Wednesday, April 29, 2009


The column i am presenting below is not a part of the topics i write on this blog but it is the most important column i have presented science i have started blogging.

According to a UN climate report, the Himalayan glaciers that are the principal dry-season water sources of Asia's biggest rivers - Ganges, Indus, Brahmaputra, Yangtze, Mekong, Salween and Yellow - could disappear by 2035 as temperatures rise and human demand rises. Approximately 2.4 billion people live in the drainage basin of the Himalayan rivers. India, China, Pakistan, Afghanistan, Bangladesh, Nepal and Myanmar could experience floods followed by severe droughts in coming decades. In India alone, the Ganges provides water for drinking and farming for more than 500 million people.

Sunday, April 26, 2009

Supplement users at risk from ignorance of tolerable upper limits

Recently i submitted a PG thesis on nutrition in Utkal University, Orissa, India. i analyzed the nutritional compositions of dietary supplements of a USA based nutrition company. i found in the recommended doses many of the dietary supplements are higher than the recommended upper limit (upper limits are taken from recommendations of upper limits in western countries). In countries like India RDA is not known for all the essential nutrients (refer RDA for Indians by ICMR-1988). what i want to convey is that when this is the scenario then RDA for Indians with known prescribed upper limits is out of question. i urge the reader to consult a doctor or a trained or certified nutritionist if you are taking suppliments. i also want to introduce the reader to the following article:

This topic is taken from:

Researchers from Canada have discovered that many dietary supplement users are unaware of the tolerable upper limits and as such could be putting themselves at risk instead of doing themselves some good.
Consuming too many nutrients can lead to harmful side-effects, a fact many users were worryingly unaware of, said researchers from McGill University in Quebec. They found that the tolerable upper level of one B vitamin, niacin, was exceeded by nearly 50 per cent of all the participants in their study who reported taking supplements. They also found excessive amounts of vitamin A and vitamin B6.
Dr Leticia Troppmann, the study leader, wrote in the June issue of the Journal of the American Dietetic Association that dietary supplements exceeding the tolerable upper limits were fairly common in the US, as the supplement industry is not regulated in the same way as pharmaceutical industry.
Troppmann's team studied 1,530 Canadian adults aged 19 to 65, quizzing them about their food and supplement intake in the 24 hours prior to the interview. "Although supplements enhanced dietary intakes of some nutrients, in our study as in previous studies, supplements were also shown to have excessive amounts of nutrients in relation to dietary requirements," she wrote in the journal.

Nutritional Ignorance in Doctors : 5 quotes & many queries


Site from which it is taken:

1. Quote: To be honest, I knew next to nothing about nutrition or nutritional supplements. In medical school I had not received any significant instruction on the subject. I was not alone. Only approximately 6 percent of the graduating physicians in the United States have any training in nutrition. Medical students may take elective courses on the topic, but few actually do. The education of most physicians is disease-oriented with a heavy emphasis on pharmaceuticals – we learn about drugs and why and when to use them.

Ray Strand, MD, What Your Doctor Doesn’t Know About Nutritional Medicine

May Be Killing You, Nashville: Thomas Nelson, 2002, page 5

2. Quote: Why don’t more doctors pay enough attention to nutrition? Because they’re not comfortable with it. They almost certainly never studied it in medical school. Your own physician probably never took a single course in nutrition! Even today, nutrition is a required course in only 25 percent of medical schools. It is still an elective in the rest, and that’s not enough to really get into the subject or to impress future doctors with its importance. So, over the years, the medical establishment has left the matter of diet to health food enthusiasts, many of whom they view as “nuts.”

Isadore Rosenfeld, MD, Doctor, What Should I Eat?,

New York: Warner, 2000, page xvi

3. Quote: Another reason why doctors seldom consider nutrition when treating patients is their lack of knowledge in the field. Medical schools have provided a shockingly inadequate education in basic nutrition for doctors. A recent investigation by a Senate subcommittee revealed that the average physician in the United States receives less than three hours of training in nutrition during four years of medical school and that less than 3 percent of the licensing exam questions are concerned with nutrition. Because of this deficiency in training, few doctors will understand or encourage any interest you may express in nutrition. Many actually feel threatened when questioned on the subject.

John McDougall, MD, 1983, The McDougall Plan, New Win, page 7

4. Quote: Although the American Cancer Society, the National Cancer Institute, the American Heart Association, the National Academy of Sciences, the American Diabetic Association, and the U.S. Surgeon General have since reached the conclusion that diet is a leading cause of death and disease, little more is taught about nutrition to medical students now than when I was trained more than twenty years ago.

John McDougall, MD, 1990, The McDougall Program, New York: Plume, page 97

5. Quote: Virtual omission of any instruction in nutrition in the medical curriculum is a glaring defect in the training of doctors. In my four years at Harvard Medical School and one year of internship, I received a total of 30 minutes of nutritional instruction. There has been little improvement since I graduated. When I was in school, medical doctors were quick to brand as a quack anyone who argued that diet could be a risk factor for cancer. It is now generally accepted that high-fat, low-fiber diets, especially those high in meat and low in vegetables, predispose people to cancer.

Andrew Weil, MD (Harvard) in Family Guide to Natural Medicine,

Pleasantville, New York: Reader’s Digest, 1993, page 12

Poverty, Hunger & Nutrition

Poverty & nutrition: Are the rich countries spared?

