Older men more likely than women to die after pneumonia

Biological response to infection differs between sexes

PITTSBURGH,30 april 2009 – Differing biological response to infection between men and women may explain higher death rates among older men who are hospitalized with community-acquired pneumonia (CAP). The findings, published online in the Critical Care Medicine journal, may have important implications for understanding sex differences in life expectancy.

"Our study found that men with CAP were less likely to survive after an infection compared to women and this was not explained by differences in demographics, health behavior, chronic health conditions or quality of care," said Sachin Yende, M.D., assistant professor in the Department of Critical Care Medicine at the University of Pittsburgh School of Medicine and corresponding author of the study.

The researchers measured blood levels of inflammatory indicators, including tumor necrosis factor (TNF) and interleukins 6 and 10, coagulation indicators including Factor IX, and fibrinolysis indicators including D-dimer concentrations. They found patterns in these biomarkers that suggest men generate a stronger inflammatory and coagulation response and, perhaps, break up blood clots more quickly than women in response to infection. "These differences in inflammatory, coagulation and fibrinolysis biomarkers among men may explain the reduced short-term and long-term survival," said Dr. Yende.

Data were gathered from the multicenter Genetic and Inflammatory Markers of Sepsis (GenIMS) study. Participants were enrolled upon emergency department admission at 28 academic and community hospitals in Pennsylvania, Connecticut, Michigan and Tennessee from 2001 to 2003. The study included 2,320 subjects, with a mean age of 64.9 years, 1,136 of whom were men. The men were sicker on admission, more likely to be smokers, and had at least one chronic health condition, such as cardiac disease or cancer. Severe sepsis occurred in 588 (31 percent) subjects. Of these, about half had severe sepsis on their first day of hospitalization.

Men had a higher risk than women of death at 30 days (7 percent vs. 4.5 percent), 90 days (11.4 percent vs. 8.6 percent) and one year (21 percent vs. 16 percent). "Even compared to women with an equivalent illness severity, men were more likely to die," Dr. Yende noted. "Survival differences persist up to one year after the initial hospitalization, when most patients had recovered from the pneumonia and left the hospital."

"To our knowledge, this is the largest study comparing biological response to infection between men and women. Our results suggest that immune response to infection may be an important target for interventions to reduce sex disparities in the outcomes of infections," said senior author Derek C. Angus, M.D., professor and chair in the Department of Critical Care Medicine at the University of Pittsburgh School of Medicine and principal investigator of the study.

"More studies will be needed to determine why the biological response differs between men and women," said Dr. Yende. "A clearer understanding may be useful toward designing interventions specifically targeted to men or women."

The GenIMS researchers hope to identify whether certain changes in the genes for key inflammatory molecules are associated with the risk of developing pneumonia, and the risk of progression to severe sepsis, septic shock, organ dysfunction or death. Because pneumonia is the most common cause of sepsis, patients with this infection represent an excellent clinical model for studying sepsis in a relatively homogeneous population.

In a paper published online on April 3 in The FASEB Journal, GenIMS researchers led by Drs. Yende and Angus found that people with certain gene variations associated with higher levels of macrophage migration inhibitory factor, an innate immune response regulator, were less likely to die following CAP.

"Macrophage migration inhibitory factor is a molecule that plays an important role in inflammation and has been shown to worsen outcomes in animal models of sepsis. Our results are intriguing in light of these findings and as other research groups are trying to design human studies to block this molecule in sepsis," said Dr. Yende. In future work, the researchers will continue to examine relationships between sex and gene variations in CAP, sepsis and survival.

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GenIMS is supported in part by the National Institute of General Medical Science with additional support from GlaxoSmithKline and Diagnostic Products Corporation. GenIMS was led by several investigators in the Department of Critical Care Medicine and in collaboration with other departments at the University of Pittsburgh, including Emergency Medicine, Human Genetics and Biostatistics.

Arterial disease of the leg frequently overlooked in patients with heart disease

Study shows peripheral arterial disease is under diagnosed in patients who are under a cardiologist's care

New York, N.Y. , 30 april 2009– Peripheral arterial disease (PAD) of the legs, in which the arteries become blocked with plaque and blood supply to the legs is reduced, affects eight million people in the U.S. Early detection of PAD is important because it can limit the ability to walk and exercise, it may place patients at greater risk for limb loss and it increases the chance of having a heart attack or stroke. Coronary artery disease (CAD) is prevalent in patients with PAD and it is known that PAD is under diagnosed in the primary care setting, but a new study found that it is often overlooked even in patients with known heart disease who are under a cardiologist's care. The study was published in the May issue of Catheterization and Cardiovascular Interventions, the official journal of The Society for Cardiovascular Angiography and Interventions (SCAI).

Led by Dr. Issam D. Moussa of New York Presbyterian Hospital/Weill Cornell Medical Center, the study involved nearly 800 patients with ischemic heart disease who were to undergo coronary angiography and/or intervention and were either at least 70 years old, or between the ages of 50 and 69 and had a history of diabetes mellitus and/or tobacco use. Researchers determined if patients had PAD by calculating the Ankle-Brachial Index, the ratio of the blood pressure in the lower legs to blood pressure in the arms, which is normally the first test administered to patients in cases where PAD is suspected. Patients also answered questionnaires on PAD awareness and functional status.

The results showed that approximately one out of six patients had previously unrecognized PAD, despite being under the care of a cardiovascular specialist. The researchers point out that this includes only those with previously undiagnosed PAD and does not represent the total prevalence of PAD in patients with heart disease, which is actually much higher. Most patients with PAD did not limp or have leg pain, two symptoms of the disease. "The combination of physician lack of awareness and lack of symptoms among patients results in failure to diagnose PAD, even in patients who are at high risk," the researchers state. "Furthermore, clinical evaluation alone often lacks the sensitivity and specificity to optimally identify PAD particularly in less advanced stages and in hospitalized patients with CAD."

The study also found that previously missed PAD was more frequent in older patients and women, which goes against the conventional wisdom that PAD is more prevalent in men and suggests that PAD is more frequently overlooked in women than men in outpatient settings. In addition, the study showed that patients with PAD had a more severe form of CAD, which may account for the worse outcome of heart patients who also have PAD compared to those who do not. The authors note that "making a diagnosis of PAD in a patient with CAD should prompt the clinician to be more aggressive with risk factor intervention, foot protection and a high clinical index of suspicion for progressive PAD symptoms," adding that these patients should be viewed as exceptionally high risk.

They also note that establishing an early diagnosis of PAD promotes the preservation of functional status in the lower limbs, which is particularly important in patients CAD, since PAD may limit active participation in cardiovascular rehabilitation following coronary interventions. Many physicians cite the lack of space, time and resources as barriers to implementing a systematic PAD screening program, however new guidelines by the American Heart Association and the American College of Cardiology advocate screening for PAD in patients with CAD. The authors conclude that their findings present a compelling argument that screening for PAD should become standard of care in these patients.

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This study is published in Catheterization and Cardiovascular Interventions. Media wishing to receive a PDF of this article may contact medicalnews@bos.blackwellpublishing.net

Issam D. Moussa, M.D., FSCAI is the Director of Endovascular Services in the Division of Cardiology at New York Presbyterian Hospital/Weill Cornell Medical Center and Associate Professor of Medicine at Weill Medical College of Cornell University in New York. Dr. Moussa can be reached for questions at ism9003@med.cornell.edu.

Depression linked with accumulation of visceral fat

Study explains association between depression and cardiovascular disease

30 april 2009--Numerous studies have shown that depression is associated with an increased risk of heart disease, but exactly how has never been clear.

Now, researchers at Rush University Medical Center have shown that depression is linked with the accumulation of visceral fat, the kind of fat packed between internal organs at the waistline, which has long been known to increase the risk of cardiovascular disease and diabetes.

The study is posted online and will be published in the May issue of Psychosomatic Medicine.

"Our results suggest that central adiposity – which is commonly called belly fat – is an important pathway by which depression contributes to the risk for cardiovascular disease and diabetes," said Lynda Powell, PhD, chairperson of the Department of Preventive Medicine at Rush and the study's principal investigator. "In our study, depressive symptoms were clearly related to deposits of visceral fat, which is the type of fat involved in disease."

