insufficiency or with ESRD requiring hemodialysis or peritoneal dialysis. Because there is a need for dosage adjustment based upon renal function, assessment of renal function is recommended prior to initiation of JANUVIA and periodically thereafter. Safety and effectiveness of JANUVIA in pediatric patients have not been established. There are no adequate and wellcontrolled studies in pregnant women. JANUVIA should be used during pregnancy only if clearly needed. It is not known whether sitagliptin is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when JANUVIA is administered to a nursing woman.

There have been postmarketing reports of hypersensitivity reactions in patients treated with JANUVIA. These reactions include anaphylaxis, angioedema and exfoliative skin conditions including StevensJohnson syndrome. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Onset of these reactions occurred within the first three months after initiation of treatment with JANUVIA, with some reports occurring after the first dose. If a hypersensitivity reaction is suspected, discontinue JANUVIA, assess for other potential causes for the event and institute alternative treatment for diabetes. There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with JANUVIA or any other antidiabetic drug.

Selected Adverse Reactions for JANUVIA

In controlled clinical studies as both monotherapy and combination therapy with metformin or pioglitazone, the overall incidences of adverse reactions, hypoglycemia, and discontinuation of therapy due to clinical adverse reactions with JANUVIA were similar to placebo. In these clinical studies, the most common adverse reactions reported with JANUVIA (≥5 percent and higher than placebo) were stuffy or runny nose and sore throat, upper respiratory infection and headache. In clinical trials in combination with a sulfonylurea (glimepiride), with or without metformin, JANUVIA demonstrated an overall incidence of adverse reactions higher than that seen with placebo, in part related to a higher incidence of hypoglycemia.

In a prespecified pooled analysis of two monotherapy studies, an addon to metformin study, and an addon to pioglitazone study, the overall incidence of adverse reactions of hypoglycemia in patients treated with JANUVIA 100 mg was similar to placebo (1.2 percent vs. 0.9 percent). Adverse reactions of hypoglycemia were based on all reports of hypoglycemia; a concurrent glucose measurement was not required. In an additional, 24week, placebocontrolled factorial study of initial therapy with sitagliptin in combination with metformin, the incidence of hypoglycemia was 0.6 percent in patients given placebo, 0.6 percent in patients given sitagliptin alone, 0.8 percent in patients given metformin alone and 1.6 percent in patients given sitagliptin in combination with metformin.

Selected cautionary information for JANUMET

The labeling for JANUMET contains a boxed warning for lactic acidosis, a rare, but serious, metabolic complication that can occur due to metformin accumulation during treatment with JANUMET. JANUMET is contraindicated in patients with renal disease, renal dysfunction, or abnormal creatinine clearance; and acute or chronic metabolic acidosis, including diabetic ketoacidosis. JANUMET should be avoided in patients with evidence of hepatic disease. Before initiation of therapy with JANUMET and at least annually thereafter, renal function should be assessed and verified as normal. Patients should be warned against excessive alcohol intake while receiving JANUMET. Patients may require discontinuation of JANUMET and temporary use of insulin during periods of stress and decreased intake of fluids and food such as may occur with fever, trauma, infection or surgery. Patients previously controlled on JANUMET who develop laboratory abnormalities or clinical illness should be evaluated promptly for evidence of ketoacidosis or lactic acidosis. The reported incidence of lactic acidosis in patients receiving metformin hydrochloride is very low (approximately 0.03 cases/1000 patientyears, with approximately 0.015 fatal cases/1000 patientyears). When lactic acidosis occurs, it is fatal in approximately 50 percent of cases.

Metformin and sitagliptin are known to be substantially excreted by the kidney. The risk of metformin accumulation and lactic acidosis increases with the degree of impairment of renal function. Thus, patients with serum creatinine levels above the upper limit of normal for their age should not receive JANUMET. In the elderly, JANUMET should be carefully titrated to establish the minimum dose for adequate glycemic effect, because aging can be associated with reduced renal function. Any dose adjustment should be based on a careful assessment of renal function. Before initiation of therapy with JANUMET and at least annually thereafter, renal function should be assessed and verified as normal.

There have been postmarketing reports of serious hypersensitivity reactions in patients treated with sitagliptin, one of the components of JANUMET. These reactions include anaphylaxis, angioedema, and exfoliative skin conditions including StevensJohnson syndrome. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Onset of these reactions occurred within the first three months after initiation of treatment with sitagliptin, with some reports occurring after the first dose. If a hypersensitivity reaction is suspected, discontinue JANUMET, assess for other potential causes for the event, and institute alternative treatment for diabetes.