According to Rose D hunger rates decline sharply with rising incomes. Surprisingly many USA based studies claim that relationship between poverty-level incomes and hunger does not exist but on contrary in that same country 13.1% of those in poverty experienced hunger and half of those experiencing hunger had incomes above the poverty level. Consuming intakes <50% of the recommended dietary allowance (RDA) are higher for adult women and elderly individuals from food-insufficient households. Preschoolers from food-insufficient households do not consume significantly lower amounts than those from food-sufficient households, but mean intakes for the rest of members in those very same households are significantly lower for the food insufficient. Examining the relationship between nutritional status & poverty in various age Bhattacharya J et al found poverty is predictive of poor nutrition among preschool children. But among school age children poverty is not associated with nutritional outcomes. Poverty related nutritional diseases are not common in Asia or Africa it also occurs in the rich countries. The nutrition and health consequences of Poverty & food insecurity comprise a potentially rich area for future. Olson CM related hunger to health and nutrition outcomes in food-rich countries such as the United States. They found severe level of food insecurity (household food insecurity) was correlated with higher body mass index (BMI) where as in low income school-age children risk of hunger and hunger were associated with compromised psychosocial functioning. Two subgroups of the population studied by Olson CM are: women of childbearing age and school-age children.

Impacts of poverty on nutrition- diseases caused by it.

A. PEM in Indian subcontinent due to poverty.

B. Other nutrition related conditions due to poverty:

1. iron deficiency (anemia)
2. iodine deficiency (goiter)
3. Calcium deficiency (rickets & osteomalacia)


1. J Health Econ. 2004 Jul;23(4):839-62.
2. J Nutr. 1999 Feb;129(2S Suppl):521S-524S.
3. J Nutr. 1999 Feb;129(2S Suppl):517S-520S.

Saturday, April 25, 2009

Rehabilitation Medicine and Microsoft came together on healthy work force issue

Rusk Institute of Rehabilitation Medicine and Microsoft to Present Innovations for a Healthy Workforce Media Forum July 13 Rehabilitation medicine and accessible technology will be presented as the major forces for maintaining the productive status of today's worker. NEW YORK -- July 5, 2005

Innovations for a Healthy Workforce, a forum presented by the Rusk Institute of Rehabilitation Medicine and Microsoft Corp., will examine the workplace issues confronted by people with physical and sensory disabilities that are caused by injury, disease or aging. Medical and technology experts will give brief presentations on health issues facing today's work force; medical issues pertaining to pain, weakness and the loss or impairment of vision, mobility or dexterity; and demonstrations of accessible technology products that can help mitigate each of those conditions.
In today's economy, computers are essential for many businesses and are a mainstay of personal and professional life around the world. Among working-age adults in the United States, 78 percent use computers -- 68 percent at home and 45 percent at work. With nearly 60 percent of the work force experiencing some level of disability or impairment due to chronic ailments (e.g., vision loss, carpal tunnel syndrome or arthritis) or serious injury, using a computer can be a challenge for many people.
Inability to operate computer technology can put workers of any age at a disadvantage that may lead to unemployment or lack of career advancement. It doesn't matter whether they are recent college graduates looking for a job, wounded soldiers returning from a tour of duty in Iraq, or aging baby boomers trying to stay competitive in today's work force. But this challenge can be overcome through the use of accessible technologies designed to help people with disabilities.

Who: Matthew H. M. Lee, M.D., Howard A. Rusk Professor of Rehabilitation Medicine, NYU Medic


Article written by :
Jurriaan Plesman BA(Psych), Post Grad Dip Clin Nutr

Site from which it is taken:

If you ever wonder why so many people are suffering from ‘treatment resistant’ depression it is because mainstream medicine and psychology can offer only ‘palliative’ remedies. They treat symptoms only and not causes.
Drug therapy can only suppress the symptoms of depression, but does nothing to address the underlying biochemical abnormality that is responsible for depression. Once a patient is on the drug band wagon, they usually go on the merry-go-round from one drug to another for maybe the rest of their lives. Several studies have shown that drug therapy and/or psychotherapy may leave about 60 per cent of patients with treatment resistant depression.

Similarly, mainstream psychologists believe that talk therapy can alleviate the symptoms of depression. They assume that our irrational thoughts, unpleasant childhood experiences or ‘bad parents’ - hidden in a mythical ‘subconscious mind’ - have caused us to be depressed. They have us believe that by changing our attitudes and beliefs (for instance by RCBT) we can overcome the underlying biochemical disorder. They truly believe that psychology is a question of ‘mind-over-matter’. We only have to bring these ‘unconscious’ thoughts into consciousness and voila we become better. Many psychologists assume that depression is caused by cognitive processes, such as a low self-esteem, making the mistake of confusing symptoms with causes. This is ‘palliative treatment’ without addressing the underlying biochemical disorder.

True, when we experience a stressful situation in life - such as divorce, bereavement, rejection by a loved-one or any other trauma - stress hormones interfere with the synthesis of our feel-good neurotransmitters and we become depressed. This is called ‘environmental’ depression, where a person is fully aware of the external source of stress. Here the production of stress hormones helps us to find a solution. See Strickland PL et als. (2002). Sometimes such person can be helped by changing their coping skills or lack of self-esteem that could be at the root of their problems.

And, when the source of stress is removed people soon start to produce the happy hormones again and life resumes.

Unfortunately, many depressed people do not fall into that category, because after the removal of the external trauma, they continue to feel depressed and often cannot understand why, which brings them into the hands of a therapist. This may explain the development of Post Traumatic Stress Disorder, when a person fails to produce serotonin following a traumatic experience in a person’s life, long after the event. See PTSD and Hypoglycemia.