The study included 409 middle-aged women, about half African-American and half Caucasian, who were participating in the Women in the South Side Health Project (WISH) in Chicago, a longitudinal study of the menopausal transition. Depressive symptoms were assessed using a common screening test, and visceral fat measured with a CT scan. Although waist size is often used as a proxy for the amount of visceral fat, it is an inaccurate measure because it includes subcutaneous fat, or fat deposited just beneath the skin.

The researchers found a strong correlation between depression and visceral fat, particularly among overweight and obese women. The results were the same even when the analysis adjusted for other variables that might explain the accumulation of visceral fat, such as the level of physical activity. The study found no association between depressive symptoms and subcutaneous fat. The findings were the same for both black and white women.

Powell speculated that depression triggers the accumulation of visceral fat by means of certain chemical changes in the body – like the production of cortisol and inflammatory compounds – but said that more research is needed to pinpoint the exact mechanism.

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Rush University Medical Center includes the 674-bed (staffed) hospital; the Johnston R. Bowman Health Center; and Rush University (Rush Medical College, College of Nursing, College of Health Sciences and the Graduate College).

Novel role of protein in generating amyloid-beta peptide

30 april 2009--A defining hallmark of Alzheimer's disease is the accumulation of the amyloid β protein (Aβ), otherwise known as "senile plaques," in the brain's cortex and hippocampus, where memory consolidation occurs. Researchers at the University of California, San Diego School of Medicine have identified a novel protein which, when over-expressed, leads to a dramatic increase in the generation of Aβ. Their findings, which indicate a potential new target to block the accumulation of amyloid plaque in the brain, will be published in the May 1 issue of the Journal of Biological Chemistry.

"The role of the multi-domain protein, RANBP9, suggests a possible new therapeutic target for Alzheimer's disease," said David E. Kang, PhD, assistant professor of neurosciences at UC San Diego and director of this study.

The neurotoxic protein Aβ is derived when the amyloid precursor protein (APP) is "cut" by two enzymes, β-secretase (or BACE) and γ-secretase (or Presenilin complex.) However, inhibiting these enzymes in order to stop the amyloid cascade has many negative side effects, as these enzymes also have various beneficial uses in brain cells. So the researchers looked for an alternative way to block the production of amyloid beta.

In order for cleavage to occur, the APP needs to travel to cholesterol-enriched sites within the cell membrane called RAFTS, where APP interacts with the two enzymes. It is this contact that the researchers sought to block.

Kang explains that the researchers identified the RANBP9 protein by studying low density lipoprotein receptor-related protein (LRP), a protein that rapidly shuttles Aβ out of the brain and across the blood-brain barrier to the body, where it breaks down into harmless waste products. A small segment of LRP can also stimulate Aβ generation, and the scientists narrowed this segment down to a 37-amino-acid stretch that can lead to changes in Aβ.

"RANBP9 is one of the proteins we identified that interacted with this LRP segment, but one that had never before been associated with disease-related neuronal changes," said Kang. "We discovered that this protein interacts with three components involved in Aβ generation – LRP, APP and BACE1 – and appears to 'scaffold' them into a structure."

Kang explained that these three components must come together to result in the first cut or cleaving that leads to production of Aβ. To test this, the scientists knocked out RANBP9 in the cell, and discovered that 60% less Aβ was produced.

"This unique factor enhances the production of beta amyloid," said Kang. "Inhibiting the RANBP9 protein may offer an alternative approach to therapy, by preventing contact between APP and the enzyme that makes the cut essential to produce amyloid plaques." The researchers' next step is to verify these findings in animal models.

According to the Alzheimer's Association, an estimated 5.3 million people have Alzheimer's disease in the United States alone, and a new case is diagnosed every seven seconds.

Madepalli K. Lakshmana, Ph.D., the study's first author, added that "this study is the first to identify RANBP9 as a target to potentially inhibit the movement of APP to RAFTS so that amyloid beta peptide generation can be prevented. As such, a small molecule drug that can reduce the RANBP9 protein levels could offer an effective treatment for Alzheimer's disease."

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Additional contributors to the study include Il-Sang Yoon, Eunice Chen and Edward H. Koo, of UC San Diego Department of Neurosciences; and Elizabetta Bianchi from the Institut Pasteur in Paris.

This work was supported in part by the American Health Assistance Foundation, the Alzheimer's Association, and the National Institutes of Health, National Institute on Aging.

Vitamin E, selenium and soy in combination does not prevent prostate cancer

LINTHICUM, MD, 30 april 2009–The combination therapy of vitamin E, selenium and soy does not prevent the progression from high-grade prostatic intraepithelial neoplasia (HGPIN) to prostate cancer, according to the new research presented at the 104th Annual Scientific Meeting of the American Urological Association (AUA). The study confirms the findings of the Selenium and Vitamin E Cancer Prevention Trial (SELECT) and expands knowledge of the affect soy has on prostate cancer.

Canadian researchers divided 303 men, with an average age of 62, into two randomized groups. All participants had HGPIN, a precursor to invasive prostate cancer, as confirmed by a central pathology review in at least one of two biopsies within 18 months prior to randomization. The combination treatment was administered daily for three years with follow-up prostate biopsies at six, 12, 24 and 36 months. Supplementation was discontinued if a man developed invasive disease. Study results show that 26.4 percent of patients developed invasive prostate cancer. Baseline, age, weight and testosterone levels did not predict the development of cancer.

"Unfortunately, as this study shows, we have yet to find a dietary supplement that will reliably prevent prostate cancer. The results of this study support the findings of the SELECT trial which also demonstrated no benefit using Vitamin E and selenium," said Christopher Amling, MD, an AUA spokesman. "These studies highlight the importance of conducting randomized trials of these agents since many of these supplements are promoted falsely to the general public as having beneficial effects on cancer prevention and progression."

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NOTE TO REPORTERS: Experts are available to discuss this study outside normal briefing times. To arrange an interview with an expert, please contact the AUA Communications Office at the number above or e-mail Lacey Dean at LDean@AUAnet.org.

What you need to know about swine flu

By LAURAN NEERGAARD

WASHINGTON, 29 april 2009 – A never-before-seen strain of swine flu has turned killer in Mexico and is causing milder illness in the United States and elsewhere. While authorities say it's not time to panic, they are taking steps to stem the spread and also urging people to pay close attention to the latest health warnings and take their own precautions.

"Individuals have a key role to play," Dr. Richard Besser, acting chief of the Centers for Disease Control and Prevention, said Monday.

Here's what you need to know:

Q: How do I protect myself and my family?

A: For now, take commonsense precautions. Cover your coughs and sneezes, with a tissue that you throw away or by sneezing into your elbow rather than your hand. Wash hands frequently; if soap and water aren't available, hand gels can substitute. Stay home if you're sick and keep children home from school if they are.

Q: How easy is it to catch this virus?

A: Scientists don't yet know if it takes fairly close or prolonged contact with someone who's sick, or if it's more easily spread. But in general, flu viruses spread through uncovered coughs and sneezes or — and this is important — by touching your mouth or nose with unwashed hands. Flu viruses can live on surfaces for several hours, like a doorknob just touched by someone who sneezed into his hand.

Q: In Mexico, officials are handing out face masks. Do I need one?

A: The CDC says there's not good evidence that masks really help outside of health care settings. It's safer just to avoid close contact with someone who's sick and avoid crowded gatherings in places where swine flu is known to be spreading. But if you can't do that, CDC guidelines say it's OK to consider a mask — just don't let it substitute for good precautions.

Q: Is swine flu treatable?

A: Yes, with the flu drugs Tamiflu or Relenza, but not with two older flu medications.

Q: Is there enough?

A: Yes. The federal government has stockpiled enough of the drugs to treat 50 million people, and many states have additional stocks. As a precaution, the CDC has shipped a quarter of that supply to the states to keep on hand just in case the virus starts spreading more than it has so far.

Q: Should I take Tamiflu as a precaution if I'm not sick yet?

A: No. "What are you going to do with it, use it when you get a sniffle?" asks Dr. Marc Siegel of New York University Langone Medical Center and author of "Bird Flu: Everything you Need To Know About The Next Pandemic." Overusing antiviral drugs can help germs become resistant to them.

Q: How big is my risk?

A: For most people, very low. Outside of Mexico, so far clusters of illnesses seem related to Mexican travel. New York City's cluster, for instance, consists of students and family members at one school where some students came back ill from spring break in Mexico.