As is typical with other antihyperglycemic agents used in combination with a sulfonylurea, when sitagliptin was used in combination with metformin and a sulfonylurea or a sulfonylurea alone, a medication known to cause hypoglycemia, the incidence of hypoglycemia was increased over that of placebo in combination with metformin and a sulfonylurea. Therefore, patients on sitagliptin also receiving an insulin secretagogue (e.g., sulfonylurea, meglitinide) may require a lower dose of the insulin secretagogue to reduce the risk of hypoglycemia.

Clinicians should be mindful that hypoglycemia could occur when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation, or during concomitant use with other glucoselowering agents (such as sulfonylureas and insulin) or ethanol. Elderly, debilitated, or malnourished patients and those with adrenal or pituitary insufficiency or alcohol intoxication are particularly susceptible to hypoglycemic effects.

There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with JANUMET or any other oral antidiabetic drug.

Selected Adverse Reactions for JANUMET

The most common adverse reactions reported in >/= 5 percent of patients started simultaneously on sitagliptin and metformin and more commonly than in patients treated with placebo were diarrhea, upper respiratory tract infection, and headache.

About Merck

Merck & Co., Inc. is a global researchdriven pharmaceutical company dedicated to putting patients first. Established in 1891, Merck currently discovers, develops, manufactures and markets vaccines and medicines to address unmet medical needs. The Company devotes extensive efforts to increase access to medicines through farreaching programs that not only donate Merck medicines but help deliver them to the people who need them. Merck also publishes unbiased health information as a notforprofit service.

ForwardLooking Statement

This press release contains “forwardlooking statements” as that term is defined in the Private Securities Litigation Reform Act of 1995. These statements are based on managements current expectations and involve risks and uncertainties, which may cause results to differ materially from those set forth in the statements. The forwardlooking statements may include statements regarding product development, product potential or financial performance. No forwardlooking statement can be guaranteed and actual results may differ materially from those projected. Merck undertakes no obligation to publicly update any forwardlooking statement, whether as a result of new information, future events, or otherwise. Forwardlooking statements in this press release should be evaluated together with the many uncertainties that affect Mercks business, particularly those mentioned in the risk factors and cautionary statements in Item 1A of Mercks Form 10K for the year ended Dec. 31, 2008, and in any risk factors or cautionary statements contained in the Companys periodic reports on Form 10Q or current reports on Form 8K, which the Company incorporates by reference.

JANUVIA is a registered trademark of Merck & Co., Inc., Whitehouse Station, New Jersey, USA

NPR interviews Dr. Elana Rios, president of the National Hispanic Medical Association (NHMA), on the onethird of Hispanics in the U.S. who are uninsured. She says the reasons are cultural as well as economic “Hispanics have health beliefs that are unique, lots of traditional ways of taking care of disease with teas and herbs and other things. And so families dont send their children or young adults to doctors. Another reason is other Hispanics come from other countries where their government provides health insurance.” She also points to problems with trust “Hispanics cannot entrust these authority figures, and let alone government, because we have mixed families with undocumented grandparents who dont want to be deported back to where they come from.”

Rios says affordable health insurance would help solve the problem, along with “lots of education and outreach of the importance of purchasing health insurance.” The NHMA “agrees with President Obama to have this health care reform system be changed for American citizens and those eligible to participate for health reform, and that does not include illegal and undocumented” (Morning Edition, Wertheimer, 9/23).

NPR also interviews Yvette Roubideaux, director of the Indian Health Service (IHS), on “what the rest of the country can learn” from the program. The IHS was started in 1955 and provides care for “about half of this countrys 4.3 million AmericanIndians and Alaskan natives” with a network of more than 600 hospitals and clinics located on or near reservations. Roubideaux says that historically, the program has “had difficulty meeting the needs and the growing demands of the patients it serves with the limited budget that it has.” It has also “had difficulty recruiting doctors to work in rural and remote areas.”