The majority of people seeking advice and information at this web site are people with ‘endogenous’ depression; that is to say that their depression is due primarily to a chemical imbalance in the brain. Mainstream medicine and psychology often fail to help these people, because they have no proper explanation as to the causes ‘endogenous’ depression. Consequently, they are not in a position to help depressed people.

Thus we need a different interpretation of endogenous depression as an alternative to the prevailing narrow drugs and/or psychotherapy model: AND which is based on scientific knowledge.

I will propose the psycho-nutritional model which says that depression - and for that matter any other non-psychotic mental illness - is a disease of energy production.

For the brain to change one molecule into another - as in the conversion of tryptophan into serotonin - it needs a disproportionate amount of biological energy called ATP. That energy is derived from the sugars in our food in the form of glucose. It is transformed into biological energy as a result of a complex biochemical pathway, called glycolysis.

The brain although 2 per cent of the body requires about 60-70 percent of all available energy, whether we are asleep or awake. A normal healthy cell requires about 2 million molecules of energy (ATP) per second to fuel biochemical reactions inside the cell. This is all derived from glucose in our food. See here.

Thus if the brain is deprived of that energy, it cannot synthesize the feel-good neurotransmitters such as serotonin, norepinephrine, dopamine or acetylcholine, to make us feel happy and relaxed when we normally should. One immediate consequence is that the body is inundated with stress hormones, which will undermine one’s self-esteem. This is often mistakenly interpreted to mean that a negative self-image is the cause of depression.

Without serotonin the body cannot produce melatonin - the sleeping neuro-chemical that makes us sleep - and so we see that depression is usually associated with insomnia. Because serotonin is also associated with the appetite mechanism, depression is often accompanied with weight problems. Unabsorbed sugars in the diet are stored in the body as fat cells, hence the association between depression and obesity. See also: Connection between obesity and depression. Not only energy, but a host of other nutrients are required to bring about these biochemical reactions in the brain. They could well be deficient.

If the universal source of energy is derived from glucose in our food, one may wonder why it is, that in a high sugar consuming society in the Western world, people would suffer from energy starvation? Could this be responsible for the exponential increase in depression and mental illness?

Excessive sugar consumption, when converted to glucose, can expose the body to free radical attack upon the immune system and DNA. Glucose is easily oxidized into peroxides and other toxins. The body has a defense mechanism against excess sugar consumption: it shuts down receptors for insulin that controls the amount of glucose (and other nutrients) getting across cell membranes into cells. This is called Insulin Resistance, which may result in hypoglycemic symptoms. There are many studies showing a significant association between depression and insulin resistance. See here.

With insulin resistance blood sugar levels tend to rise, triggering more release of insulin - called hyperinsulinism - and this may provoke a sudden descent in blood sugar level called hypoglycemia. Thus the brain tends to be exposed to wildly fluctuating blood sugar levels, responsible for many ‘psychological’ symptoms. See graph here.

When the brain is starved of energy it could lead to the death of brain cells in a matter of minutes. In reaction to this threat, the brain triggers the release of stress hormones - such as adrenaline and cortisol - that function to convert sugar stores in the body (glycogen and amino acids) back into glucose so as to feed the brain again.

But these stress hormones, generated within the body are also responsible for the varied symptoms of mental illness, from depression, anxiety attacks, phobias, insomnia, compulsive behaviours and thoughts, alcoholism, drug addiction, hypochondria, PTSD, OCD and so on and on.

Thus hypoglycemia is characterized by unstable blood sugar levels feeding the brain, causing excess stress hormones to flood the system.

The non-drug treatment for hypoglycemia is the adoption of the Hypoglycemic Diet - a virtual panacea for depression - which is a natural diet, but specifically designed to regulate blood sugar levels, stress hormones and insulin levels. One should not be surprised to find that he medico-pharmaceutical industrial complex would be strenuously opposed to the treatment of mood disorders without resort to drugs, and that it pays doctors to be ignorant of nutritional medicine.

Thus depression is in fact a NUTRITIONAL DISORDER.

This concept is difficult to accepts for those who have believed for so many years that mental illnesses is one of ‘mind over matter’. This perception is still held by the majority of practitioners in the field. But scientific truth is not very democratic and is not determined by majority rule.

This disorder can be medically tested with a special Glucose Tolerance Test for Hypoglycemia (GTTH) designed by Dr George Samra of Kogarah (Australia) and as described at our web site at:

“Testing for Hypoglycemia and How your Doctor can help”.

We also have a paper-and-pencil test called the NBI that can indicate a metabolic disorder if you score high on that test. Another home test can be found at: The Hypo Quizz.

The scientific basis of this new nutritional approach is supported by numerous scientific studies, that have shown a significant association between Depression and Insulin Resistance.
The first step in treatment is going on a hypoglycemic diet, with the appropriate supplements such as B-complex vitamins including vitamin B3 (niacin), B6 (Pyridoxine), B12 (ask your doctor for injections) and folic acid, zinc, magnesium, chromium picolinate, cinnamon, glycerine, high doses of EPA fishoil, Rhodiola rosea (Amoryn), Seredyn, Try out Olive Leaf Extract, Coconut Oil and others. Experiment with combining the Hypoglycemic Diet with Herbal Remedies for Mood Disorders, such as Camu-Camu, Damiana, Ginseng, Hops, Kanna (reduces cravings for cigarettes), Lavender, Passion Flower, Rhodiola, St John's Wort, Vervain, with the help of a herbalist or a health care professional. Remember herbal remedies may interact with psychotropic medications. Generally, herbal remedies and AD medications do not mix.