Q: Why are people dying in Mexico and not here?

A: That's a mystery. First, understand that no one really knows just how many people in Mexico are dying of this flu strain, or how many have it. Only a fraction of the suspected deaths have been tested and confirmed as swine flu, and some initially suspected cases were caused by something else.

Q: Should I cancel my planned trip to Mexico?

A: The U.S. did issue a travel advisory Monday discouraging nonessential travel there.

Q: What else is the U.S., or anyone else, doing to try to stop this virus?

A: The U.S. is beginning limited screening of travelers from Mexico, so that the obviously sick can be sent for treatment. Other governments have issued their own travel warnings and restrictions. Mexico is taking the biggest steps, closings that limit most crowded gatherings. In the U.S., communities with clusters of illness also may limit contact — New York closed the affected school for a few days, for example — so stay tuned to hear if your area eventually is affected.

Q: What are the symptoms?

A: They're similar to regular human flu — a fever, cough, sore throat, body aches, headache, chills and fatigue. Some people also have diarrhea and vomiting.

Q: How do I know if I should see a doctor? Maybe my symptoms are from something else — like pollen?

A: Health authorities say if you live in places where swine flu cases have been confirmed, or you recently traveled to Mexico, and you have flulike symptoms, ask your doctor if you need treatment or to be tested. Allergies won't cause a fever. And run-of-the-mill stomach bugs won't be accompanied by respiratory symptoms, notes Dr. Wayne Reynolds of Newport News, Va., spokesman for the American Academy of Family Physicians.

Q: Is there a vaccine to prevent this new infection?

A: No. And CDC's initial testing suggests that last winter's flu shot didn't offer any cross-protection.

Q: How long would it take to produce a vaccine?

A: A few months. The CDC has created what's called "seed stock" of the new virus that manufacturers would need to start production. But the government hasn't yet decided if the outbreak is bad enough to order that.

Q: What is swine flu?

A: Pigs spread their own strains of influenza and every so often people catch one, usually after contact with the animals. This new strain is a mix of pig viruses with some human and bird viruses. Unlike more typical swine flu, it is spreading person-to-person. A 1976 outbreak of another unusual swine flu at Fort Dix, N.J., prompted a problematic mass vaccination campaign, but that time the flu fizzled out.

Q: So is it safe to eat pork?

A: Yes. Swine influenza viruses don't spread through food.

Q: And whatever happened to bird flu? Wasn't that supposed to be the next pandemic?

A: Specialists have long warned that the issue is a never-before-seen strain that people have little if any natural immunity to, regardless of whether it seems to originate from a bird or a pig. Bird flu hasn't gone away; scientists are tracking it, too.

WHO says possible swine flu pandemic may be mild

GENEVA, 29 april 2009- The World Health Organization said on Tuesday the current outbreak of swine flu could lead to only a mild pandemic but warned the 1918 flu pandemic, which killed tens of millions, started that way.

"It is entirely possible...that we may see a very mild pandemic. That would be the best of all situations short of this current situation simply stopping and disappearing," Keiji Fukuda, WHO acting assistant director-general, told reporters.

"I think we have to be mindful and respectful of the fact that influenza moves in ways we cannot predict.

"The worst pandemic of the 20th century occurred ... in 1918 and it also started out as a relatively mild pandemic that wasn't very much noticed in most places. Then in the fall time (it) became a very severe pandemic, one of the most severe infectious disease episodes ever recorded."

The new strain of swine flu virus that has killed up to 149 people in Mexico spread to more countries on Tuesday, raising the specter of a pandemic and hurting financial markets.

Fukuda, an American specialist in influenza, said that there was no good explanation for why the cases in Mexico appeared to be more severe than in other countries. Seven of the 26 laboratory-confirmed cases in Mexico had died, he said.

Worldwide, a total of 79 cases have now been confirmed in laboratories recognized by the WHO and officially notified to the United Nations agency. The latest are three cases in New Zealand, two cases in Britain and a second case in Spain.

Fukuda said there was a definite possibility that the new virus could establish community-wide infections in multiple countries, but it was too early to say that this was inevitable.

The WHO was turning its focus more toward the needs of developing countries, which history shows usually lack resources and infrastructure to combat emerging infectious diseases.

"They really get hit disproportionately hard," he said.

Officials say US deaths expected from swine flu

By SARA KUGLER

NEW YORK, 29 april 2009 – The global swine flu outbreak worsened Tuesday as authorities said hundreds of students at a New York school have fallen ill and federal officials said they expected to see U.S. deaths from the virus. Cuba suspended flights to and from Mexico, becoming the first country to impose a travel ban to the epicenter of the epidemic.

The mayor of the capital cracked down further on public life, closing gyms and swimming pools and ordering restaurants to limit service to takeout.

Confirmed cases were reported for the first time as far away as New Zealand and Israel, joining the United States, Canada, Britain and Spain.

Swine flu is believed to have killed more than 150 people in Mexico, and the Centers for Disease Control and Prevention said the U.S. has 68 confirmed cases in five states, with 45 in New York, one in Ohio, one in Indiana, two in Kansas, six in Texas and 13 in California.

"I fully expect we will see deaths from this infection," said Richard Besser, acting director of the CDC.

That was echoed by Homeland Security Secretary Janet Napolitano.

"It is very likely that we will see more serious presentations of illness and some deaths as we go through this flu cycle," she said.

President Barack Obama asked Congress for $1.5 billion in emergency funds to fight the illness.

In New York, there were growing signs that the virus was moving beyond St. Francis Preparatory school, where sick students started lining up last week at the nurse's office. The outbreak came just days after a group of students returned from spring break in Cancun.

At the 2,700-student school, the largest Roman Catholic high school in the nation, "many hundreds of students were ill with symptoms that are most likely swine flu," said Health Commissioner Thomas Frieden. The cases haven't been confirmed.

Twelve teachers reported flu-like symptoms as well, said the principal, Brother Leonard Conway.

A nearby public school for special education students was shut down after more than 80 students called in sick. Frieden said that some of the students have siblings at St. Francis.

"It is here and it is spreading," Frieden said.

Some of the New York students who tested positive for swine flu after a trip to Mexico passed it on to others who had not traveled — a significant fact because it suggests the strain suspected in dozens of deaths in Mexico can also spread through communities in other countries, said Keiji Fukuda, assistant director-general of the World Health Organization.

"There is definitely the possibility that this virus can establish that kind of community wide outbreak capacity in multiple countries, and it's something we're looking for very closely," Fukuda said. So-called "community" transmissions are a key test for gauging whether the spread of the virus has reached pandemic proportions.

Fukuda warned, however, against jumping to the conclusion that the virus has become firmly established in the United States.

Still, U.S. officials stressed there was no need for panic and noted that flu outbreaks are quite common every year. The CDC estimates about 36,000 people in the U.S. died of flu-related causes each year, on average, in the 1990s.

The increase in cases was not surprising. For days, CDC officials said they expected to see more confirmed cases — and more severe illnesses. Health officials nationwide stepped up efforts to look for symptoms, especially among people who had traveled to Mexico.

Scientists hope to have a key ingredient for a vaccine ready in early May, but it still will take a few months before any shots are available for the first required safety testing. Using samples of the flu taken from people who fell ill in Mexico and the U.S., scientists are engineering a strain that could trigger the immune system without causing illness.

"We're about a third of the way" to that goal, said Dr. Ruben Donis of the CDC.

The economic toll also spread. Officials said Mexico City is losing $57 million a day amid a shutdown that includes schools, state-run theaters and other public places.

Cuba announced a 48-hour ban on flights to and from Mexico, except in "exceptional cases." The last flight from Mexico touched down in Havana around 4 p.m., then returned to Mexico City with passengers before the two-day suspension officially began.

The U.S. stepped up checks of people entering the country and warned Americans to avoid nonessential travel to Mexico. Canada, Israel and France issued similar travel advisories.

For all the government intervention, health officials suggested that efforts to contain the flu strain might prove ineffective. Around the world, officials hoped the outbreak would not turn into a full-fledged pandemic, an epidemic that spreads across a wide geographical area.

"Border controls do not work. Travel restrictions do not work," said WHO spokesman Gregory Hartl, recalling the SARS epidemic earlier in the decade that killed 774 people, mostly in Asia, and slowed the global economy.