The IHS is not a singlepayer system Roubideaux explains that at some facilities, more than half of the total budget comes from billing to Medicare, Medicaid and private insurance. She adds that the quality of care from IHS is “sort of a mixed picture. If you look at the quality of care over time, since 1955, there are some areas where weve made great improvements. Weve been able to reduce mortality for some conditions and especially in the area of diabetes, weve been able to reduce care to the point to where I think its actually better than what people did in the general U.S. health care system.” But, “sometimes the budget doesnt stretch far enough for us to do more of the preventive practices,” she explains (Tell Me More, Martin, 9/23).

Related KHN column The Indian Health Service Paradox

This information was reprinted from kaiserhealthnews.org with kind permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery at kaiserhealthnews.org.

© Henry J. Kaiser Family Foundation. All rights reserved.

Most people dont think twice about the ability to choose the movie they want to watch, the book they want to read or with whom they will have coffee. But what if you didnt have the choice, or were never taught how to make decisions regarding leisure activities? Thats the reality for some women living in group homes according to a new study from the University of Alberta.

Brenda RossowKimball, who did postgraduate research with Donna Goodwin, in the Faculty of Physical Education and Recreation, investigated the leisure experiences of five women with intellectual disabilities in two group homes. They found major differences in how leisure was experienced in each group home. In one, the women were provided with support and encouraged to make their own decisions about how they used their leisure time; there was a genuine interest in the women engaging in independent spontaneous leisure, according to RossowKimball. In the other home leisure was supervised by the staff, scheduled into the activities of the home, and managed by the staff, which, the researchers say, doesnt teach the women how to discover what they like to do for leisure.

The stark contrast of selfdirected leisure against staffdirected leisure time concerned both researchers because the women in the study are approaching retirement and will soon have a lot of free time on their hands.

“If we dont provide people with the opportunity to experience choice and to learn leisure skills, their longawaited retirement time could be quite empty,” said Goodwin.

The findings are published in Adapted Physical Activity Quarterly.

Notes
Quinn Phillips

An ectopic pregnancy is a pregnancy where the fertilized egg settles and grows outside the inner lining of the uterus (not in the uterus). The uterus is the womb. Most ectopic pregnancies occur in the Fallopian tube known as a tubular pregnancy but they can also occur in the cervix (neck of the womb), abdominal cavity and ovary.

Slightly over 1% of all pregnancies are ectopic pregnancies. In a normal pregnancy the egg should be fertilized by the sperm in a fallopian tube; the fertilized egg then travels into the uterus (womb) and implants itself in the lining of the uterus. The embryo develops into a fetus and remains in the uterus until the baby is born.

An ectopic pregnancy that remains untreated may kill the mother. For example, the fallopian tube can rupture, causing internal abdominal bleeding and serious blood loss. These days, very few ectopic pregnancies result in death. Out of 31,000 ectopic pregnancies that occurred in the UK from 2000 to 2002, eleven women died, or 0.035% of the total (according to The National Health Service, UK).What are the signs and symptoms of an ectopic pregnancy?The initial signs and symptoms of an ectopic pregnancy are the same as any normal pregnancy, and includeMissing a menstrual periodFatigue (tiredness) NauseaBreast tendernessIf it is an ectopic pregnancy, the distinctive signs and symptoms will appear between weeks 4 and 10 of the pregnancy. Symptoms may includePain on one side of the abdomen. The pain may be severe and continuous.
Vaginal bleeding bleeding will be lighter or darker than menstrual bleeding, and is usually less viscous (more watery). In some cases a woman may not know she is pregnant and think her period has come.
Shoulder tip pain this is usually a sign that internal bleeding is occurring. Experts say the bleeding irritates the phrenic nerve, which causes referred pain in the shoulder. Referred pain is pain which exists in one part of the body but is felt by the patient in another part.
Pain when passing urine.
Pain when passing stools (feces).
Collapse if the fallopian tubes rupture the woman may collapse, due to serious internal bleeding. When the fallopian tubes rupture it is a medical emergency. The woman may

Feel light headedFeel faintFeel sickHave diarrheaFeel something is seriously wrongLook very paleOver half of all women with an ectopic pregnancy have no symptoms until they experience a collapse. Any woman who thinks she is pregnant again after previously having an ectopic pregnancy should tell her doctor immediately in order to find out whether the current pregnancy is ectopic.