Follow this up with a thorough assessment of possible allergies and food sensitivities by systematically recording a food diary as per Finding your Allergies. If possible have a hair analysis done to detect abnormal mineral levels.

If you are presently on medication for any mood disorder, the best strategy is to remain on any medication and prepare your body to produce the right neurotransmitters and hormones by nutritional therapy. This should be done in consultation with your doctor. This may take some time (perhaps up to a year), but as soon as you start to feel better you could then gradually withdraw from your medication, under doctor’s supervision, whilst being on the hypoglycemic and anti-allergenic diet or other nutritional therapy. (See also here) If you strike any problem It is suggested that you be referred to a Nutritional Doctor, Clinical Nutritionist or Nutritional Psychologist. See: Looking for Nutritional Therapists.

Thus patients do have a choice, if mainstream medicine and psychology have failed to help them.

Please discuss with your therapist.

“An active cell requires more than 2 million ATP molecules per second. The store of ATP in a human body is sufficient to satisfy a person's needs for only a few seconds, therefore, the store needs to be continuously replenished.” Source

Thursday, April 23, 2009

It is DISH don’t confuse with AS Or OA spine

DISH stands for diffuse idiopathic skeletal hyperostosis.

DISH is known as Forestier’s disease as this condition was described by Forestier and Rotes-Querol over 50 years ago. It was termed was termed senile ankylosing hyperostosis.
Epidemiology (discussion of USA stats only):

1. DISH is very common, affecting between six and 12 percent of North Americans.
2. It rarely occurs among people younger than 50.
3. It affects more men than women.

DISH is thought to be the second most common form of arthritis after osteoarthritis. It affects between six and 12 percent of North Americans, almost always occurring among people older than 50. Unlike most types of arthritis, DISH occurs more often among men (65%) than women (35 %), and affects 28 percent of men over the age of 80.
What signs & symptoms may the patients present with:

1. Back pain and stiffness, especially in the middle area of the back
2. Sharp pain associated with bending or twisting of the back
3. Problems with swallowing and neck movement
4. What seems like “tendonitis” in the shoulder, elbow, knee or ankle.
5. DISH is characterized by excessive bone growth along the sides of the vertebrae of the spine
6. It also involves inflammation and bone growth where tendons and ligaments attach to bone, such as at the elbow, knee and the heel of the foot.


In the absence of validated diagnostic criteria the diagnosis is usually based on the definition suggested by Resnick and Niwayama. This radiographic approach requires the presence of right-sided, flowing, coarse osteophytes in the thoracic spine, connecting at least four contiguous vertebrae, or ossification of the anterior longitudinal ligament, preserved intervertebral disk height in the involved segment, and the absence of apophyseal joint ankylosis and sacroiliac joint involvement.

According to Colina M et al, as seen on radiographic images D.I.S.H. presents characteristically with hyperostosis of the antero-lateral aspect of the spinal column, that sometimes leads to bone ankylosis, and by ossification of extra-spinal entheses. Other features include:

1. Ossification of the ALL (anterior longitudinal ligament) of the spine causes the formation of flowing osteophytes, while intervertebral disc space is quite preserved in early phases of the disease.
2. Pain and stiffness in spine usually worsened by inaction and dampness.
3. Appendicular skeleton is symmetrically involved in early phases of the disease. Most affected sites are being feet (planter fascia), olecranon and patella. Hip involvement is also frequent and may lead to severe disability and represents an important cause of invalidity.
Association with other diseases: The pathogenesis is not fully understood, but several factors have been implicated in the disease based on frequent associations with various metabolic conditions. Some of these factors are: hyper-insulinemia with or without diabetes mellitus, obesity, gout, dyslipidemia, and prolonged use of isoretinol.

1. This condition is often associated with the metabolic derangement of type 2 diabetes.
2. Primary hypertension, its cardiovascular aftereffects and lithiasis are also often present in these patients.
3. PLL (posterior longitudinal ligament) may lead to serious repercussions on the spinal cord & root anatomies & functions. Medullary canal stenosis may present with myelopathic features; presenting features are indicative of site of such changes.
Differentiating features between DISH & AS are:

The inflammatory spondyloarthropathies are usually easily distinguishable from non-inflammatory conditions. The clinical history, physical examination, extra-articular features, laboratory results, and various imaging modalities help in reaching the correct diagnosis. Kozanoglu E & colleagues and Moreno AC & colleagues reported Simultaneous occurrence of diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis. However the following features are of importance:

1. HLA B27
2. Spinal fracture is well known in ankylosing spondylitis but exceptional in diffuse idiopathic skeletal hyperostosis (2).
3. SI joint involvement & it’s radiological features are of paramount importance in diagnosis of AS. According to Maertens M et al CT scan is helpful in differentiating the sacroiliitis of spondylarthropathies (6). However Computed tomography of the sacroiliac joints revealed several abnormalities including asymmetric intraarticular partial fusion, osteophytes with or without bridging, and vacuum phenomenon (5). According to Maertens M et al radiological differentiating points are:

a. absence of left side ossified enthesis (it is said that becuaes of presence of big abdominal vessels on left side this side enthesis are not ossified) & osteophytes.
b. The predominantly horizontal nature of the enthesiophyte in DISH.
c. A midthoracic notch was described in DISH which seemed to be confined to noninflammatory conditions, but is not found in ankylosing spondylitis.