The pork industry was dealing with a public relations nightmare over the virus, which is a never-before-seen hybrid of human, swine and bird influenza that is widely called swine flu.

Public health officials have said people cannot get sick from eating pork, but some countries, such as China, Russia and Ukraine, have banned imports from Mexico and parts of the U.S.

U.S. officials said they may abandon the term "swine flu" for fear of confusing people into thinking they could catch it from eating pork.

"It's killing our markets," said Francis Gilmore, 72, who runs a 600-hog operation in Perry, Iowa, outside Des Moines, and worries his small business could be ruined by the crisis. "Where they got the name, I just don't know."

Gov. Arnold Schwarzenegger declared a state of emergency to help California agencies coordinate efforts in response to the outbreak. He cautioned, however, that "there is no need for alarm."

In New York, the city called on the CDC for additional resources to investigate the outbreak at St. Francis Prep.

About 1,500 students replied to surveys sent out by the health department about the outbreak, helping the city get a better sense of how the virus is spreading. Some students have complained of sudden nausea; others dealt with high fever, sore throats, coughs and aches.

Rachel Mele and her mother, Linda, were relieved when the 16-year-old's fever broke Tuesday for the first time in five days. It had been hovering around 101.

The family could finally breathe easy — a relief after a terrifying night Thursday in which Mele's parents bundled her into the car and rushed her to the hospital when they realized she was having trouble breathing.

"I could barely even catch my breath. I've never felt a pain like that before," Mele said. "My throat, it was burning, like, it was the worst burning sensation I ever got before. I couldn't even swallow. I couldn't even let up air. I could barely breathe through my mouth."

FDA allows uncleared uses of flu drugs, tests

WASHINGTON, 29 april 2009 - The U.S. Food and Drug Administration authorized emergency uses of the flu drugs Tamiflu and Relenza on Monday and a diagnostic test to help get a grip on a new strain of swine flu, the agency said on Monday.

The U.S. government's declaration on Sunday that the swine flu is a public health emergency freed the FDA to take such action, the agency said in a statement.

The FDA will now have the authority to allow public health and medical personnel to prescribe Relenza, GlaxoSmithKline's inhaled flu drug also known as zanamivir, and Roche AG's Tamiflu, a pill also known as oseltamivir, for unapproved uses.

Tamiflu, approved for treating and preventing the flu in people over a year old, can now be used in children under 1 year. Doctors can also change the recommended dosage for children older than 1 year under the emergency use authorization.

The FDA also gave more healthcare workers authority to distribute Tamiflu and Relenza, including some public health officials and volunteers.

More than 40 people have been sickened by the new flu strain in the United States.

The rRT-PCR Swine Flu Panel diagnostic test was authorized for testing samples from flu patients to determine if they have the new strain.

A positive finding will presumptively conclude that the patient has the new, previously unseen strain of H1N1 swine flu. But a negative result will not be considered conclusive that a patient does not have the virus, the agency said.

New swine flu infections intensify travel fears

By Catherine Bremer

MEXICO CITY , 29 april 2009- New swine flu infections were found around the world on Tuesday and the specter of a pandemic hit the travel industry as governments warned people to stay away from Mexico where 149 people have died.

The number of infections in the United States rose to 65, Canada has 13, and new cases were also confirmed in Israel and New Zealand.

The United States, Canada and the European Union are telling people to avoid non-essential travel to Mexico, and Cuba suspended all flights to and from Mexico for 48 hours.

Travel companies were also staying away. Carnival Cruises canceled stops at Mexican ports for three of its ships on Tuesday and Canadian tour operator Transat AT postponed flights to Mexico until June 1.

President Barack Obama asked the U.S. Congress for $1.5 billion to finance its response to the flu threat, and California declared a state of emergency, allowing it to deploy more resources to prevent new infections.

The World Health Organization said a pandemic -- a global outbreak of a serious new illness -- is not yet inevitable but that all countries should prepare for the worst, especially poorer developing nations.

"They really get hit disproportionately hard," said the WHO's acting assistant director-general Dr. Keiji Fukuda.

One of the mysteries of the outbreak is why the virus has killed scores of people in Mexico while the cases outside the country have been relatively mild and no one has died.

Experts say this may be simply a matter of where they have been looking to find it and officials say they expect to find deaths as the disease spreads.

A pandemic could snuff out fragile signs of economic recovery around the world as travel, trade and manufacturing output would all be hit.

The last flu pandemic was in 1968, when "Hong Kong" flu killed about 1 million people around the world.

Seven countries have confirmed cases of the swine flu and a dozen others have suspected infections.

Mexico City is at the center of the outbreak and many residents are staying in their homes while schools, churches, cinemas and restaurants have all been shut down.

Airline share prices declined again on Tuesday on fears that they could experience a sharp drop in traffic.

U.S., European and Asian stock markets all retreated despite positive U.S. consumer confidence data as flu fears and worries about American banks weighed on sentiment.

"Prices remain in a bit of a swoon as market participants fret that a potential influenza pandemic might prove fatal to the frail signs of recovery just beginning to show," said Mike Fitzpatrick, vice president at MF Global in New York.

Oil dropped almost 2 percent to below $50 a barrel and investors cut their exposure to riskier currencies.

The swine flu virus is not caught from eating pig meat products but several countries, led by Russia and China, banned U.S. pork imports. The EU said it has no plans to restrict pig meat products from the United States.

TRAVEL ALERTS

A barrage of travel warnings by foreign governments and travel firms threatened to batter Mexico's tourism industry, a main source of foreign currency for the country.

UK travel firms Thomson Holidays and First Choice decided to repatriate their customers from Mexico and cancel flights bound for Cancun, although most airlines continued to operate their services.

Many private companies took their own precautions, restricting travel to Mexico and other countries with confirmed cases. Honda Motor Co, which like most major auto makers has production facilities in Mexico, has suspended all global business travel until at least May 6.

Experts say that while it is impossible to stop the spread of the disease, efforts to slow its progress could buy crucial time for countries to procure essential drugs.

The WHO's Fukuda said a mild pandemic is possible but he also cautioned that the 1918 "Spanish" flu that killed tens of millions of people emerged from mild beginnings.

Worldwide, seasonal flu kills between 250,000 and 500,000 people in an average year.

In Mexico, people from company directors to couriers wore face masks while airlines checked passengers for flu symptoms.

The government has shut all schools across Mexico until at least May 6. Restaurants, bars, cinemas and even churches in the capital have been closed to limit new infections.

Residents rushed to stock up on food, water and surgical masks but the usually hectic city is otherwise very quiet.

Mexico says the first fatal case that alerted authorities to the strange new virus was in the southern state of Oaxaca but they have not yet found the origin of the outbreak.

AUA counters mainstream recommendations with new best practice statement on PSA testing

New guidance stresses that PSA testing should be individualized, men should get baseline reading at age 40

LINTHICUM, MD, 28 april 2009—The American Urological Association (AUA) today issued new clinical guidance – which directly contrasts recent recommendations issued by other major groups – about prostate cancer screening, asserting that the prostate-specific antigen (PSA) test should be offered to well-informed, men aged 40 years or older who have a life expectancy of at least 10 years. The PSA test, as well as how it is used to guide patient care (e.g., at what age men should begin regular testing, intervals at which the test should be repeated, at what point a biopsy is necessary) is highly controversial; however, the AUA believes that, when offered and interpreted appropriately the PSA test may provide essential information for the diagnosis, pre-treatment staging or risk assessment and post-treatment monitoring of prostate cancer.

The new Best Practice Statement updates the AUA's previous guidance, which was issued in 2000. Major changes to the AUA statement include new recommendations about who should be considered for PSA testing, as well as when a biopsy is indicated following an abnormal PSA reading. According to the AUA, early detection and risk assessment of prostate cancer should be offered to well-informed men 40 years of age or older who have a life expectancy of at least 10 years. The future risk of prostate cancer is closely related to a man's PSA score; a baseline PSA level above the median for age 40 is a strong predictor of prostate cancer. Such testing may not only allow for earlier detection of more curable cancers, but may also allow for more efficient, less frequent testing. Men who wish to be screened for prostate cancer should have both a PSA test and a digital rectal exam (DRE). The Statement also notes that other factors such as family history, age, overall health and ethnicity should be combined with the results of PSA testing and physical examination in order to better determine the risk of prostate cancer. The Statement recommends that the benefits and risks of screening of prostate cancer should be discussed including the risk of over-detection, detecting some cancers which may not need immediate treatment

"The single most important message of this statement is that prostate cancer testing is an individual decision that patients of any age should make in conjunction with their physicians and urologists. There is no single standard that applies to all men, nor should there be at this time," Dr. Carroll said. He also notes that the "panel carefully reviewed the most recently reported trials of PSA testing in both the United States and Europe before finalizing their guidelines. The strengths and limitations of these trials are reviewed in the guideline."