In most cases fallopian tube rupture is successfully treated. It can be fatal, but this is very rare today if the patient receives treatment.What are the risk factors for ectopic pregnancy? A risk factor is something that increases your risk of developing a condition or disease. For example, smoking regularly significantly increases your risk of developing lung cancer; hence, smoking is a risk factor for lung cancer. The risk factors for ectopic pregnancy areHaving had an ectopic pregnancy before women who have had a prior ectopic pregnancy have a 10% risk of having a subsequent ectopic pregnancy.
Age while a 25yearold womans risk is 1%, a 44yearold woman who becomes pregnant has an 8% risk of having an ectopic pregnancy.
Salpingitis women who have had salpingitis (inflammation of the fallopian tube) have a higher risk of ectopic pregnancy.
Other infections infections of the uterus or ovaries (pelvic inflammatory disease, or PID) increase the risk of subsequent ectopic pregnancies. Some STDs, such as gonorrhea or Chlamydia, also increase the risk of PID.
Smoking women who smoke are more likely to have an ectopic pregnancy compared to women who dont.
Ovulation medications women with fertility problems who have been taking drugs to stimulate ovulation are more likely to have an ectopic pregnancy, compared to other women.
Fallopian tube abnormality a woman who has an abnormallyshaped fallopian tube, or a fallopian tube that has been damaged runs a higher risk of ectopic pregnancy. Fallopian tube damage may have been caused by surgery.
Previous surgery such as a Csection (Cesarean section) or surgical fibroid removal.
Taking contraceptive if a woman is taking the contraceptive pill or an IUD (intrauterine device) and gets pregnant she has a higher chance of having an ectopic pregnancy.
Tubal ligation in the unlikely event of becoming pregnant after a tubal ligation (having the tubes tied), there is a greater chance that that pregnancy is an ectopic one. 47% of women who have an ectopic pregnancy have none of the risk factors mentioned above.What causes an ectopic pregnancy? The fertilized egg becomes stuck on its way to the uterus. This usually occurs because the fallopian tube is scarred, has an abnormal shape or is damaged. In many cases nobody knows what the specific cause was.How is an ectopic pregnancy diagnosed? Blood test HCG (chorionic gonadotropin), a hormone, is produced in pregnancy and detected in a blood test women with a normal pregnancy will have high levels of HCG. If HCG levels are lower than normal for pregnancy, it could be a sign of an ectopic pregnancy.
Urine test a urine test can only tell whether an egg has been fertilized whether the woman is pregnant. It cannot distinguish between an ectopic or normal pregnancy.
Transvaginal ultrasound this is an ultrasound scan through the vagina and can sometimes confirm an ectopic pregnancy. Sound waves are emitted by an ultrasound probe that has been inserted in the vagina. The sound waves bounce off the vaginal wall and other tissue; a computer uses the ultrasound echoes to create a sonogram (a picture). If it is too early to detect an ectopic pregnancy and the diagnosis is doubtful, the doctor may monitor the patients condition with blood tests until the ectopic pregnancy can either be confirmed or ruled out through a subsequent ultrasound some time later.What are the treatment options for ectopic pregnancy? Several treatment options are possible if diagnosis is made before the fallopian tube ruptures.Surgery the embryo is surgically removed using laparoscopic (keyhole) surgery. The surgeon makes a small incision near or in the navel, inserts a thin tube with a camera and light at the end (laparoscope) to view the area. Other surgical instruments are inserted into a tube or through other small incisions to remove the ectopic tissue. If the fallopian tube is damaged it will either be removed or repaired.
Medication if the ectopic pregnancy is detected soon enough methotrexate is injected into the patients muscle or directly into the fallopian tube to halt cell growth and dissolve existing cells. The patient is then monitored for blood levels of HCG (chorionic gonadotropin). If blood HCG levels do not drop, the patient may receive another injection. This drug can cause abdominal pain as a side effect.
Wait and see if the symptoms are very mild the doctor may recommend waiting to see how things develop. Often, ectopic pregnancies terminate on their own. Ruptured fallopian tube if the fallopian tube ruptures (bursts) the patient will need emergency surgery. If possible the fallopian tube will be repaired, if not it will be removed.What are the possible complications of an ectopic pregnancy? A complication is more likely to occur if diagnosis or treatment is either delayed or never done. A woman who has an ectopic pregnancy and does not get timely diagnosis/treatment is more likely to experience severe internal bleeding, which can lead to shock. Shock in some cases can be fatal.

Delayed treatment can also result in damage to the fallopian tube; significantly raising the risk of further ectopic pregnancies in future.