Peculiarity of Radiological features of fractures in both AS & DISH (2)

1. Spinal fractures in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis generally occur spontaneously or after low-energy trauma. Subsequent complications have serious consequences. Late diagnosis either results from missing a radiologically visible fracture or from the presence of an occult "paper thin" fracture.
2. Repeating standard x-rays the second and third weeks and use of a spiral scan or multiple spiral scan could provide early diagnosis.
Physiotherapy in DISH:

Physiotherapy in DISH is individualized according to the presentation. Spinal presentations are treated with mobilization for pain reduction. It must be noted though DISH mostly affects thoracic area, lumbar & cervical area pain may be presented by the patients. Strength training low load high repetition exercises. For acral enthesiopathies electro-therapeutics, soft tissue therapies, mobilization and strengthening can go side by side. Promotion of proper physical activity & modification of stressful ones are also key to successful management. Hydrotherapy is also a useful tool.
References: 1. Reumatismo. 2006 Apr-Jun;58(2):104-11. 2. Rev Chir Orthop Reparatrice Appar Mot. 2004 Sep;90(5):456-65. 3. Rev Rhum Engl Ed. 1996 Apr;63(4):292-5. 4. Clin Rheumatol. 2002 Jun;21(3):258-60. 5. J Rheumatol. 1988 Oct;15(10):1506-11. 6. Clin Rheumatol. 1992 Dec;11(4):551-7. 7.

Friday, April 17, 2009


During recent years, coincident with the recommendation to position infants supine ("Back to Sleep") (7).The "Back to Sleep" campaign has dramatically decreased the incidence of sudden infant death syndrome; however, its sequelae of deformational plagiocephaly have today reached epidemic proportions (8). One in 300 new born is suffering this condition. Positional plagiocephaly has become an increasing problem for pediatricians and craniofacial specialists. Diagnosis is commonly based on history and clinical features, but may be difficult in some cases when characteristic features are missing and radiographic studies seem to be necessary (5).

What is plagiocephaly?

The term plagiocephaly, from the Greek plagios (oblique) and kephalê (head), means distortion of the head, and refers clinically to cranial asymmetry (4). Plagiocephaly is a condition characterized by an asymmetrical distortion (flattening of one side) of the skull. It is a common finding at birth and may be the result of a restrictive intrauterine environment (1).

2 broad causes of plagiocephaly:

According to Margulis A it is a deformity produced by intrauterine and/or postnatal deformational forces. Categorization and diagnosis of plagiocephaly as synostotic or deformational (nonsynostotic plagiocephaly- NSP) is reliably made by physical examination and computerized tomography (2). If there is premature union of skull bones, this is more properly called craniosynostosis. The unusual head shape in plagiocephaly is caused by pressure in the womb giving a "diamond" shaped head when seen from above. In pronounced cases there may be flattening of one side of the chest as well (2).
Torticollis leading to plagiocephaly in newborns:
According to Stellwagen L et al asymmetries of the head and neck are very common in normal newborns. In their study 16% of 102 study newborns were found to have torticollis. Such newborns, especially if they sleep supine, are thought to be at risk of developing deformational posterior plagiocephaly (6).
Identification of affected infants may allow early implementation of positioning recommendations or physical therapy to prevent the secondary craniofacial deformations that are part of an increasingly common phenomenon (6).

Why differential diagnosis in Plagiocephaly in children is important?

In the last decade, the medical fraternity has learned to distinguish deformational plagiocephaly clinically from craniosynostosis (8). Its differential diagnosis is extremely important because prompt surgical correction is usually indicated for the synostotic type. In contrast, infants with deformational frontal or occipital plagiocephaly generally respond to helmet treatment (2). Awareness of deformational plagiocephaly allows more accurate diagnosis and appropriate treatment, avoiding unnecessary surgical intervention in patients with positional molding.

Palpatory diagnosis of plagiocephaly (4).

Sergueef N et al reviewed the mechanics of the occipital bone and the adjacent atlas and bones of the cranial base, in relation to records of 649 functional plagiocephaly children. The review of available data consisted of
Gender, age at presentation, birth history, obstetrical data (breech presentation, vacuum extraction, forceps delivery or Caesarean section), presenting complaint, side of posterior plagiocephaly, side of frontal plagiocephaly, torticollis, motion pattern of the occipital bone upon the atlas, and motion pattern of the spheno-occipital synchondrosis.

Sergueef N et al found a significant correlation between the lateral strain pattern of the spheno-occipital synchondrosis and plagiocephaly and between rotational dysfunction of the occiput upon the atlas and the side of posterior plagiocephaly. Hence they suggested that neonatal osteopathic examination can identify individuals predisposed to develop posterior plagiocephaly.

Advantages of ultrasound in diagnosis of positional plagiocephaly.
Near-field high-frequency ultrasound has been used to evaluate the sonographic findings of suture anatomy and confirm the diagnosis of positional plagiocephaly as well as provide information of prognostic value (5). Regelsberger J et al reported 100 pediatric patients between the ages of 2 and 13 months, who were admitted to their department since 2004 with an abnormal head shape suggesting nonsynostotic plagiocephaly (NSP) diagnosed with High-frequency ultrasound.