In regard to biopsy, a continuum of risk exists at all values, and major studies have demonstrated that there is no safe PSA value below which a man may be reassured that he does not have biopsy-detectable prostate cancer. Therefore, the AUA does not recommend a single PSA threshold at which a biopsy should be obtained. Rather, the decision to biopsy should take into account additional factors, including free and total PSA, PSA velocity and density, patient age, family history, race/ethnicity, previous biopsy history and co-morbidities. Additionally, the AUA statement emphasizes that not all prostate cancers require active treatment and that not all prostate cancers are life-threatening. The decision to proceed to active treatments is one that men should discuss in detail with their urologists to determine whether active treatment is necessary, or whether surveillance may be an option for their prostate cancer.

"Prostate cancer comes in many forms, some aggressive and some not," said Peter Carroll, MD, chair of the panel that developed the Statement. "But the bottom line about prostate cancer testing is that we cannot counsel patients about next steps for cancer that we do not know exist." He also notes that "the AUA is committed to the timely, expert and appropriate care for men either with or at risk of getting prostate cancer and is prepared to revise these guidelines continuously as new information becomes available."

Additionally, the Best Practice Statement clarifies a number of key points about the use of PSA in treatment selection and post-treatment follow up of prostate cancer patients:

• Serum PSA predicts the response of prostate cancer to local therapy.
• Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is equal to or less than 20.0 ng/mL.
• Computed tomography or magnetic resonance imaging scans may be considered for the staging of men with high-risk clinically localized prostate cancer when the PSA is greater than 20.0 ng/mL or when locally advanced or when the Gleason score is greater than or equal to 8.
• Pelvic lymph node dissection for clinically localized prostate cancer may not be necessary if the PSA is less than 10.0 ng/mL and the Gleason score is less than or equal to 6.
• Periodic PSA determinations should be offered to detect disease recurrence.
• Serum PSA should decrease and remain at undetectable levels after radical prostatectomy.
• Serum PSA should fall to a low level following radiation therapy, high intensity focused ultrasound and cryotherapy and should not rise on successive occasions.
• PSA nadir (low point) after androgen suppression therapy predicts mortality.
• Bone scans are indicated for the detection of metastases following initial treatment for localized disease, but the PSA level that should prompt a bone scan is uncertain. Additional important prognostic information can be obtained by evaluation of PSA kinetics (velocity).
• The kinetics of PSA rise after local therapy for prostate cancer can help distinguish between local and distant recurrence.

The new AUA statement is based on panel review of all available professional literature, members' clinical experience and expert opinion. The new statement will be available online to the public at www.AUAnet.org on Monday, April 27, 2009 at 7 a.m. EDT.

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The AUA Foundation will be issuing an official Patient Guide outlining what men need to know when it comes to prostate cancer testing. The Guide will be introduced on Monday, April 27th at the AUA Annual Meeting in Chicago in conjunction with the AUA's new best practices statement on prostate cancer testing.

Major statin study reveals several important findings for reducing prostate cancer and disease

ROCHESTER, Minn., 28 april 2009 -- Statins, drugs widely prescribed to lower cholesterol, may have protective effects on prostate health. This large Mayo Clinic cohort study looked at three different aspects of urological health -- prostate cancer, erectile dysfunction and prostate enlargement. Initial research results are being presented April 25-30, 2009, at the American Urological Association (AUA) meeting in Chicago.

These Mayo Clinic study findings came from data in the Olmsted County Study of Urinary Health Status among Men, a large cohort study of men living in Olmsted County, Minn. This study has followed 2,447 men ages 40 to 79 from 1990 to the present to assess various urologic outcomes among aging men.

"One of the major advantages of this large cohort study is that the men have participated in this study for over 15 years. Because of this, we have the ability to look at associations between statin use, how long statins were used and multiple aspects of urologic function," says Jennifer St. Sauver, Ph.D., Mayo Clinic epidemiologist and study author.

Three significant abstracts are being presented at the AUA meeting:

Statins May Reduce Risk of Prostate Cancer

In the first study, researchers followed the 2,447 men for over 15 years and discovered that men taking statins were less likely to develop prostate cancer, compared to men who did not take statins.

Of the statin users, 38 (6 percent) were diagnosed with prostate cancer. Comparatively, non-statin users were three times more likely to develop prostate cancer, suggesting statin use may prevent development of prostate cancer.

"In recent years, it has been suggested that statin medications may prevent development of cancer. However, until now, there has been limited evidence to support this theory," says Rodney Breau, M.D., a Mayo Clinic urologic oncology fellow who led the study. "Our research provides evidence that statin use is associated with a threefold reduced risk of being diagnosed with prostate cancer."

Statin medications are currently used to lower cholesterol or to help prevent heart attack and stroke in high-risk patients. In the laboratory setting, researchers have observed that statin medications prevent cancer cells from dividing and, in fact, may cause some cancer cells to die.

"In the United States, one in six men will develop prostate cancer; however, far more will develop heart disease," says Jeffrey Karnes, M.D., Mayo Clinic urologist and senior author on the study. "I tell my patients to take care of their heart — because what's good for the heart is also good for the prostate."

The investigators emphasize that these results are preliminary. To determine if statins are protective for prostate cancer, randomized controlled trials are necessary, says Dr. Karnes.

Statin Use May Protect Against Erectile Dysfunction

Hyperlipidemia, high cholesterol and other risk factors for heart disease have been shown to put men at risk for erectile dysfunction (ED). With this in mind, Mayo Clinic researchers studied 1,480 men from the Olmsted County cohort to determine if men who used statins were less likely to develop erectile dysfunction, compared to men who did not use statins.

Overall, statin use was not significantly associated with a decreased risk of developing ED. However, statins were associated with a decreased risk of ED among older men (>60 years). Men in this age category who used statins were less likely to develop ED, compared to older men who did not use statins. Additionally, men who took statins for a longer time were more protected against developing ED. For example, men who took statins for nearly nine years or more were 64 percent less likely to develop ED, while men who took statins for less than three years had about the same risk of developing ED. compared to men who did not take statins.

"Protection of vascular health remains an important concomitant of preserving erectile health. Our data suggest that longer use of statins may result in the lowest risk of erectile dysfunction," says Ajay Nehra, M.D. , Mayo Clinic urologist and senior study author.

ED is common, and prevalence increases with age. It affects 5 to 10 percent of men at age 40. By age 70, from 40 to 60 percent of men have the condition.

Autologous muscle-derived cells may treat stress urinary incontinence

LINTHICUM, MD, 28 april 2009–Researchers have confirmed that transplanting autologous muscle-derived cells (AMDC) into the bladder is safe at a wide range of doses and significantly improves symptoms and quality of life in patients with stress urinary incontinence. The study was presented at the 104th Annual Scientific Meeting of the American Urological Association (AUA) and showed that the injection of muscle-derived cells was well tolerated and significantly improved symptoms.

Researchers conducted two study phases on the efficacy and safety of muscle-derived cell transplantation. In the study phases, which are ongoing, 29 women (mean age of 49.5), whose stress urinary incontinence symptoms had not improved within a year of standard therapy, received cystoscope-assisted periurethral cell injections. At the three month follow-up appointment, participants could elect a second injection of the same dose. Follow-up occurred at one, three, six and 12 months after the last injection. Clinical outcomes were evaluated with a pad weight test, a voiding diary and validated quality of life questionnaires. In the first, double-blind phase, 20 patients were randomized into five groups to receive one, two, four, eight or 16 x 106 AMDCs. In the second, single-blind phase, nine patients were randomized into three groups to receive 32, 64, or 128 x 106 AMDCs.

Results showed that 86.2 percent of the 29 patients elected a second injection. To date, 17 patients have reached the 12-month follow-up appointment. No serious adverse events have been encountered. Minor events occurred at similar rates among all dose groups and included pain and bruising at the muscle biopsy site, pain at the injection site, mild and self-limiting urinary retention and urinary tract infection. One patient experienced notably worsened incontinence. Quality of life measures improved in 68 percent of patients three months after the first injection and in 67 percent of patients three months after the second injection. Symptoms improved in 61 percent of patients at three months after the first injection and three months after the second injection. Urinary leaks were reduced after both injections. At 12 months, 13 of 17 patients (76.5 percent) reported an overall reduction in stress leaks and urgency compared to baseline; four reported no leaks.

"This study confirms that autologous muscle-derived cells constitute a safe and effective treatment for incontinence at various dosages," said Anthony Atala, MD, an AUA spokesman. "It is important to note that this therapy has few side effects and seems to improve symptoms for most patients in whom other therapies failed."

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NOTE TO REPORTERS: Experts are available to discuss this study outside normal briefing times. To arrange an interview with an expert, please contact the AUA Communications Office at the number above or e-mail Lacey Dean at LDean@AUAnet.org.

Carr, L; Herschorn, S, Birch, C; Murphy, M; Robert, M; Jankowski, R; Pruchnic, R; Wagner, D; Chancellor, M. Autologous muscle-derived cells as therapy for stress urinary incontinence: a randomized, blinded multi-dose study. J Urol, suppl. 2009: 181, 4, abstract 1526.

Uterus sparing surgery is a safe and effective treatment for pelvic organ prolapse

LINTHICUM, MD, 28 april 2009–Researchers presented data at the 104th Annual Scientific Meeting of the American Urological Association (AUA) showing that uterus sparing surgery is an effective and safe treatment for women who want to preserve the integrity of vaginal function after pelvic organ prolapse. Hysterectomy may not be the only option for women with pelvic organ prolapse.

In the first long-term follow-up study of uro-genital prolapse repair associated with uterus preservation, researchers showed that the surgery can be effective (vaginal prolapse of less than or equal to grade 2 and cervix and/or vaginal apex remaining well supported more than six centimeters above the hymen plane). Researchers also found that 82.97 percent of the 47 patients were satisfied with the treatment results. None of the patients required further surgery and few patients reported persisting symptoms. Three patients reported persistence of voiding symptoms and six patients reported persistence of storage symptoms. Two patients reported de novo urgency and four reported de novo urinary incontinence. Sexual activity was maintained in 95.5 percent of patients.

"This study is important because it is the first long-term look at uterus sparing surgery for pelvic organ prolapse," said Anthony Y. Smith, MD, an AUA spokesman. "The findings are encouraging, not only because the procedures were so effective, but also because they will help to dispel the myth that a hysterectomy is the only treatment for pelvic organ prolapse."

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NOTE TO REPORTERS: Experts are available to discuss this study outside normal briefing times. To arrange an interview with an expert, please contact the AUA Communications Office at the number above or e-mail Lacey Dean at LDean@AUAnet.org.

Costantini, E; Lazzeri, M; Zucchi, A; Mearini, L; Del Zingaro, M; Porena, M. Long-term follow-up of uterus sparing surgery for pelvic organ prolapse (POP). J Urol, suppl. 2009: 181, 4, abstract 1355.

Men treated for localized prostate cancer could benefit from pomegranate juice consumption

LINTHICUM, MD, 28 april 2009–Pomegranate juice may slow the progression of post-treatment prostate cancer recurrence, according to new long-term research results being presented at the 104th Annual Scientific Meeting of the American Urological Association (AUA). Researchers found that men who have undergone treatment for localized prostate cancer could benefit from drinking pomegranate juice.

The two-stage clinical trial followed a total of 48 participants over six years. Eligible participants had a rising PSA after surgery or radiotherapy, a PSA greater than 0.2 ng/ml and less than 5 ng/ml and a Gleason score of 7 or less. These patients were treated by drinking eight ounces of pomegranate juice daily. Currently, in the sixth year of treatment, active patients who remain on the study have a median total follow-up of 56 months. These participants continue to experience a significant increase in PSA doubling time following treatment, from a mean of 15.4 months at baseline to 60 months post-treatment, with a median PSA slope decrease of 60 percent, 0.06 to 0.024.

Researchers compared active patients, who remain on the study, with non-active patients, who no longer remain on the study. Though these two groups demonstrated similar mean PSA doubling times at baseline, both the PSA doubling time prolongation and the decline in median PSA slope were greater in active patients when compared to non-active patients.

"This study suggests that pomegranate juice may effectively slow the progression of prostate cancer after unsuccessful treatment," said Christopher Amling, MD, an AUA spokesman. "This finding and other ongoing research might one day reveal that pomegranate juice is an effective prostate cancer preventative agent as well."

Parts of this ongoing study suggest that some patients may be more sensitive to the effects of pomegranate juice on PSA doubling time. Phase three of this study is currently underway to further evaluate the benefits of pomegranate juice in a placebo-controlled manner.

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NOTE TO REPORTERS: Experts are available to discuss these studies outside normal briefing times. To arrange an interview with an expert, please contact the AUA Communications Office at the number above or e-mail Lacey Dean at LDean@AUAnet.org.

Pantuck, A; Zomorodian, N; Rettig, M; Aronson, W; Heber, D; Belldegrun, A. Long term follow up of phase 2 study of pomegranate juice for men with prostate cancer shows durable prolongation of PSA doubling time. J Urol, suppl. 2009: 181, 4, abstract 826.

About the American Urological Association: Founded in 1902 and headquartered near Baltimore, Maryland, the American Urological Association is the pre-eminent professional organization for urologists, with more than 16,000 members throughout the world. An educational nonprofit organization, the AUA pursues its mission of fostering the highest standards of urologic care by carrying out a wide variety of programs for members and their patients.

Mexico fights swine flu with 'pandemic potential'

MEXICO CITY, 26 april 2009 – Mexico's president assumed new powers Saturday to isolate people infected with a deadly swine flu strain as authorities struggled to contain an outbreak that world health officials warned could become a global epidemic.

New cases of swine flu were confirmed in Kansas and California and suspected in New York City, but health officials said they didn't know whether it was the strain that has killed up to 68 people in Mexico and likely sickened more than 1,000.

Mexican soldiers and health workers patrolled airports and bus stations as they tried to corral people who may be infected with the swine flu, as it became clearer that the government may have been slow to respond to the outbreak in March and early April.

Now, even detaining the ill may not keep the strain — a combination of swine, bird and human influenza that people may have no natural immunity to — from spreading, epidemiologists say.

The World Health Organization on Saturday asked countries around the world to step up reporting and surveillance of the disease and implement a coordinated response to contain it.

Two dozen new suspected cases were reported in Mexico City alone, where authorities suspended schools and all public events until further notice. More than 500 concerts, sporting events and other gatherings were canceled in the metropolis of 20 million.

The Mexican government issued a decree authorizing President Felipe Calderon to invoke special powers letting the Health Department isolate patients and inspect homes, incoming travelers and baggage.

Officials said the decree gives clear legal authority to Health Department workers who might otherwise face reprisals.

At Mexico City's international airport, health workers passed out written questionnaires seeking to identify passengers with flu symptoms. Surgical masks and brochures were handed out at bus and subway stations. The U.S. embassy in Mexico posted a message advising U.S. citizens to avoid large crowds, shaking hands, greeting people with a kiss or using the subway.

But with confirmed swine flu cases in at least six states — and possibly as many as 14 — the efforts seemed unlikely to stop the spread of the disease.

Particularly difficult in a metropolis as crowded as Mexico City was the embassy's advice to maintain "a distance of at least 6 feet from other persons may decrease the risk of exposure."

WHO Director-General Margaret Chan said the outbreak of the never-before-seen virus has "pandemic potential." But she said it is still too early to tell if it would become a pandemic.

"The situation is evolving quickly," Chan said in Geneva. "A new disease is by definition poorly understood."

WHO lays out three criteria necessary for a global epidemic to occur: The virus is able to infect people, can readily spread person-to-person and the global population has no immunity to it. The agency held off raising its pandemic alert level, citing the need for more information. Out of the many cases in Mexico reported, relatively few samples have been tested.

Early detection and treatment are key to stopping any outbreak. WHO guidance calls for isolating the sick and blanketing everyone around them with antiviral drugs such as Tamiflu.

Now, with patients showing up all across Mexico and its teeming capital, simple math suggests that kind of response is impossible.

Mexico appears to have lost valuable days or weeks in detecting the new virus.

Health authorities started noticing a threefold spike in flu cases in late March and early April, but they thought it was a late rebound in the December-February flu season.

Testing at domestic labs did not alert doctors here to the new strain, although U.S. authorities detected an outbreak in California and Texas last week.

Perhaps spurred by the U.S. discoveries, Mexico sent 14 mucous samples to the CDC April 18 and dispatched health teams to hospitals looking for patients with severe flu or pnuemonia-like symptoms.

Those teams noticed something strange: The flu was killing people aged 20 to 40. Flu victims are usually either infants or the elderly. The Spanish flu pandemic, which killed at least 40 million people worldwide in 1918-19, also first struck otherwise healthy young adults.

As recently as Wednesday, authorities were referring to it as a late-season flu.

But mid-afternoon Thursday, Mexico City Health Secretary Dr. Armando Ahued said, officials got a call "from the United States and Canada, the most important laboratories in the field, telling us this was a new virus."

"That was what led us to realize it wasn't a seasonal virus ... and take more serious preventative measures," Health Secretary Jose Cordova said.

Some Mexicans suspected the government had been less than forthcoming. "They always make a big deal about good things that happen, but they really try to hide anything bad," Mexico City paralegal Gilberto Martinez said.

Hospitals dealt with crowds of people seeking help. A hot line fielded 2,366 calls in its first hours from frightened city residents who suspected they might have the disease.

Doctors reported that anti-viral medications and even steroids were working well against the disease, noting no new deaths had been reported in the capital in the last day.

Airports around the world were screening travelers from Mexico for flu symptoms. But containing the disease may not be an option.

"Anything that would be about containing it right now would purely be a political move," said Michael Osterholm, a University of Minnesota pandemic expert.

Ahued, the capital's health secretary, said Mexico City may not even be the epicenter of the outbreak.

"The country's best health care facilities are concentrated in the city," he said. "All the cases here get reported, that's why the number is so high."

Scientists have warned for years about the potential for a pandemic from viruses that mix genetic material from humans and animals.

This swine flu and regular flu can have similar symptoms — mostly fever, cough and sore throat, though some of the U.S. victims who recovered also experienced vomiting and diarrhea. But unlike with regular flu, humans don't have natural immunity to a virus that includes animal genes — and new vaccines can take months to bring into use.

The same virus also sickened at least 11 people in the United States, though there have been no deaths north of the border.

The Kansas Department of Health and Environment on Saturday confirmed two cases of swine flu in two adults in the same household. One of the patients had recently traveled to Mexico. Another eight students at a New York City high school probably have human swine influenza, but health officials said they don't know for sure whether it is the same strain.

A "seed stock" genetically matched to the new swine flu virus has been created by the CDC, said Dr. Richard Besser, the agency's acting director. If the government decides vaccine production is necessary, manufacturers would need that stock to get started.

None of that provided any easy answers to Mexico City residents, who reacted with fatalism and confusion, anger and mounting fear at the idea that their city may be ground zero for a global epidemic.

Outside Hospital Obregon in the capital's middle-class Roma district, a tired Dr. Roberto Ortiz, 59, leaned against an ambulance and sipped coffee Saturday on a break from an unusually busy shift.

"The people are scared," Ortiz said. "A person gets some flu symptoms or a child gets a fever and they think it is this swine flu and rush to the hospital."

He said none of the cases so far at the hospital had turned out to be swine flu.

Discontinuing Drugs for BPH May Prove Harmful

Leads to increased prostate volume, aggravation of symptoms, study suggests

26 april 2009-- Discontinuing combination therapy for benign prostate hyperplasia (BPH) leads to increased prostate volume and worsening of symptoms, according to a study in the April issue of Urology.

Young Beom Jeong, M.D., and colleagues from Chonbuk National University in Jeonju, South Korea, randomly assigned 120 men with moderate to severe BPH to two groups. Both received the same doses of one of the uroselective α-blockers alfuzocin or tamsulosin, plus the 5α-reductase inhibitors finasteride (5 milligrams) or dutasteride (0.5 milligrams).

The researchers found that patients in both groups had significant reductions in prostate volume after one year (24.5 percent for finasteride and 26.1 percent for dutasteride). After discontinuing finasteride and remaining on α-blocker monotherapy for one year, prostate volume significantly increased (20.7 percent for finasteride and 18.6 percent for dutasteride). The International Prostate Symptom Score also significantly deteriorated one year after discontinuing finasteride and dutasteride.

"Our data demonstrate that the discontinuation of 5α-reductase inhibitors during combination therapy induces prostate regrowth, as well as aggravation of symptoms in men with BPH," Jeong and colleagues conclude. "This result, therefore, suggests that the life-long use of 5α-reductase inhibitors should be considered for the prevention of BPH progression."

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Questions and answers about swine flu

26 april 2009--Mexico is contending with an outbreak of swine flu, suspected in the deaths of dozens of people and sickening perhaps 1,000. In the United States, at least eight cases have been confirmed with the infection, all of them in California and Texas; only one person was hospitalized. Here are some questions and answers about the illness:

Q. What is swine flu?

A. Swine flu is a respiratory illness in pigs caused by a virus. The swine flu virus routinely causes outbreaks in pigs but doesn't usually kill many of them.

Q. Can people get swine flu?

A. Swine flu viruses don't usually infect humans. There have been occasional cases, usually among people who've had direct contact with infected pigs, such as farm workers. "We've seen swine influenza in humans over the past several years, and in most cases, it's come from direct pig contact. This seems to be different," said Dr. Arnold Monto, a flu expert with the University of Michigan.

Q. Can it spread among humans?

A. There have been cases of the virus spreading from human to human, probably in the same way as seasonal flu, through coughing and sneezing by infected people.

Q. What are the symptoms of swine flu?

A. The symptoms are similar to those of regular flu — fever, cough, fatigue, lack of appetite.

Q. Is the same swine flu virus making people sick in Mexico and the U.S.?

A. The Centers for Disease Control and Prevention said the Mexican virus samples match the U.S. virus. The virus is a mix of human virus, bird virus from North America and pig viruses from North America, Europe and Asia.

Q. Are there drugs to treat swine flu in humans?

A. There are four different drugs approved in the U.S. to treat the flu, but the new virus has shown resistance to the two oldest. The CDC recommends the use of the flu drugs Tamiflu and Relenza.

Q. Does a regular flu shot protect against swine flu?

A. The seasonal flu vaccine used in the U.S. this year won't likely provide protection against the latest swine flu virus. There is a swine flu vaccine for pigs but not for humans.

Q. Should residents of California or Texas do anything special?

A. The CDC recommends routine precautions to prevent the spread of infectious diseases: wash your hands often, cover your nose and mouth when you cough or sneeze, avoid close contact with sick people. If you are sick, stay at home and limit contact with others.

Q. What about traveling to Mexico?

A. The CDC has not warned Americans against traveling to Mexico but advises that they be aware of the illnesses there and take precautions to protect against infections, like washing their hands.

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Source: Centers for Disease Control and Prevention

Swine Flu is Public Health Emergency, With New U.S. Cases

26 april 2009--The World Health Organization declared a deadly new strain of swine flu to be a "public health emergency of international concern," as health officials identified possible new cases in two additional U.S. states and called the disease widespread.

Several children at a school in the New York City borough of Queens may have been infected, and two people were confirmed with the disease in Kansas, according to reports from local health departments. The U.S. Centers for Disease Control and Prevention said it expects to find more cases soon throughout the country.

Swine Flu Strain Hits U.S. Cities

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The World Health Organization has stepped up operations after eight school kids in New York and two other people in Kansas tested positive for a strain of the swine flu.

In Geneva, WHO Director-General Margaret Chan warned Saturday that the virus had the potential to cause a pandemic, but cautioned that it was too early to tell whether it would erupt into a global outbreak. Following an emergency meeting Saturday, a WHO panel declared the developments thus far a public health emergency and urged governments around the world to intensify surveillance for unusual outbreaks of flu-like illness and severe pneumonia. But the panel held off on raising a global pandemic alert, saying it needed more information before making a decision.

Mexican health authorities said the death toll from the new strain of A/H1N1 swine flu remains at 20, and they are continuing to investigate whether more than 1,000 others were infected with the mysterious bug, which attacked in three geographically diverse areas of the country and is taking its heaviest toll in young adults.

The CDC said early Saturday afternoon the number of confirmed cases of the new flu in the U.S. remained at eight, but it expects to identify more soon. A statement from the Kansas Department of Health and Environment Saturday afternoon said the CDC had additionally confirmed swine flu infection in two people, bringing the U.S. total to 10.

In New York City, further testing will be required to know whether more than 100 of roughly 2,700 students at St. Francis Preparatory School in Queens were ill with swine flu when they missed school last week, said Thomas Frieden, the city's health commissioner. Health officials have interviewed most of the ill students or their families; all reported mild symptoms, and none required hospitalization.

The health department has tested nine samples taken from ill students, eight of which have been classified "probable human swine influenza," Dr. Frieden said. Local testing confirmed that the samples were influenza type A, which occurs in both humans and swine, and the samples did not match common subtypes of human influenza. Under current CDC definitions, cases of influenza type A that do not match subtypes of human influenza are considered probable swine flu, pending confirmation by the CDC.

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The samples have been sent to the CDC for additional testing, Dr. Frieden said. Results could be available as soon as tomorrow. If swine flu is confirmed, the health department will recommend that the school cancel classes on Monday to reduce the risk of further spread.

The city health department is also investigating a report of about 30 children who became ill at a day-care center in the Bronx. But Dr. Frieden emphasized that the status in that case remains unclear and may turn out to be unrelated to swine flu.

The CDC has sent teams to California, Texas, and Mexico to assist with investigations. Confirmed cases include six children and adults in San Diego and Imperial Counties in Southern California. Two 16 year-old boys in Guadalupe County near San Antonio, Tex., were also found to have had the disease. Only one of the cases, a 41 year-old woman, was hospitalized, and the others had only mild disease, the CDC said.

It's unclear so far why U.S. cases identified so far are mostly mild, while Mexico has experienced severe disease, Dr. Schuchat said, though expanded surveillance is likely to yield more clues.

The CDC is also taking initial steps toward preparing a vaccine should that become necessary, but producing enough for a mass vaccination program could take months, Dr. Schuchat cautioned.

President Felipe Calderon urged Mexicans to remain calm and reassured them that government has plenty of antiviral medicines to treat the outbreaks. Two antiviral medications, marketed as tamiflu and relenza, both work against the bug, according to the CDC.

In Mexico City, blue surgical masks proliferated and entrepreneurs were selling them on the streets. Two soccer games scheduled for Sunday are expected to be played in front of empty stadiums but broadcast on TV.

Nicotine Gum cancer risk

26 april 2009--The cancer risk from using nicotine gum and lozenges is higher than previously thought, The Times has reported. According to the newspaper new research has found that the nicotine levels “that are typically found in smoking cessation products” can interact with a mutation that increases the risk of cancer.

This study has looked at normal and cancerous mouth tissue and cells in the laboratory, examining the level of activity of the FOXM1 gene, which is active in many tumours, Researchers then looked at the effects nicotine had on these cells and the activity of the gene.

While nicotine increased cancer-like properties of some cells in the laboratory, these findings do not prove that nicotine replacement products are specifically associated with an increased risk of cancer. What is already clear is that smoking increases risk of cancer and quitting will reduce people’s risk. Nicotine replacement products can be an important source of help for some people trying to quit, and therefore help them reduce their cancer risk. People using these products should follow the advice available from their GP, pharmacist or nurse and included on product information leaflets.

Where did the story come from?

This research was conducted by Emilios Gemenetzdis and colleagues from Queen Mary University of London, and other cancer research centres in the UK and Malaysia. The study was funded by the Medical Research Council and the Institute of Dentistry, Barts and the London School of Medicine and Dentistry and Queen Mary University of London. The study was published in the peer-reviewed scientific journal, PLoS One.

What kind of scientific study was this?

This was a laboratory study looking at the activity of a gene called FOXM1 in tissues and cells from head and neck cancers plus normal tissue, and how chemicals that could potentially cause cancer affect the gene’s activity.

The FOXM1 gene is known to be highly active in many human tumours, but it is still unclear exactly what action and role it plays in the development and progression of cancer.

The researchers obtained a number of cell and tissue types for examination from 75 patients. These were:

• normal tissue from the human mouth lining,
• normal mouth lining cells,
• tissue from head and neck cancers (head and neck squamous cell carcinomas, which include mouth cancers), and
• abnormal (precancerous) tissue from the mouth.

The researchers looked at whether the FOXM1 gene is switched on in these cells and tissues, and how active it was. They also took thin slices of these tissues, or cultures, of the cells grown in the laboratory and used antibodies to the FOXM1 protein (which is made by the FOXM1 gene) to determine whether the protein was present, and if so, how much was present.

Use of tobacco and betel (a plant whose leaves are chewed in some Asian countries) are risk factors for developing head and neck cancer. The researchers thought that chemical compounds in these substances called alkaloids, including nicotine and two other alkaloids from betel, could be increasing the activity of the FOXM1 gene.

To test this theory the scientists used various cell types grown in the laboratory: premalignant mouth cancer cells, malignant mouth cancer cells and malignant tongue cancer cells. They exposed these cells to levels of nicotine that might be expected in the mouths of people chewing tobacco and looked at the effects on FOXM1 activity and cell survival. They did the same with the two alkaloids from betel.

The scientists then took premalignant mouth cells and genetically engineered them so that the FOXM1 gene was overactive. They took some of these cells and some control cells with normal FOXM1 activity and looked at the effect of adding nicotine to them. In particular, they were looking at whether these cells would be able to form –‘colonies’ – clumps of cells that could grow without being attached to the petri dish. This is a characteristic of malignant cells. They also carried out various other experiments to look at the characteristics of these cells.

What were the results of the study?

The FOXM1 gene was not very active in normal mouth tissue, more active in precancerous mouth tissue and most active in tissue from head and neck cancers. The FOXM1 protein was also present at low levels in normal mouth tissue, at higher levels in precancerous mouth tissue and at the highest levels in tissue from head and neck cancers.

Adding nicotine to premalignant mouth cancer cells, malignant mouth cancer cells and tongue cancer cells in the laboratory increased the activity of the FOXM1 gene. The two chemicals that they tested from betel did not have this effect. At high levels of nicotine, some of the premalignant mouth cells died but the cancerous mouth and tongue cells did not.

The researchers also found that if the premalignant mouth cancer cells were genetically engineered to have an overactive form of the FOXM1 gene and then treated with nicotine they could form colonies of cells that could grow without being attached to the petri dish. This property is a characteristic of cells that are malignants. This did not happen if the cells only had the overactive form of the FOXM1 gene, or were just exposed to nicotine.

What interpretations did the researchers draw from these results?

The researchers concluded that their findings suggest the FOXM1 gene plays a role in the early development of head and neck cancer. They add analysis of FOXM1 activity could potentially be used as a diagnostic marker for early detection of this type of cancer.

This study has looked at the activity of the FOXM1 gene in normal and cancerous mouth tissue and cells in the laboratory, plus the effects of nicotine on this activity and the behaviour of these cells.

On their own, these findings do not indicate whether the use of nicotine replacement products is associated with an increased risk of mouth cancer. This would require studies specifically comparing the rate of these cancers in users and non-users of these products.

What is already clear is that smoking is associated with an increased risk of cancer, including mouth cancer. Quitting smoking will reduce people’s cancer risk, and the use of nicotine replacement products will help some people to achieve this, and therefore help reduce their cancer risk.

People using these products should follow advice from their healthcare professionals (GPs, pharmacists or nurses) and consult product information leaflets for guidance on how long these nicotine replacement products should be used for.

Links to the science

Gemenetzidis E, Bose A, Riaz AM, FOXM1 Upregulation Is an Early Event in Human Squamous Cell Carcinoma and it Is Enhanced by Nicotine during Malignant Transformation. PLOS one 2009: March 16

Further reading

Review by Cochrane:
Nicotine replacement therapy for smoking cessation