There is also a risk of depression and sadness if the woman worries about the possibility of never being able to have a healthy pregnancy. It is important to remember that even if a fallopian tube is removed it is still possible to get pregnant. If both are removed IVF (invitro fertilization) is still an option.PreventionAlthough there is nothing a woman can do to prevent the occurrence of an ectopic pregnancy developing, she can reduce her risk of having a PID (pelvic inflammatory disease), which can damage the fallopian tubes. STIs (sexually transmitted infections), such as Chlamydia and gonorrhea are one of the main causes of PID. Therefore, “safe sex” using a male condom helps reduce the risk of catching an STI.

As smoking is known to increase the risk of having an ectopic pregnancy, giving it up would lower the risk.

Elsevier is pleased to announce that ten of its professional and scholarly books were honored at the annual BMA Medical Book Competition ceremony in London on September 8th 2009. An additional 19 Elsevier books were highly commended. In total, 684 books were entered to the BMAs competition with 126 prizes awarded with 26 first prizes, 91 highly commended prizes and 9 commended prizes.

Grays Anatomy for Students by Richard Drake, Wayne Vogl, and Adam Mitchell won first prize in the BMA Basic and Clinical Science category. This is the second edition of an anatomy textbook for medical students that has quickly become a favorite textbook around the world, translated into a dozen languages. It has captured a strong following because it explains complex anatomy with clear, understandable language, strong clinical correlations, and a stunning fullcolor artwork program. It is now part of an extensive family of Grays products including Grays Atlas of Anatomy, Grays Anatomy for Students Flashcards, Grays Anatomy Review, Dorland/Grays Pocket Atlas of Anatomy and, of course, Grays Anatomy, 40th Edition.

Elseviers Rheumatoid Arthritis by Marc C. Hochberg, Alan J. Silman, Josef S. Smolen, Michael E. Weinblatt, and Michael H. Weisman was awarded first prize in the BMA Orthopaedics and Rheumatology category. A first edition in brilliant color, it provides the most current insights into the pathogenesis of rheumatoid arthritis, while also including comprehensive coverage of clinical features of the disease, as well as evidencebased options for treatment.

“We congratulate all of the winners and especially thank all of the authors, editors and Elsevier publishing staff who have worked on these prizewinning titles,” said Randy Charles, Managing Director Global Clinical Reference Group at Elsevier. “This is an amazing achievement and reflects our dedication to developing and delivering quality content.”

First prizes were awarded to Elsevier books in the following categories Anesthesia Andrew Bersten and Neil Soni Ohs Intensive Care Manual, 6th edition

Basic and Clinical Science Richard Drake, A. Wayne Vogl, and Adam WM Mitchell Grays Anatomy for Students, 2nd edition

Cardiology John Hampton The ECG in Practice, 5th edition

Haematology Stuart H. Orkin and others Nathan and Oskis Hematology of Infancy and Childhood, 7th edition

Health Care for the Elderly Hylton B. Menz Foot Problems in Older People

Medicine Mark Strachan, Surendra Sharma and John Hunter Davidsons Clinical Cases

Orthopaedics and Rheumatology Marc C. Hochberg and others Rheumatoid Arthritis

Primary Health Care Andrew Polmear EvidenceBased Diagnosis in Primary Care

Radiology Gerald de Lacey, Simon Morley and Laurence Berman The Chest XRay A Survival Guide

BMA Student Textbook Award Elspeth Brown and others Heart Sounds Made Easy with CDROM, 2nd edition Source
Anna Hogrebe

Scientists expect a new mathematical model of chronic wound healing could replace intuition with clear guidance on how to test treatment strategies in tackling a major publichealth problem.

The Ohio State University researchers are the first to publish a mathematical model of an ischemic wound a chronic wound that heals slowly or is in danger of never healing because it is fed by an inadequate blood supply. Ischemic wounds are a common complication of diabetes, high blood pressure, obesity and other conditions that can be characterized by poor vascular health.

An estimated 6.5 million people in the United States are affected by chronic wounds, and many are at risk of losing limbs or even dying as a result of the most severe of these wounds.

Modeling by mathematicians with expertise in biomedical processes has become increasingly important in the health sciences. The modeling reduces the need for guesswork and timeconsuming animal testing traditionally required as researchers pursue prevention, diagnosis and treatment of complex diseases.