They recommend:

High-frequency ultrasound is a relatively inexpensive, safe, and easy-to-use tool for confirming the diagnosis of positional plagiocephaly and excluding true synostosis. Suture anatomy was examined using a 7.5-MHz linear transducer. Morphological characteristics of the sutures--interosseous hypoechoic areas between hyperechoic bone plates--were comparable to those of normal cranial sutures. Overlapping hyperechoic bone plates were found plagiocephaly. Overlapping bone plates may be seen on the affected side of the skull in a majority of plagiocephalic patients, but this finding seems to have no prognostic value regarding early fusion of sutures and therefore should not affect treatment decisions (5).
Because US scan does not involve ionizing radiation, sonography has the potential to be a standard modality for investigating plagiocephaly in infants and should be offered in craniofacial outpatient clinics (5).

Early signs of cranial flattening in healthy neonates (7):

In a study Peitsch WK et al tried to determine whether early signs of cranial flattening could be detected in healthy neonates and to document incidence and potential risk factors.
They proposed that (7):
1. Localized lateral or occipital cranial flattening at birth is a precursor to posterior deformational plagiocephaly. The infant lies supine, with the head turned to the flattened area, and is unable to roll.
2. Intrauterine risk factors for localized cranial flattening are the same as for deformational plagiocephaly.
They concluded (7):
To avoid postnatal progression from a localized cranial flattening to posterior-lateral deformational plagiocephaly, we suggest amending the recommendation of the American Academy of Pediatrics on sleep position: Alternate the head position and allow sleeping on the side and, when awake, supervise prone time.

Role of primary care givers In Plagioceplahy:

Primary care providers must increasingly be aware of this condition and, in turn, educate new parents about its prevention. Should preventative measures fail and infants develop persistent sleep patterns that result in craniofacial deformities, deformational plagiocephaly can be treated successfully with behavior modification or cranial molding-helmet therapy.

Role of physical therapy & Cranial osteopathy as a complementary treatment of postural plagiocephaly

For the majority of neonates and young infants, appropriate postures and standard physiotherapy succeed in preventing or correcting acquired cranial deformations (fetal due to restricted mobility in utero or postnatal secondary to exclusive dorsal decubitus) (4). Identification of affected infants may allow early implementation of positioning recommendations or physical therapy to prevent the secondary craniofacial deformations that are part of an increasingly common phenomenon (6).
However, Cranial Osteopathy, since it was first proposed, has focussed upon the diagnosis and treatment of birth trauma and cranial asymmetries, and consequently specific therapy for plagiocephalic deformities has been described. Osteopathic manipulation also has been proposed as a treatment for torticollis, a condition associated with plagiocephaly (4).

Why osteopathic treatment is fruitful in plagiocephalic deformities?

1. At first, diagnostic palpation will identify which suture is normally mobile with the respiratory cycle, and which has limited or absent mobility secondary to abnormal postures.
2. Later on, the goal of the therapeutic phase is to mobilise impaired sutures, by various gentle maneuvers depending on the topography of the impairment.
3. The treatment of plagiocephalic deformities in osteopathy is not restricted to the skull but extended to the spine, pelvis and lower extremities which contribute to the deformative sequence.
Osteopathic treatment belongs to complementary medicine, therefore demonstration of its scientific value and favorable results have to be provided. However, referring pediatricians should be more aware of the method and expectations: major deformative sequence since birth and increasing deformations despite preventive postures and standard physiotherapy are reasonable indications for such complementary treatment. Moreover osteopathy has no place in the treatment of craniosynostosis ; the latter belong to malformations, completely distinct from postural deformations (4).

Reference (s):
2. Margulis A; Harefuah. 1999 Apr 2;136(7):532-7, 588, 587.
3. Arch Pediatr. 2008 Jun;15 Suppl 1:S24-30.
4. Sergueef N et al; Complement Ther Clin Pract. 2006 May;12(2):101-10. Epub 2006 Mar 29.
5. Regelsberger J et al; J Neurosurg. 2006 Nov;105(5 Suppl):413-7.
6. Arch Dis Child. 2008 Oct; 93(10):827-31. Epub 2008 Apr 1.
7. Peitsch WK et al ; Pediatrics. 2002 Dec;110(6):e72.
8. Losee JE et al; Clin Plast Surg. 2005 Jan;32(1):53-64, viii.

Wednesday, April 15, 2009

Heamarthrosis of the knee- Causes

The primary diagnostic tool for patients with a knee injury is a clinical examination by a physician well trained in knee evaluation (4). With knowledge of the common causes of Heamarthrosis and understanding of the knee examination, a trained examiner can make an accurate diagnosis 80% to 90% of the time and prescribe the appropriate treatment (1).
Rapid swelling (swelling within minutes-hours) of the knee following a blow or twisting injury is considered a significant injury. The history of trauma coupled with a thorough examination should provide an accurate diagnosis in most patients (1). Aspiration of the fluid may help to establish diagnosis, reduce pain, and prevent capsular damage by the sustained turgid pressure from within the capsule. However, it should not be performed routinely. Splinting and re-evaluation are recommended as the initial treatment of an acute Heamarthrosis (1). However, according to Iobst CA et al treatment algorithm especially for ACL injury must take into account the patient's physiologic maturity, not chronological age (4).
Investigations in Heamarthrosis:
1. X-ray
2. MRI- MR imaging has significant limitations in this younger group. (4)
3. Arthroscopic Evaluation
Early in 1980s, acute Heamarthrosis, was rather a contraindication to arthroscopy, are in fact one of the best indications for use of this procedure (3). Arthroscopy helps to complete the diagnosis or as a means of early surgical intervention.