“Before you treat any problem successfully, you have to understand it,” said Chandan Sen, professor and vice chair for research in Ohio States Department of Surgery and a senior author of the study. “Now that we have this model, we can take the next step to find what factors in the equations can be finetuned to the point where the net result is improvement in the ischemic wound outcome.”

The modeling research appears this week in the online early edition of the Proceedings of the National Academy of Sciences.

The mathematical model, to date, simulates both nonischemic wounds those typical of wounds in healthy people with good circulation and ischemic wounds. The current model produced results that generally match preclinical expectations that a normal wound will close in about 13 days, and that 20 days after the development of an ischemic wound, only 25 percent of the wound will be healed.

The model also showed that normal wounds have higher concentrations of proteins and cells expected to be present during the healing process, while ischemic wounds lack oxygen and remain in a prolonged inflammatory phase that interferes with the subsequent cascade of events required to begin wound closure.

Sen, also executive director of the Comprehensive Wound Center at Ohio State, recently published a report about a biological preclinical model of an ischemic wound that his lab designed using the skin on a pigs back. The new mathematical model, a system of partial differential equations, borrowed some data from the animal model, but also includes numerous calculations assigning values to the various cells and chemicals involved in the woundhealing process.

“Wound geometry is complicated because it is threedimensional,” said Avner Friedman, a senior author of the paper and a Distinguished University Professor at Ohio State. “It would be infeasible to perform our computations within the framework of this geometry. However, we used some mathematical ideas to reduce the problem to a simpler geometry without giving up any of the important aspects of the process.”

It is not just the wound that is threedimensional, the researchers noted. The complexity of this process is compounded by the fact that the woundhealing model must take into account both the total space occupied by the wound and the time required for the healing process.

Wound healing under normal conditions occurs in four overlapping stages haemostasis, when platelets make clots to stop bleeding and release chemicals that attract cells to the wound; transient inflammation, when a variety of white blood cells go to work to kill infectious agents and generate growth factors needed for repair; proliferation, when new blood vessels form and when cells produce a bed, called the extracellular matrix, on which the repair occurs; and remodeling, which can take years, as the repaired wound site gains strength.

Sen and colleagues have spent years studying the characteristics of wounds and the intricate details of the healing process. Oxygen is a known essential element to the healing process, and highpressure oxygen chambers are used to treat some wounds. But for ischemic wounds, oxygen alone isnt enough.

Scientists know that reduced blood flow to a wound site means that oxygen, important nutrients and circulating cells are not finding their way to the wound to initiate healing. Researchers hope that manipulating mathematical models of these conditions could offer guidance on how to approach this problem without the time and trialanderror required in biological studies on animals.

“Were not just considering what type of therapy should be used for these wounds. It is the specifics of when and how you apply it those are the details that matter,” Sen said. “Mathematical algorithms provide more pointed data that biologists can use to develop hypotheses.”

Developing the biological model was an important start, Sen and Friedman noted. To create an animal model of an ischemic wound, researchers had to strike a careful balance so they reduced blood flow to the wound site without killing all the surrounding tissue by cutting off too much blood. Sen said the 8millimeterwide cylindrical puncture wounds rest on what the researchers consider an “island” of skin receiving too little blood to effectively deliver healing cells and chemicals to the wound. Details about the animal model are published in the May issue of the journal Physiological Genomics, a publication of the American Physiological Society.

In developing the mathematical model, Friedman worked with first author Chuan Xue, a postdoctoral researcher in Ohio States Mathematical Biosciences Institute, to assign values to variables in the first two stages of wound healing. These included oxygen concentration, concentration of growth factors, density of white blood cells that fight pathogens, density of fibroblasts that perform part of the repair, and density of tips and sprouts of tiny new blood vessels.

The two also modeled the extracellular matrix the bed on which cells work to close the wound in a way that allows for the matrix to change the way it functions over time. This part of the model also allowed for simulation of the exertion of pressure a characteristic of certain types of ulcers that people with diabetes are prone to develop.

Xue noted that the equations were borrowed from the mathematical theory of homogenization by manipulating a single parameter called parameter alpha to draw the distinction between ischemic and nonischemic wounds in the model. This is one example, Friedman noted, of simplifying the model without leaving out important biological details.

This work is supported by the National Science Foundation, the National Institutes of Health and the Center for Clinical and Translational Science at Ohio State.

Source
Chandan Sen