Causes of Haemarthrosis:
Heamarthrosis is associated with peripheral meniscal tears, anterior cruciate ligament ruptures, tibial tubercle avulsion injuries, and patellar/femoral osteochondral fractures and cannot be ignored (4).
Cazenave A et al Reviewed 161 traumatic Heamarthrosis of the knee cases. These cases ware evaluated clinically, radiologically and arthroscopically.

Anatomical lesions were never benign: they consisted of
1. Ligaments ruptures (65%),
2. Patella dislocations (20.5%),
3. Chondral lesions (41%),
4. Meniscal lesions (31%).

This study confirmed: (1) that a traumatic Heamarthrosis indicates a serious knee injury, and (2) the important contribution of arthroscopy for diagnosis and treatment of these traumatic knees.

Back in 1980 DeHaven KE studied 113 athletes, who had sustained significant acute trauma to the knee with immediate disability and the early onset of Heamarthrosis.

The cases studied had no demonstrable clinical laxity, were examined under anesthesia and had arthroscopy within 3 weeks of injury (the majority within 10 days).

Anatomical lesions were:
1. ACL plus Meniscus lesions were present in 81 (72%)
2. Major meniscus tears without ACL or PCL lesions were found in 17 cases (15%),
3. Osteochondral fractures in 7 cases (6%),
4. PCL tears in 3 cases (3%),
5. No internal derangement in 5 cases (4%).

Analysis of both the above said studies taken together:

The analysis tells us a fact that meniscal lesions with or without associated lesions to other anatomical structures are fairly common & some where between (32-33) % of all acute traumatic heamarthrosis.

Heamarthrosis & Patellar dislocation.
Patella dislocation although do not find a place in the 2nd review; review 1 shows a considerable population may be affected by the patellar dislocation presenting with heamarthrosis. Sillanpää P et al (5) investigated incidence, nature, and risk factors of primary traumatic patellar dislocations. The sample consisted in this study was of 128,714 Finnish male conscripts (median age 20). Heamarthrosis was present in all patients, and when MRI or open surgery was performed, medial retinacular disruption and medial patellofemoral ligament (MPFL) injury were identified. This study concluded that Heamarthrosis and MPFL rupture are the definite signs of an acute traumatic primary patellar dislocation. Height and weight were significant risk factors, whereas poor physical performance was not associated with primary patellar dislocation.

1. Baker CL; J Med Assoc Ga. 1992 Jun;81(6):301-5.
2. Cazenave A; J Chir (Paris). 1990 Nov;127(11):522-7.
3. DeHaven KE; Am J Sports Med. 1980 Jan-Feb;8(1):9-14.
4. Iobst CA et al; Clin Sports Med. 2000 Oct;19(4):621-35, vi.
5. Sillanpää P et al; Med Sci Sports Exerc. 2008 Apr;40(4):606-11.

NB: sorry friends i have missed to provide graphs i have plotted for this article. i dont know how to publish a graph. help wanted in this regard.

Monday, April 13, 2009

What you do to the Aspirated blood?: help diagnosis further by Looking at it !!!

Occasionally in the situation of a tense haemarthrosis, the knee can be aspirated under sterile conditions to remove the blood from within the joint, and some local anaesthetic can be injected into the knee to help with pain relief. The aspirated blood should be placed into a container and left to stand. If the injury involves a fracture of the underlying bone, in other words if the damaged fragment that has been knocked off includes cartilage and bone, then usually droplets of fat from the bone marrow are released into the knee and these are visible in the aspirated fluid and will float to the top pf the aspirated blood if left to stand.

Wednesday, April 8, 2009

Are Caffeine & Guarana Synergistic?

Caffeine is a bitter, white crystalline xanthine alkaloid that acts as a psychoactive stimulant drug and a mild diuretic. Caffeine is also part of the chemical mixtures and insoluble complexes guaranine found in guarana, mateine found in mate, and theine found in tea; all of which contain additional alkaloids such as the cardiac stimulants theophylline and theobromine, and often other chemicals such as polyphenols which can form insoluble complexes with caffeine.
In humans, caffeine is a central nervous system (CNS) stimulant, having the effect of temporarily warding off drowsiness and restoring alertness. Beverages containing caffeine, such as coffee, tea, soft drinks and energy drinks enjoy great popularity. Caffeine is the world's most widely consumed psychoactive substance, but unlike many other psychoactive substances it is legal and unregulated in nearly all jurisdictions. In North America, 90% of adults consume caffeine daily. The U.S. Food and Drug Administration lists caffeine as a "Multiple Purpose Generally Recognized as Safe Food Substance".
1. The precise amount of caffeine necessary to produce effects varies from person to person depending on body size and degree of tolerance to caffeine. It takes less than an hour for caffeine to begin affecting the body and a mild dose wears off in three to four hours. Consumption of caffeine does not eliminate the need for sleep: it only temporarily reduces the sensation of being tired.
2. With these effects, caffeine is an ergogenic: increasing the capacity for mental or physical labor. One study showed a 44% increase in "race-pace" endurance, as well as a 51% increase in cycling endurance, after a dosage of 9 milligrams of caffeine per kilogram of body weight. Additional studies have reported similar effects. Another study found 5.5 milligrams of caffeine per kilogram of body mass resulted in subjects cycling 29% longer during high intensity circuits.
3. Caffeine citrate has proven to be of short and long term benefit in treating the breathing disorders of apnea of prematurity and bronchopulmonary dysplasia in premature infants.
4. Caffeine relaxes the internal anal sphincter muscles and thus should be avoided by those with fecal incontinence.
Caffeine and Health
Current research on how caffeine affects a variety of health issues is summarized below. Keep in mind that most experts agree that moderate use of caffeine is not likely to cause any health problems.
1. Studies have looked at the effects of caffeine on heart health. Moderate caffeine consumption does not appear to adversely affect cardiovascular health.
2. Caffeine appears to increase the excretion of calcium, a mineral needed for healthy bones. Calcium is particularly important to prevent osteoporosis, a bone disease characterized by loss of bone strength and seen especially in older women (although men get it too). Moderate caffeine intake does not seem to cause a problem with calcium, as long as one is consuming the recommended amount (adult men and women should be taking between 1,000 and 1,200 milligrams of calcium, depending on age and gender).
3. In the past there have been concerns that the caffeine in coffee may cause cancer. Research has shown that caffeine in coffee does not cause breast or intestinal cancer. However, not enough research has been done to determine if caffeine in coffee is involved in urinary bladder or pancreatic cancer. Taken in moderation, it is unlikely that caffeine will cause cancer.
4. Evidence suggests that, at levels over 500 milligrams per day, caffeine may delay conception. Moderate caffeine consumption does not appear to be of concern to women trying to get pregnant. Moderate consumption is also important for a healthy pregnancy. Excessive caffeine intake has been associated with miscarriages and low birth weight babies.
5. Because children have developing nervous systems, it is important to moderate their caffeine consumption. For children, major sources of caffeine include soft drinks and chocolate.
6. Caffeine may be useful as part of a weight control program because it increases the rate at which the body burns calories for three or more hours after being consumed.
7. Caffeine's ability to improve physical performance is well known among well-trained athletes. Through a mechanism that is not completely understood, caffeine seems to increase endurance and speed in some situations. Excessive use of caffeine is restricted in international competitions.

Guarana seed extract:
Guarana is an herbal stimulant that contains a form of caffeine called guaranine, which is 2.5 times stronger than the caffeine found in coffee, tea and soft drinks. What makes guaranine unique from caffeine found in beverages is its slower release. That's because the guarana seed is fatty (even in powder form) and is not readily water-soluble. Therefore the body does not quickly absorb it. Since the guaranine is released slowly, the energy boost that is experienced from guarana is not like that of coffee with its sudden rush and quick drop-off. Rather, it continues to escalate over hours.
While caffeine from beverages provides a short-lived energy burst that overheats and excites the body, guaranine has a cooling action that revitalizes and relaxes. This is because guarana contains other components that modify the activity of this substance. The end result is more beneficial to the body than tea or coffee.
1. Caffeine accelerates the effectiveness of CLA, thus making CLA a more potent fat burner. Guarana has been shown to stimulate the migration of lipids so fat can be burned as energy.
2. It is also an appetite suppressant.
3. Guarana aids in a temporary, natural increase in body temperature and metabolic thermogenesis through nutritional stimulation of the body's ß receptor pathway, which can induce the breakdown and release of stored body fat, thereby allowing stored fats to be turned into energy.
4. Thermogenesis refers to the body's production of heat, a normal part of metabolic processes. Thermogenesis can be enhanced by certain nutritional substances. When stimulated through appropriate dietary supplementation, thermogenesis is also a mechanism that increases metabolic rate. Stored body fat, if released and available for use, can provide the fuel for this increased metabolic rate.
5. Other active constituents of guarana are theobromine and theophylline, which are called xanthines (a class of thermogenic substances found in coffee, tea and certain beans). They have some effect on increasing metabolic rate, suppressing appetite and enhancing both physical and mental performance. They also act as muscle relaxants and possess diuretic properties.
6. It is reported to help overcome heat fatigue, detoxify the blood and is useful for flatulence and obesity.
7. In body care products, it has been used for its tonifying and astringent properties, and in the treatment of cellulite.
8. Guarana increases mental alertness, fights fatigue, and increases stamina and physical endurance.

Thursday, April 2, 2009

Please read this post by Karim Khan (sports medicine specialist)

This following article is written by Karim Khan (sports medicine specialist), a well known author & researchers in the field of sports medicine in British journal of sports medicine.

This article exposes a fraud on COX-2 inhibitors (pain management medicines)

Dietary facts on Calcium

Helping hints for meeting the CALCIUM needs:

As the 2000 Dietary Guidelines for Americans states, "Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need". For more information about building a healthful diet, refer to the Dietary Guidelines for Americans and the US Department of Agriculture's Food Guide Pyramid

The following are strategies and tips to help you meet your calcium needs each day:
  1. Use low fat or fat free milk instead of water in recipes such as pancakes, mashed potatoes, pudding and instant, hot breakfast cereals.
  2. Blend a fruit smoothie made with low fat or fat free yogurt for a great breakfast.
  3. Sprinkle grated low fat or fat free cheese on salad, soup or pasta.
  4. Choose low fat or fat free milk instead of carbonated soft drinks.
  5. Serve raw fruits and vegetables with a low fat or fat free yogurt based dip.
  6. Create a vegetable stir-fry and toss in diced calcium-set tofu.
  7. Enjoy a parfait with fruit and low fat or fat free yogurt.
  8. Complement your diet with calcium-fortified foods such as certain cereals, orange juice and soy beverages.
Reference site: