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No Cancer Link With Cell Phone Towers

June 24, 2010 (London, United Kingdom) — There is no association between a pregnant mother's proximity to a cell phone tower and early childhood cancers, according to results of the largest study of its kind to date.

Paul Elliott, MD, PhD, professor of epidemiology and public health medicine from Imperial College, London, United Kingdom, led the research. The paper was published online June 22 in BMJ.

"We found no pattern to suggest that the children of mums living near a [cell phone tower] during pregnancy had a greater risk of developing cancer than those who lived elsewhere," Dr. Elliot told Medscape Oncology.

He added that unlike previous studies of associations between cancer and cell phone towers, this study used larger numbers of cases so was not subject to the selection and reporting biases seen with smaller sample sizes.

Case–Control Study

In this British study, data on nearly 1400 children younger than 4 years were drawn from the national cancer registry. All case subjects had leukemia or tumors of the central nervous system or brain from 1999 and 2001. Each child with cancer was matched with 3 control subjects for sex and date of birth from the national birth register.

The distance between registered address at time of birth and the nearest of 81,781 cell towers was assessed for each case. Likewise, total power output across all towers within 700 meters (765 yards) of the cell tower was recorded. The researchers then computed modeled power density at each birth address for towers within 1400 meters (1531 yards). Exposure beyond 1400 meters was considered to be at background levels.

This information was correlated with the incidence of cancers of the brain and central nervous system, leukemia, and non-Hodgkin's lymphomas, and all cancers combined.

In their paper, the authors acknowledge that despite low levels of exposure from cell phone towers, there are theoretical concerns about the effects on children because of the relatively greater dose (per kg body mass), the potentially greater susceptibility of children than of adults, and the potential effects of lifelong cumulative exposure to radiofrequency electromagnetic fields.

Only cancers with a short latency period, typically within the first 4 years of life, were investigated. In addition, the study was restricted to exposure of children in utero, although the authors state that postnatal exposure might be relevant to the incidence of early childhood cancers.

"We only looked at estimated exposures during the fetal period and were unable to look at exposure patterns for the children after birth. This is clearly a limitation and it would have been good to look at data after birth, if they had been available. However, our findings do not suggest any link between early childhood cancers and [cell phone tower] exposure," added Dr. Elliott.

Encourage Patients Not to Worry

In an accompanying editorial, John Bithell, MA, DPhil, honorary research fellow at the Childhood Cancer Research Group, University of Oxford, United Kingdom, points out that of the 3 surrogates of exposure considered in the study, the most convincing is the modeled power density at varying distances from the nearest tower. "This is probably the best measure used in an epidemiological study to date."

However, he adds that individual exposure could still vary substantially according to building design, lifestyle, and migration, so the prospects for good estimates of individual exposure are poor.

Based on these results, he concludes that the medical profession should encourage their patients not to worry about harm caused by proximity to cell phone towers. "The epidemiological evidence is also supported by experimental evidence, which has so far failed to show any biological effects — in vivo or in vitro — that might lead us to worry about the impact on health," concluded Dr. Bithell.

However, Sam Milham, Jr. MD, MPH, former chronic disease epidemiologist at the Washington State Department of Health and clinical associate professor at the University of Washington, School of Public Health, Seattle, believes the study used the wrong metric.

"All cell towers operate on direct current, which is changed from the grid alternating current (AC) by switching power supplies. These interrupt the AC current and create high-voltage transients, which get back into the grid. The transients are a potent carcinogen," he explained.

Dr. Milham, who was approached by Medscape Oncology for comment, is currently investigating a cluster of cancers in school teachers in Palm Springs, California. He explained the relation between distance from tower, transient levels, and cancer cases.

"It has a cell tower 20 feet from a classroom wing. The transient levels in the classrooms are inversely related to distance from the tower base, and the cancer cases are found to be overrepresented in the rooms near the tower. This is a close-in phenomenon. I also find very high transient levels in firehouses and businesses near cell towers."

"The BMJ study's high-dose group, by distance, was under 612 meters [669 yards]. If they can show me that the case–control risks were similar for residences less than 100 and 200 meters [109 and 218 yards, respectively] from the tower, I'll accept their findings," Dr. Milham said.

The study was funded through the UK Mobile Telecommunications Health Research (MTHR) Programme, an independent body set up to provide funding for research into the possible health effects of mobile telecommunications. The MTHR is jointly funded by the UK Department of Health and the mobile telecommunications industry. Dr. Elliott and Dr. Milham have disclosed no relevant financial relationships. Dr. Bithell reports a beneficial interest in shares in Vodafone Group not exceeding £3000 in value.

How Does the San Francisco Syncope Rule Perform in Canada?

How Does the San Francisco Syncope Rule Perform in Canada?
The rule had a sensitivity of 90% for predicting serious outcomes at 30 days

Patients with syncope often are admitted to the hospital despite negative
emergency department (ED) evaluations. The San Francisco Syncope Rule was
developed to identify syncope patients who are at sufficiently low risk for
serious outcomes to be safely discharged home after ED evaluation. The rule
classifies patients as high risk if they have histories of congestive heart
failure, hematocrit <30%,>
or triage systolic blood pressure <90>
to have 96% and 98% sensitivity for predicting serious outcomes at 7 days
and 30 days, respectively, but has not performed as well in subsequent
validation studies in the U.S. and Australia, where sensitivities ranged
from 74% to 90% (JW Emerg Med Sep 19 2008 and JW Emerg Med Jun 8 2007).

To evaluate performance of the rule in Canada, researchers retrospectively
applied the rule to 505 patients who presented to a single tertiary care
hospital with syncope during an 18-month period. Serious outcomes were
defined as death, myocardial infarction, arrhythmia, pulmonary embolism,
stroke, subarachnoid hemorrhage, significant bleeding, any procedural
intervention to treat a related cause of syncope, any condition causing or
likely to cause a return emergency visit, and hospitalization for a related
event. Overall, 9.7% of patients had serious outcomes within 30 days. The
rule had a sensitivity of 90% for predicting these outcomes.

Comment: The results of this study are consistent with those from other
validation studies. The San Francisco Syncope Rule will likely need to be
improved and then validated before it is adopted in practice. Until then,
clinical judgment should continue to guide treatment and disposition.

— Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine

SOUTH AFRICAN DOCTOR INVENTS FEMALE CONDOMS WITH "TEETH" TO FIGHT RAPE

South African doctor invents female condoms with 'teeth' to fight rape

Dr. Sonnet Ehlers was on call one night four decades ago when a devastated rape victim walked in. Her eyes were lifeless; she was like a breathing corpse. "She looked at me and said, 'If only I had teeth down there,'" recalled Ehlers, who was a 20-year-old medical researcher at the time. "I promised her I'd do something to help people like her one day." Forty years later, Rape-aXe was born. Ehlers is distributing the female condoms in the various South African cities where the World Cup soccer games are taking place. The woman inserts the latex condom like a tampon. Jagged rows of teeth-like hooks line its inside and attach on a man's penis during penetration, Ehlers said.

Once it lodges, only a doctor can remove it -- a procedure Ehlers hopes will be done with authorities on standby to make an arrest. "It hurts, he cannot pee and walk when it's on," she said. "If he tries to remove it, it will clasp even tighter... however, it doesn't break the skin, and there's no danger of fluid exposure." Ehlers said she sold her house and car to launch the project, and she planned to distribute 30,000 free devices under supervision during the World Cup period. "I consulted engineers, gynecologists and psychologists to help in the design and make sure it was safe," she said.

After the trial period, they'll be available for about $2 a piece. She hopes the women will report back to her. "The ideal situation would be for a woman to wear this when she's going out on some kind of blind date ... or to an area she's not comfortable with," she said. The mother of two daughters said she visited prisons and talked to convicted rapists to find out whether such a device would have made them rethink their actions. Some said it would have, Ehlers said.

Critics say the female condom is not a long-term solution and makes women vulnerable to more violence from men trapped by the device. It's also a form of "enslavement," said Victoria Kajja, a fellow for the Centers for Disease Control and Prevention in the east African country of Uganda. "The fears surrounding the victim, the act of wearing the condom in anticipation of being assaulted all represent enslavement that no woman should be subjected to." Kajja said the device constantly reminds women of their vulnerability. "It not only presents the victim with a false sense of security, but psychological trauma," she added. "It also does not help with the psychological problems that manifest after assaults."

However, its one advantage is it allows justice to be served, she said. Various rights organizations that work in South Africa declined to comment, including Human Rights Watch and Care International. South Africa has one of the highest rape rates in the world, Human Rights Watch says on its website. A 2009 report by the nation's Medical Research Council found that 28 percent of men surveyed had raped a woman or girl, with one in 20 saying they had raped in the past year, according to Human Rights Watch.

In most African countries, rape convictions are not common. Affected women don't get immediate access to medical care, and DNA tests to provide evidence are unaffordable. "Women and girls who experience these violations are denied justice, factors that contribute to the normalization of rape and violence in South African society," Human Rights Watch says.

Women take drastic measures to prevent rape in South Africa, Ehlers said, with some wearing extra tight biker shorts and others inserting razor blades wrapped in sponges in their private parts. Critics have accused her of developing a medieval device to fight rape. "Yes, my device may be a medieval, but it's for a medieval deed that has been around for decades," she said. "I believe something's got to be done ... and this will make some men rethink before they assault a woman."

Jadilah Pasien Pintar! (In Bahasa Indonesia)

Jadilah Pasien Pintar!


Salah satu sebab mengapa orang enggan pergi ke dokter atau rumah sakit, bisa jadi karena persoalan komunikasi. Hal ini diungkapkan guru besar Fakultas Kedokteran Universitas Indonesia, Prof. Daldiyono Hardjodisastro, dalam bukunya yang berjudul Pasien Pintar dan Dokter Bijak.

Dalam buku tersebut diungkapkan, untuk mendapat hasil maksimal dari pertemuan dengan dokter, pasien harus mempersiapkan diri, di antaranya:

* Mengenakan pakaian yang memudahkan dokter melakukan pemeriksaan.

* Mencatat keluhan yang hendak disampaikan ke dokter secara lengkap, kapan dirasakan, dan upaya yang sudah dilakukan untuk mengurangi rasa sakit. Beritahukan pula penyakit yang pernah atau sedang diderita, obat yang sedang diminum, serta jika ada alergi.

* Dari tanya jawab soal keluhan dan pemeriksaan fisik pasien, dokter akan menegakkan diagnosis kemudian memberikan terapi, termasuk resep obat. Pasien berhak mendapat informasi yang jelas mengenai hasil pemeriksaan, menanyakan bila ada yang belum jelas, juga mengambil keputusan untuk menerima atau menolak saran dokter tentang terapi yang akan diberikan. Jika pasien tidak menerima keputusan dokter, ia berhak mencari pendapat kedua (second opinion) dari dokter lain.

* Pasien yang pintar perlu bertanya dan mengetahui obat apa yang diresepkan dokter serta manfaatnya.

* Jika kondisi keuangan tidak memungkinkan, pasien perlu meminta obat generik. Hilangkan persepsi bahwa penyakit harus cepat sembuh. Ingat, pengobatan memerlukan waktu, kesabaran, dan ketekunan. Tak jarang, ada dokter terbawa kemauan pasien yang ingin cepat sembuh, sehingga melakukan berbagai jenis pemeriksaan yang belum tentu diperlukan atau memberi obat berlebihan.

* Sebaliknya, dokter yang bijak adalah yang mampu berkomunikasi secara efektif dengan pasien. Dokter mau mendengarkan keluhan pasien, menjawab pertanyaan dan menjelaskan situasi pasien, memberi nasihat cukup, serta tidak sekadar memberi resep, sehingga pasien merasa puas.

* Kemampuan berkomunikasi merupakan inti dari pekerjaan dokter. Kepandaian sebenarnya hanya nomor dua. Pasalnya, 60 persen pasien sebenarnya tidak sakit, tetapi mengalami kelainan fungsional. Hanya 40 persen yang benar-benar sakit, itu pun 20 persennya akan sembuh sendiri.

Lalu, bagaimana menghadapi dokter yang tidak komunikatif? Konsultan gastroenterologi-hepatolog

i ini menyarankan untuk meninggalkan ruangan dan segera pindah dokter jika memungkinkan.

Jika Merasa Tak Puas

Pernah dikecewakan oleh pelayanan di rumah sakit? Agar keluhan Anda tersampaikan dengan baik, berikut beberapa caranya:

* Jika mempunyai keluhan, catat dengan jelas tanggal, hari, dan jam kejadian, kalau perlu nama petugas yang memberikan pelayanan. Kemudian Anda dapat menghubungi bagian humas maupun customer service rumah sakit tersebut.

* Ada rumah sakit yang kepala perawatannya bertugas mengurus masalah atau keluhan, sehingga pasien disarankan menghubungi Kepala (Bidang) Perawatan bila merasa tidak puas. Bila masalah belum terpecahkan, tidak tertutup kemungkinan langsung maju ke direktur atau pimpinan rumah sakit.

* Anda dapat menghubungi perwakilan Persatuan Rumah Sakit Seluruh Indonesia setempat. Persi mempunyai kepengurusan di semua wilayah di seluruh provinsi di Indonesia.

* Manfaatkan kotak saran yang ada di setiap rumah sakit untuk mengomunikasikan hal-hal yang dianggap pasien (konsumen) tidak patut dilakukan oleh petugas rumah sakit. Hal ini merupakan masukan positif agar pihak rumah sakit memperbaiki diri. Tanpa masukan dari konsumen, pengelola rumah sakit akan selalu merasa bahwa pelayanan yang diberikan sudah cukup baik. Jadi, masukan atau kritik harusnya diterima sebagai satu mekanisme kontrol dari pengguna jasa rumah sakit.

* Jika merasa tidak puas dengan layanan dokter, konsumen dapat langsung mengklarifikasi dengan dokter yang merawat terlebih dahulu. Termasuk adanya dugaan kesalahan prosedur layanan (obat, dosis, maupun tindakan).

* Sangat tidak dibenarkan bila sewaktu pasien melakukan klarifikasi, dokter tidak melayani dengan baik, misalnya menghindar atau mengaku tidak punya waktu. Seorang dokter yang memberikan layanan kepada pasien sudah terikat satu kontrak, yang dikenal dengan kontrak terapeutik (Prof. Dr. Leenen), sehingga dokter bersangkutan harus memberikan penjelasan atas setiap pertanyaan pasien. Sikap profesional harus dijaga oleh para dokter.

* Pahami hak pasien, salah satunya mendapatkan informasi yang jelas dan benar. Pergunakan hak itu dengan baik, beritahu dokter bahwa Anda berhak mendapatkan informasi yang Anda inginkan. Bila ada yang kurang jelas, misalnya soal pilihan jenis obat (generik atau paten), dosis, tindakan medis, pasien juga memiliki hak bertanya atas kuitansi tagihan rumah sakit bagi penderita rawat inap untuk diklarifikasi hingga jelas benar, juga mengenai penggunaan obat dan peralatan yang harus bayar.

* Mencermati dan meneliti tindakan medis apa saja yang sudah lakukan, apakah sesuai dengan yang seharusnya dibayarkan. Adalah hak pasien untuk mengetahui setiap rupiah yang dikeluarkan untuk membayar biaya rumah sakit.

Red : Kes. Kompas

When Fights Over Money Ruin Marriages

Much has been written about how tough economic times have forced couples to postpone divorces. They just can't afford it. Legal costs and accountant fees grow as a union dissolves and a two-income household lives cheaper than a two-household pair of singles. As the economy improves, we will probably see divorce rates creep up. But even if money woes are keeping couples together, financial disputes remain the root cause of irreconcilable differences

Here are seven common financial issues that can lead to divorce:

Paycheck Envy
More women are entering marriage with assets of their own and many are earning more than their spouses. According to the Bureau of Labor Statistics, one in three married women out-earns her husband. That amount expands to more than half if they earn $55,000 or more. Men can feel threatened by not having their traditional bragging rights as breadwinners. For women, it means they have their own money to protect from the irresponsible actions of a mate. With more at-stake, women can't afford to be deferential to their mate the way past generations were.

Debt
Utah State University professor Jeffrey Dew authored a widely cited study that concluded that couples who argue about finances at least once a week are 30% more likely to divorce than those who only vent occasionally about money issues. Couples with no assets were 70% more likely to divorce compared to couples with assets of $10,000. Cutting into the ability to build assets is America's longstanding addiction to credit cards, but there may be cause for optimism. Having amassed a record-setting $988 billion in revolving debt in 2008, Americans chipped away at nearly $90 billion of it last year, according to the Federal Reserve. Fewer credit cards and less debt should mean increased savings, more assets and potentially happier couples.

Bills
As part of a survey last year, Fidelity Investments found that less than half of couples make day-to-day financial decisions together on issues such as budgeting and paying bills (45%). In many couples, one person always pays monthly bills early while the other might procrastinate until the due date and beyond. Cutting checks can be even more stressful when an unnecessary shopping spree blows the monthly budget or a mate doesn't take kindly to the premium cable channels or costly text messages their better half piles into the mix.

Saving
While one half of a relationship may be thrifty, dedicated to building savings and committed to a retirement plan, the other may be more carefree, with a "live for today, you can't take it with you" outlook.

Investing
One can assume that investment decisions are increasingly dividing couples if both partners are financially savvy. Risk tolerance may be incompatible, with goals out-of-synch.

Dump
Apple or go long may be as divisive a debate as how often a mother-in-law should visit. Looking over an investment portfolio or 401(k) plan, one spouse may want to explore emerging market funds, while the other dismisses anything but safe domestic large caps and bonds. Can a quant guy find true happiness with a fundamental-analysis kind of gal?

Differing Expectations
There's no shortage of men and women who value money more than love and companionship. You may be quite content to "live on love" and weather financial situations "for better or worse." But she may feel entitled to a McMansion in a tony suburb and a Mercedes in which to drive your kids to private school. Trouble will be brewing along with her high-priced lattes.

Secret Stash
Financial infidelity is a newly coined term that describes situations in which a spouse hides cash or credit from his mate. It may seem a good idea to have a secret credit card or bank account that you can dip into, but your partner will probably take great offense at the covert action. Beyond the financial dishonesty on display, such hidden reserves may be a warning sign of even bigger transgressions -- keeping a slush fund to pay for strip club tabs or supporting a mistress on the sly.

The Link Between Endometriosis and Cancer

Endometriosis and Cancer Risk

Women with endometriosis appear to be more likely to develop certain types of cancer. What scientists know about the link -- and why it might occur -- were the focus of a session at the inaugural symposium of the Endometriosis Foundation of America.

"We've got pretty good evidence that there's some increase in the risk for ovarian cancer" with endometriosis, said Louise Brinton, PhD, Chief of the Hormonal and Reproductive Epidemiology branch at the National Cancer Institute, in an interview with Medscape following the session. "But there are still other cancers that need further study."

Dr. Brinton's interest in the long-term effects of endometriosis led her to Sweden about 20 years ago. Using the country's national inpatient register, she identified more than 20,000 women who had been hospitalized for endometriosis. After an average follow-up of more than 11 years, the risk for cancer among these women was elevated by 90% for ovarian cancer, 40% for hematopoietic cancer (primarily non-Hodgkin's lymphoma), and 30% for breast cancer. Having a longer history of endometriosis and being diagnosed at a young age were both associated with increased ovarian cancer risk.

"We found an increased risk for tumors with increasing years of follow-up," said Dr. Brinton, "making it unlikely that the ovarian cancer diagnoses were related to increased surveillance during endometriosis treatment." Also of special interest was the finding that "women whose site of origin of endometriosis was the ovary ... had a particularly high risk for ovarian cancer."

Dr. Brinton and colleagues published their research in 1997. A larger, more recent examination of the Swedish register, published in 2006 by Anna-Sofia Melin and colleagues, produced similar results.

"The 2 studies indicate a high risk related to follow-up time and site of origin of endometriosis, which suggests a biologic effect between the 2 diseases," said Dr. Brinton. On the other hand, confounding factors could be at work. For example, women being treated for endometriosis are more likely to be experiencing infertility, which affects risk because childbearing offers some protection against ovarian cancer.

A 2002 pooled case-control study by Roberta B. Ness and colleagues found that the odds of developing ovarian cancer were 50% higher among women diagnosed with endometriosis, even after adjusting for factors such as duration of oral contraception use and number of births. The risk was even higher -- a 3.5-fold increase -- for women with endometrioid or clear cell tumors, 2 subtypes of ovarian cancer. A 2005 case-control study by Brinton and colleagues also found a 2.5- to 3.5-fold increase in endometrioid and clear cell tumors among women with endometriosis.

The overall lifetime risk for ovarian cancer is 1.4%, according to the American Cancer Society. Endometriosis affects as many as 7% to 15% of women of reproductive age.

Farr Nezhat, MD, Chief of Gynecologic Minimally Invasive Surgery and Robotics at St. Luke's and Roosevelt Hospitals in New York City and Professor of Obstetrics and Gynecology at Columbia University, spoke on the pathogenesis of endometriosis and ovarian cancer. Dr. Nezhat also cited research on the link between epithelial ovarian cancer and endometriosis. According to a 2000 study of women with ovarian cancer by Hiroyuki Yoshikawa and colleagues, endometriosis was present in 39% of the women with clear cell tumors and 21% of those with endometrioid tumors, vs just 3% of those with serous or mucinous tumors.

Dr. Nezhat's own research with Liane DeLigdisch and colleagues also identified a link between endometriosis and ovarian cancer. A pathology review of samples from 76 patients with stage 1 ovarian cancer revealed that most were associated with endometriosis or endometrioma. Most patients presented with pelvic pain or adnexal mass, supporting the idea that healthcare providers should be alert to the possibility of ovarian cancer in women with a history of endometriosis.

Studies have been inconsistent on whether endometriosis is linked to breast cancer or non-Hodgkin's lymphoma. Anecdotal evidence has linked endometriosis to melanoma, brain and endocrine cancers, and thyroid cancer. Large epidemiologic studies are required to examine these associations.

The Pathogenesis of Endometriosis and Cancer
What do endometriosis and ovarian cancer have in common? A lot, it turns out.

"Both of these diseases are progressive and depend on estrogen for their growth," said Dr. Nezhat. Studies have shown that endometrial tissue shows elevated activity of aromatase, an enzyme used for a key step in the biosynthesis of estrogens.

Another factor that appears to play a role in both diseases is inflammation. "We know that inflammation can cause cancer, as in hepatitis of the liver and asbestosis of the lung," said Dr. Nezhat. Endometriosis is characterized by a chronic inflammatory state, which leads to the release of cytokine. These cytokines may promote the growth of tumors by causing unregulated mitotic division, growth, and differentiation.

"If you combine inflammation with estrogen, it's going to be a vicious circle," said Dr. Nezhat.

The 2 diseases share numerous other characteristics. For example, both are related to early menarche and late menopause, infertility, and nulliparity. Factors that relieve or offer protection against both conditions include tubal ligation, oral contraceptives, hysterectomy, and progesterone exposure.

Mutations in genes that are known to suppress tumors, such as PTEN, p53, and bcl, have been found in both ovarian tumors and adjacent endometriotic lesions.

Of course, links between the 2 diseases don't prove that one causes the other. But Dr. Nezhat said there's reason to believe that endometriosis contributes to ovarian cancer, as evidenced by Dr. Brinton's finding that cancer risk increases with duration of endometriosis.

If endometriosis does increase the risk for ovarian cancer, then treating it might reduce the risk. "Endometrial implants produce estrogen and inflammation," he said. "So if you remove the endometriosis, you should theoretically reduce the risk for cancer."

Advice to Surgeons and Patients
Dr. Nezhat said that surgeons who operate on women with endometriosis, which includes fertility specialists performing in vitro fertilization (IVF), need to be alert to the possibility of ovarian cancer. "Do an ultrasound during the preoperative evaluation and during the follow-up," he told Medscape. He also cautioned surgeons to biopsy any ovarian cysts instead of draining them. "Every adnexal mass has to be thoroughly evaluated," he said.

Although the elevated risk for ovarian cancer appears to be real, Dr. Brinton emphasized that women with endometriosis should not become anxious about it. "Even though we see a 2- to 3-fold increase in the risk for ovarian cancer, it's still a very rare condition," she said. "The absolute risk is low."

The New FIGO Staging for Carcinoma of the Vulva, Cervix, Endometrium, and Sarcomas

The International Federation of Gynecology and Obstetrics (FIGO) staging systems for vulva, cervix, endometrium, and sarcomas have been revised for the first time in over a decade. The purpose of the staging system is to provide uniform terminology for better communication among health professionals and to provide appropriate prognosis to the patients which results in treatment improvement. This is a constantly evolving process as new therapeutic modalities are developed, new imaging and surgical approaches are applied, and more prognostic information becomes available. The previous system did not reflect the prognosis in some patient subsets where medical research and practice have shown explosive growth of new knowledge in recent years. The 41st Annual Meeting of the Society of Gynecologic Oncologists was held in March 2010. Several abstracts reported retrospective studies that evaluated the prognostic significance of new 2009 FIGO staging guidelines compared to the old 1988 FIGO system. In endometrial cancer, the reduction in the substages within stage I, and the separation of pelvic and para-aortic nodal involvement further clarified important prognostic factors that yielded clear delineation of survival. The new 2009 FIGO vulvar cancer staging system was validated by clearly demonstrating distinct groups with differing survivals. The following revisions on carcinoma of vulva, cervix, and endometrium staging will replace prior tables 41-6, 41-8, and 41-9, respectively.

Carcinoma of the Vulva

IA Tumor confined to the vulva or perineum, = 2cm in size with stromal invasion = 1mm, negative nodes

IB Tumor confined to the vulva or perineum, > 2cm in size or with stromal invasion > 1mm, negative nodes

II Tumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodes

IIIA Tumor of any size with positive inguino-femoral lymph nodes
(i) 1 lymph node metastasis greater than or equal to 5 mm
(ii) 1-2 lymph node metastasis(es) of less than 5 mm
IIIB
(i) 2 or more lymph nodes metastases greater than or equal to 5 mm
(ii) 3 or more lymph nodes metastases less than 5 mm

IIIC Positive node(s) with extracapsular spread

IVA
(i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone
(ii) Fixed or ulcerated inguino-femoral lymph nodes IVB Any distant metastasis including pelvic lymph nodes

Carcinoma of the Cervix

IA1 Confined to the cervix, diagnosed only by microscopy with invasion of <>
IA2 Confined to the cervix, diagnosed with microscopy with invasion of > 3 mm and <>
IB1 Clinically visible lesion or greater than A2, <>
IB2 Clinically visible lesion, > 4 cm in greatest dimension
IIA1 Involvement of the upper two-thirds of the vagina, without parametrial invasion, <>
IIA2 > 4 cm in greatest dimension
IIB With parametrial involvement
IIIA/B Unchanged
IVA/B Unchanged

Carcinoma of the Endometrium

IA Tumor confined to the uterus, no or < ½ myometrial invasion
IB Tumor confined to the uterus, > ½ myometrial invasion
II Cervical stromal invasion, but not beyond uterus
IIIA Tumor invades serosa or adnexa
IIIB Vaginal and/or parametrial involvement
IIIC1 Pelvic node involvement
IIIC2 Para-aortic involvement
IVA Tumor invasion bladder and/or bowel mucosa
IVB Distant metastases including abdominal metastases and/or inguinal lymph nodes

Uterine sarcomas were staged previously as endometrial cancers, which did not reflect clinical behavior. Therefore, a new corpus sarcoma staging system was developed based on the criteria used in other soft tissue sarcomas. This is described as a best guess staging system, so data will need to be collected and evaluated for further revision.

Uterine Sarcomas (Leiomyosarcoma, Endometrial Stromal Sarcoma, and Adenosarcoma)

IA Tumor limited to uterus <>
IB Tumor limited to uterus > 5 cm
IIA Tumor extends to the pelvis, adnexal involvement
IIB Tumor extends to extra-uterine pelvic tissue
IIIA Tumor invades abdominal tissues, one site
IIIB More than one site
IIIC Metastasis to pelvic and/or para-aortic lymph nodes
IVA Tumor invades bladder and/or rectum
IVB Distant metastasis

Adenosarcoma Stage I Differs from Other Uterine Sarcomas
IA Tumor limited to endometrium/endocervix
IB Invasion to < ½ myometrium IB Invasion to > ½ myometrium

MANAGEMENT OF SEVERE COPD REVIEWED

Various strategies and recommendations to treat patients with severe chronic obstructive pulmonary disease (COPD) are provided in a clinical review published in the April 15 issue of the New England Journal of Medicine.

"The sentinel clinical feature of severe ...COPD is dyspnea on exertion," writes Dennis E. Niewoehner, MD, from the Pulmonary Section, Veterans Affairs Medical Center in Minneapolis, Minnesota. "Its onset is usually insidious, and it may progress to severe disability over a period of years or decades. Other common symptoms include cough, sputum production, wheezing, and chest congestion."

The typical clinical manifestations of advanced COPD result from severe airflow obstruction, which can be confirmed by spirometry. Although physical findings may include a barrel-shaped chest, inspiratory retraction of the lower ribs (Hoover's sign), a prolonged expiratory phase, and use of the accessory muscles of respiration, these findings are sometimes absent even in patients with severe COPD.

Failure to confirm COPD with spirometry often leads to misdiagnosis. However, spirometry is a poor guide for decision making regarding treatment continuation or modification in an individual patient. Spirometric evidence of airflow obstruction is defined as a ratio of the postbronchodilator forced expiratory volume in 1 second (FEV₁) to a forced vital capacity of less than 0.70. Overall severity of COPD can be classified based on FEV₁ percentage of the predicted normal value, as well as on clinical criteria, such as the degree of breathlessness caused by specific tasks and the frequency of exacerbations.

Exacerbations often require medical visits and hospitalizations, causing a dramatic increase in healthcare costs. The relative risk for treatment failure (defined as no resolution or clinical deterioration) is lowered by approximately 50% when antibiotics are used for COPD exacerbations. Antibiotics are most effective in patients who have cough productive of purulent sputum.

Complications of severe COPD include pulmonary hypertension and cor pulmonale resulting from chronic hypoxemia and hypercapnia. Severe COPD is also associated with an elevated risk for cardiovascular disease, osteoporosis, lung cancer, depression, and other systemic diseases.

Management Strategies

Management should include patient education during the initial visit, which should focus on the signs and symptoms of a severe exacerbation and the need for prompt recognition and treatment. The most important aspect of management is smoking cessation, which should be addressed at every visit, as long as the patient continues smoking.

Pharmacotherapy may include an inhaled long-acting β2-agonist, an inhaled long-acting anticholinergic agent, and/or an inhaled corticosteroid. The long-acting β2-agonists salmeterol and formoterol offer at least 12 hours of sustained bronchodilation, whereas the inhaled long-acting anticholinergic agent tiotropium is effective for at least 24 hours.

Drugs from 2 of these 3 classes should be combined for patients with severe, exacerbation-prone COPD. Because they lower the relative risk for a severe exacerbation by 15% to 20%, these medications should be continued even if they do not provide symptomatic relief. Adverse events of long-acting bronchodilators are typically mild.

For rescue use, a short-acting bronchodilator should be given. Albuterol or other short-acting β2-adrenergic agonist and ipratropium bromide, a short-acting anticholinergic agent, may be used alone or combined. Patients should be instructed regarding proper inhaler technique. The faster onset of action of albuterol vs ipratropium bromide may give patients more rapid relief.

Long-term oxygen therapy should be prescribed and used for 18 hours or more each day if arterial oxygen saturation is 88% or lower at rest in a stable clinical state.

Patients with COPD should be vaccinated against influenza every autumn, and they should also receive pneumococcal vaccination, with revaccination as needed, unless there is a contraindication.

Patients with access to pulmonary rehabilitation should be offered this therapy, provided there are no medical contraindications.

The recommendations in this review are generally consistent with guidelines on the management of COPD published by the Global Initiative for Chronic Obstructive Lung Disease, the American Thoracic Society-European Respiratory Society, and the American College of Physicians.

Conclusion: Uncertainty Remains

"The role of disease-management programs for patients with COPD remains uncertain," Dr. Niewoehner concludes. "Randomized, controlled trials of case management for COPD have shown promise in reducing hospitalization rates, but the evidence is insufficient to make specific recommendations. Pulmonary rehabilitation improves health status and exercise capability for selected patients, but national surveys indicate that few patients complete such programs, and it is unclear how best to maintain the benefits achieved."

Dr. Niewoehner has received consulting fees from Boehringer Ingelheim, Adams Respiratory Therapeutics, GlaxoSmithKline, AstraZeneca, Nycomed, and Forest Research Institute and speaking fees from Boehringer Ingelheim, Pfizer, Sepracor, and Nycomed.

N Engl J Med. 2010;362:1407-1416.

What Is COPD?

COPD, or chronic obstructive pulmonary (PULL-mun-ary) disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.

Overview

To understand COPD, it helps to understand how the lungs work. The air that you breathe goes down your windpipe into tubes in your lungs called bronchial tubes, or airways.

The airways are shaped like an upside-down tree with many branc

hes. At the end of the branches are tiny air sacs called alveoli (al-VEE-uhl-eye).

The airways and air sacs are elastic. When you breathe in, each air sac fills u

p with air like a small balloon. When you breathe out, the air sac deflates and the air goes out.

In COPD, less air flows in and out of the airways because of one or more of the following:

• The airways and air sacs lose their elastic quality.
• The walls between many of the air sacs are destroyed.
• The walls of the airways become thick and inflamed (swollen).
• The airways make more mucus than usual, which tends to clog the airways.

In the United States, the term "COPD" includes two main conditions—emphysema (em-fi-SE-ma) and chronic obstructive bronchitis (bron-KI-tis).

In emphysema, the walls between many of the air sacs are damaged, causing them to lose their shape and become floppy. This damage also can destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tiny ones.

In chronic obstructive bronchitis, the lining of the airways is constantly irritated and inflamed. This causes the lining to thicken. Lots of thick mucus forms in the airways, making it hard to breathe.

Most people who have COPD have both emphysema and chronic obstructive bronchitis. Thus, the general term "COPD" is more accurate.

Outlook

COPD is a major cause of disability, and it's the fourth leading cause of death in the United States. More than 12 million people are currently diagnosed with COPD. An additional 12 million likely have the disease and don't even know it.

COPD develops slowly. Symptoms often worsen over time and can limit your ability to do routine activities. Severe COPD may prevent you from doing even basic activities like walking, cooking, or taking care of yourself.

Most of the time, COPD is diagnosed in middle-aged or older people. The disease isn't passed from person to person—you can't catch it from someone else.

COPD has no cure yet, and doctors don't know how to reverse the damage to the airways and lungs. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.

Other Names for COPD

• Chronic obstructive airway disease
• Chronic obstructive bronchitis
• Chronic obstructive lung disease
• Emphysema

What Causes COPD?

Most cases of COPD develop after long-term exposure to lung irritants that damage the lungs and the airways.

In the United States, the most common irritant that causes COPD is cigarette smoke. Pipe, cigar, and other types of tobacco smoke also can cause COPD, especially if the smoke is inhaled. Secondhand smoke—that is, smoke in the air from other people smoking—also can irritate the lungs and contribute to COPD.

Breathing in air pollution and chemical fumes or dust from the environment or workplace also can contribute to COPD.

In rare cases, a genetic condition called alpha-1 antitrypsin deficiency may play a role in causing COPD. People who have this condition have low levels of alpha-1 antitrypsin (AAT)—a protein made in the liver.

Having a low level of the AAT protein can lead to lung damage and COPD if you're exposed to smoke or other lung irritants. If you have this condition and smoke, COPD can worsen very quickly.

Who Is At Risk for COPD?

The main risk factor for COPD is smoking. Most people who have COPD smoke or used to smoke. People who have a family history of COPD are more likely to get the disease if they smoke.

Long-term exposure to other lung irritants also is a risk factor for COPD. Examples of other lung irritants include air pollution and chemical fumes and dust from the environment or workplace.

Most people who have COPD are at least 40 years old when symptoms begin. Although it isn't common, people younger than 40 can have COPD. For example, this may happen if a person has alpha-1 antitrypsin deficiency, a genetic condition.

What Are the Signs and Symptoms of COPD?

The signs and symptoms of COPD include:

• An ongoing cough or a cough that produces large amounts of mucus (often called "smoker's cough")
• Shortness of breath, especially with physical activity
• Wheezing (a whistling or squeaky sound when you breathe)
• Chest tightness

These symptoms often occur years before the flow of air into and out of the lungs declines. However, not everyone who has these symptoms has COPD. Likewise, not everyone who has COPD has these symptoms.

Some of the symptoms of COPD are similar to the symptoms of other diseases and conditions. Your doctor can determine if you have COPD.

If you have COPD, you may have frequent colds or flu. If your COPD is severe, you may have swelling in your ankles, feet, or legs; a bluish color on your lips due to low levels of oxygen in your blood; and shortness of breath.

COPD symptoms usually slowly worsen over time. At first, if symptoms are mild, you may not notice them, or you may adjust your lifestyle to make breathing easier. For example, you may take the elevator instead of the stairs.

Over time, symptoms may become bad enough to see a doctor. For example, you may get short of breath during physical exertion.

How severe your symptoms are depends on how much lung damage you have. If you keep smoking, the damage will occur faster than if you stop smoking. In severe COPD, you may have other symptoms, such as weight loss and lower muscle endurance.

Some severe symptoms may require treatment in a hospital. You—with the help of family members or friends, if you're unable—should seek emergency care if:

• You're having a hard time catching your breath or talking.
• Your lips or fingernails turn blue or gray. (This is a sign of a low oxygen level in your blood.)
• You're not mentally alert.
• Your heartbeat is very fast.
• The recommended treatment for symptoms that are getting worse isn't working.

How Is COPD Diagnosed?

Your doctor will diagnose COPD based on your signs and symptoms, your medical and family histories, and test results.

He or she may ask whether you smoke or have had contact with lung irritants, such as air pollution, chemical fumes, or dust. If you have an ongoing cough, your doctor may ask how long you've had it, how much you cough, and how much mucus comes up when you cough. He or she also may ask whether you have a family history of COPD.

Your doctor will examine you and use a stethoscope to listen for wheezing or other abnormal chest sounds.

You also may need one or more tests to diagnose COPD.

Lung Function Tests

Lung function tests measure how much air you can breathe in and out, how fast you can breathe air out, and how well your lungs can deliver oxygen to your blood.

The main test for COPD is spirometry (spi-ROM-eh-tre). Other lung function tests, such as a lung diffusing capacity test, also may be used. (For more information, see "Types of Lung Function Tests.")

Spirometry

During this painless test, a technician will ask you to take a deep breath in and then blow as hard as you can into a tube connected to a small machine. The machine is called a spirometer.

The machine measures how much air you breathe out. It also measures how fast you can blow air out.

Your doctor may have you inhale medicine that helps open your airways and then blow into the tube again. He or she can then compare your test results before and after taking the medicine.

Spirometry can detect COPD long before its symptoms appear. Doctors also may use the results from this test to find out how severe your COPD is and to help set your treatment goals.

The test results also may help find out whether another condition, such as asthma or heart failure, is causing your symptoms.

Other Tests

Your doctor may recommend other tests. These tests include:

• A chest x ray or chest computed tomography (CT) scan. These tests create pictures of the structures inside your chest, such as your heart and lungs. The pictures can show signs of COPD. They also may show whether another condition, such as heart failure, is causing your symptoms.
• An arterial blood gas test. This blood test measures the oxygen level in your blood using a sample of blood taken from an artery. The test can help find out how severe your COPD is and whether you may need supplemental oxygen therapy.

How Is COPD Treated?

COPD has no cure yet. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.

Quitting smoking is the most important step you can take to treat COPD. Talk to your doctor about programs and products that can help you quit. Many hospitals have programs that help people quit smoking, or hospital staff can refer you to a program. Ask your family members and friends to support you in your efforts to quit. Also, try to avoid secondhand smoke.

The National Heart, Lung, and Blood Institute's "Your Guide to a Healthy Heart" booklet has more information about how to quit smoking.

Other treatments for COPD may include medicines, vaccines, pulmonary rehabilitation (rehab), oxygen therapy, surgery, and managing complications.

The goals of COPD treatment are to:

• Relieve your symptoms
• Slow the progress of the disease
• Improve your exercise tolerance (your ability to stay active)
• Prevent and treat complications
• Improve your overall health

Specialists Involved

To assist with your treatment, your family doctor may advise you to see a pulmonologist. This is a doctor who specializes in treating people who have lung problems.

Medicines

Bronchodilators

Bronchodilators relax the muscles around your airways. This helps open your airways and makes breathing easier.

Depending on how severe your disease is, your doctor may prescribe short-acting or long-acting bronchodilators. Short-acting bronchodilators last about 4 to 6 hours and should be used only when needed. Long-acting bronchodilators last about 12 hours or more and are used every day.

Most bronchodilators are taken using a device called an inhaler. This device allows the medicine to go right to your lungs. Not all inhalers are used the same way. Ask your health care team to show you the right way to use your inhaler.

If your COPD is mild, your doctor may only prescribe a short-acting inhaled bronchodilator. In this case, you may only use the medicine when symptoms occur.

If your COPD is moderate or severe, your doctor may prescribe regular treatment with short- and long-acting bronchodilators.

Inhaled Glucocorticosteroids (Steroids)

Inhaled steroids are used for some people who have moderate or severe COPD. These medicines may reduce airway inflammation (swelling).

Your doctor may ask you to try inhaled steroids for a trial period of 6 weeks to 3 months to see whether the medicine is helping with your breathing problems.

Vaccines

Flu Shots

The flu (influenza) can cause serious problems for people who have COPD. Flu shots can reduce your risk for the flu. Talk with your doctor about getting a yearly flu shot.

Pneumococcal Vaccine

This vaccine lowers your risk for pneumococcal pneumonia (nu-MO-ne-ah) and its complications. People who have COPD are at higher risk for pneumonia than people who don't have COPD. Talk with your doctor about whether you should get this vaccine.

Pulmonary Rehabilitation

Pulmonary rehab is a medically supervised program that helps improve the health and well-being of people who have lung problems. Rehab may include an exercise program, disease management training, and nutritional and psychological counseling. The program aims to help you stay more active and carry out your day-to-day activities.

Your rehab team may include doctors, nurses, physical therapists, respiratory therapists, exercise specialists, and dietitians. These health professionals work together and with you to create a program that meets your needs.

Oxygen Therapy

If you have severe COPD and low levels of oxygen in your blood, oxygen therapy can help you breathe better. For this treatment, you're given oxygen through nasal prongs or a mask.

You may need extra oxygen all the time or just sometimes. For some people who have severe COPD, using extra oxygen for most of the day can help them:

• Do tasks or activities, while having fewer symptoms
• Protect their hearts and other organs from damage
• Sleep more during the night and improve alertness during the day
• Live longer

Surgery

In rare cases, surgery may benefit some people who have COPD. Surgery usually is a last resort for people who have severe symptoms that have not improved from taking medicines.

Surgeries for people who have COPD that's mainly related to emphysema include bullectomy (bul-EK-to-me) and lung volume reduction surgery (LVRS). A lung transplant may be done for people who have very severe COPD.

Bullectomy

When the walls of the air sacs are destroyed, larger air spaces called bullae form. These air spaces can become so large that they interfere with breathing. In a bullectomy, doctors remove one or more very large bullae from the lungs.

Lung Volume Reduction Surgery

In LVRS, surgeons remove damaged tissues from the lungs. This helps the lungs work better. In carefully selected patients, LVRS can improve breathing and quality of life.

Lung Transplant

A lung transplant may benefit some people who have very severe COPD. During a lung transplant, your damaged lung is removed and replaced with a healthy lung from a deceased donor.

A lung transplant can improve your lung function and quality of life. However, lung transplants have a high risk of complications. These include infections and death due to the body rejecting the transplanted lung.

If you have very severe COPD, talk to your doctor about whether a lung transplant is an option. Discuss with your doctor the benefits and risks of this type of surgery.

Managing Complications

COPD symptoms usually slowly worsen over time. However, they can become more severe suddenly. For instance, a cold, the flu, or a lung infection may cause your symptoms to quickly worsen. You may have a much harder time catching your breath. You also may have chest tightness, more coughing, changes in the color or amount of your sputum (spit), and a fever.

Call your doctor right away if this happens. He or she may prescribe antibiotics to treat the infection and other medicines, such as bronchodilators and glucocorticosteroids, to help with your breathing.

Some severe symptoms may require treatment in a hospital.

How Can COPD Be Prevented?

You can take steps to prevent COPD before it starts. If you already have COPD, you can take steps to prevent complications and slow the progress of the disease.

Prevent COPD Before It Starts

The best way to prevent COPD is to not start smoking or to quit smoking before you develop the disease. Smoking is the leading cause of COPD.

If you smoke, talk to your doctor about programs and products that can help you quit. Many hospitals have programs that help people quit smoking, or hospital staff can refer you to a program. The National Heart, Lung, and Blood Institute's "Your Guide to a Healthy Heart" booklet has more information about how to quit smoking.

Also, try to avoid secondhand smoke and other lung irritants that can contribute to COPD, such as air pollution, chemical fumes, and dust.

Prevent Complications and Slow the Progress of COPD

If you have COPD, the most important step you can take is to quit smoking. This can help prevent complications and slow the progress of the disease. You also should avoid exposure to the lung irritants mentioned above.

Follow your treatments for COPD exactly as your doctor prescribes. They can help you breathe easier, stay more active, and avoid or manage severe symptoms.

Talk with your doctor about whether and when you should get flu and pneumonia vaccines. These vaccines can lower your chances of getting these illnesses, which are major health risks for people who have COPD.

Living With COPD

COPD has no cure yet. However, you can take steps to manage your symptoms and slow the progress of the disease. You can:

• Avoid lung irritants
• Get ongoing care
• Manage the disease and its symptoms
• Prepare for emergencies

Avoid Lung Irritants

If you smoke, quit. Smoking is the leading cause of COPD. Talk to your doctor about programs and products that can help you quit. Many hospitals have programs that help people quit smoking, or hospital staff can refer you to a program. The National Heart, Lung, and Blood Institute's "Your Guide to a Healthy Heart" booklet has more information about how to quit smoking.

Try to avoid secondhand smoke and other lung irritants that can contribute to COPD, such as air pollution, chemical fumes, and dust. Keep these irritants out of your home. If your home is painted or sprayed for insects, have it done when you can stay away for awhile.

Keep your windows closed and stay at home (if possible) when there's a lot of air pollution or dust outside.

Get Ongoing Care

If you have COPD, it's important to get ongoing medical care. Take all of your medicines as your doctor prescribes. Make sure to refill your prescriptions before they run out. Bring all of the medicines you're taking when you have medical checkups.

Talk with your doctor about whether and when you should get flu and pneumonia vaccines. Also, ask him or her about other diseases for which COPD may increase your risk, such as heart disease, lung cancer, and pneumonia.

Manage COPD and Its Symptoms

You can do things to help manage your disease and its symptoms. Depending on how severe your disease is, you may ask your family and friends for help with daily tasks. Do activities slowly. Put items that you need often in one place that's easy to reach.

Find very simple ways to cook, clean, and do other chores. Some people find it helpful to use a small table or cart with wheels to move things around and a pole or tongs with long handles to reach things. Ask for help moving things around in your house so that you will not need to climb stairs as often.

Keep your clothes loose, and wear clothes and shoes that are easy to put on and take off.

Prepare for Emergencies

If you have COPD, knowing when and where to seek help for your symptoms is important. You should seek emergency care if you have severe symptoms, such as trouble catching your breath or talking. (For more information on severe symptoms, see "What Are the Signs and Symptoms of COPD?")

Call your doctor if you notice that your symptoms are worsening or if you have signs of an infection, such as a fever. Your doctor may change or adjust your treatments to relieve and treat symptoms.

Keep phone numbers handy for your doctor, hospital, and someone who can take you for medical care. You also should have on hand directions to the doctor's office and hospital and a list of all the medicines you're taking.

Key Points

• COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.
• COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.
• Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.
• In the United States, the term "COPD" includes two main conditions—emphysema and chronic obstructive bronchitis. Most people who have COPD have both conditions. Thus, the general term "COPD " is more accurate.
• COPD is a major cause of disability, and it's the fourth leading cause of death in the United States.
• COPD develops slowly. Symptoms often worsen over time and can limit your ability to do routine activities. Severe COPD may prevent you from doing even basic activities like walking, cooking, or taking care of yourself.
• Your doctor will diagnose COPD based on your signs and symptoms, your medical and family histories, and test results.
• COPD has no cure yet. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.
• Quitting smoking is the most important step you can take to treat COPD. Other treatments include medicines, vaccines, pulmonary rehabilitation, oxygen therapy, surgery, and managing complications.
• You can take steps to prevent COPD before it starts. The best way to prevent COPD is to not start smoking or to quit smoking before you develop the disease. Also, try to avoid other lung irritants that can contribute to COPD.
• If you have COPD, you can take steps to manage your symptoms and slow the progress of the disease. Quit smoking and try to avoid other lung irritants. Also, get ongoing care, manage the disease and its symptoms, and prepare for emergencies.

HEALTH TIPS FOR MUSICIAN

HEALTH TIPS FOR THE MUSICIAN

Being healthy means you don't miss gigs, and don't have to spend money you would rather spend on studio time or instruments on a doctor's visit. Here are a few ways you can keep a little more of that money in your pockets, and where it can do more for your career.

WATER IS YOUR FRIEND

Sometimes the simplest things are the hardest to do. There is a lot to be said for drinking more water and less other things. Water has no calories, costs very little to nothing, and is great for keeping vital things like vocal cords and skin healthy. There are few things more irritating than a scratchy throat or split fingers if you are trying to play your instrument, and drinking plenty of water can help prevent both of these. This can also help you keep your skin less wrinkled and your weight down, allowing you to need less money in the long run trying to fix appearance problems as you age, and, in this sadly Hollywood-image field we are in, can probably up your chances of getting contracts simply because you are more youthful and healthy looking than your competition. If you happen to play in a very air-conditioned or heated area, keeping the place humidified can also keep your instruments in better shape and prevent a lot of cracking problems in things like wooden parts and skins, saving you money in repairs and replacement costs. To help keep humidity in the place if you can't afford a humidifier, try keeping a few potted plants around-keeping them moist enough to be healthy seems to keep the air around them the right moisture level as well. Keeping some lotion around that you find works helps a lot, too-seal in all that good moisture to your hands and face.

LEARN TO RELAX

This is another simple thing that is really hard to do. Many musicians have a really hard time "coming down" from a stage show, big meeting with industry bigwigs, or a really good writing session. Many methods exist to allow one to sit still and force oneself to unwind without the need for chemicals so you can get a decent night's sleep. Consider taking a class in Yoga or meditation; find something that really helps you wind down like a warm bubble bath, reading or some other pursuit. Things that work for me, strangely enough, are working on my taxes (so boring it numbs my brain out), curling up in front of the television watching cartoons, a long, slow workout followed by a hot shower or reading a book-especially if the book has a lot of imagery or highly technical data to absorb. I've also found that doing the meditation trick of thinking about sitting and relaxing doing something that soothes you is very helpful-many classes do the scene about sitting on a beach and thinking about being there, while I find thinking about doing yard work or building very relaxing. The important thing is to bore yourself with something that is fun for you, or lets you feel you are accomplishing something beneficial to you. Avoiding chemicals also prevents you from becoming habituated to them-something that can hurt you in the long run. Longer and longer runs or reading can only do you good, while costly chemical solutions often end careers in one way or another. Try to find fun, healthy, low-cost rituals instead.

CREATIVE FIDGETING

You can never really get enough practice, so try to find ways to practice even if you don't have your instrument around. Flexing your fingers backwards like your hands are eagle claws about to strike is great for many instrumentalists, as is doing this then drawing your fingers towards your palms after doing the claw stretch, as if you were about to make a fist, but then allowing the finger to come back to the initial position. I find this is a great way to work kinks out if I have been doing too much work with a pencil, too, at times when I have been frantically writing lyric ideas down. Pretending you are doing scales with both fingers or trying to make your fingers hold a certain chord position helps, too. Drawing your knees up as high as you can one at a time while sitting watching television or doing desk duty at work can help keep your legs and waistline in shape, too, and this can not only help your appearance but help things like your singing or ability to stand holding your instrument for longer periods of time, too. Try surfing the web for other fun exercises you can do while seated-there are lots of fun ones, and any exercise helps keep your weight down and helps you avoid all the health problems associated with that.

So try these simple suggestions and see how it helps your writing. It is amazing how much more endurance you may find you'll have just by drinking more water, learning to relax, and getting a little more exercise.

WHAT MAKES MUSICIANS PRONE TO REPETITIVE STRAIN INJURIES (RSI) ?

What makes musicians prone to Repetitive Strain Injuries (RSI)?

Many musicians have heard horror-stories about comrades who were excellent performing artists until they developed a repetitive strain injury to the arm or hand. Then their career either temporarily stopped or was finished due to this debilitating injury. Why are musicians prone to these injuries? What can be done about them? In this article you will learn why your hands and arms are at risk for injury, and what you can do to help prevent problems from developing in the first place.

In my experience working with hundreds of people who have suffered RSIs, there's a common trait among them. It is the "I thought the pain would go away" concept. Many musicians are out their (maybe yourself) who are currently attempting to play their instrument, even though their arms, elbows, shoulders, or neck are killing them. You have to realize that pain is your body's warning signal. It is like the oil light in your car. If the oil light goes on, do you simply say "let's see if that will turn off by itself. It can't be that important." That would be ludicrous, wouldn't it? Eventually, the engine would dry out, heat up, and for all intensive purposes seize up and be destroyed.

Are you letting this happen to your body? Are you letting the signs and symptoms of a major malfunction in your body, escalate to the point of total
destruction? I'm sorry to say, but I usually see musicians who've reached this point. They come in my office in desperation, stating they can't play anymore because of the pain, and their career is ruined. Don't let this happen to you!

Let's first begin to understand why the body malfunctions. There's some basic information you need to know about the body. I'll keep it simple and
as short as possible.

1. Your nervous system (the brain, spinal cord, and all the nerves that branch off the spinal cord) controls EVERYTHING in your body. This includes muscles, organs, glands, tissues, cells, immunity, hormones, etc. Let's put it another way - there's nothing that occurs in your body without the brain
   controlling it.
2. The nerve system is the "life force" of the body. It literally supplies life to the muscles, tissues, glands, and organs. Without this life-supplying nerve input, your tissues disease and eventually die. Ever see what a spinal cord injury does to a person? That's a pure example of a deadened nerve system.
3. Insults to your body, in the form of physical stresses, chemical stresses, or emotional stresses can "blow fuses" and irritate the nervous system. This causes abnormal signals to reach the tissues, organs, and glands. Let's break down these types of stresses and how they relate to musicians:
   • Physical stresses: (things that physically stress your body) Bad posture while playing your instrument, prolonged playing times without breaks,
     playing in one position (sitting for example) for a long time, previous car or motorcycle accidents, birth injuries (as a baby), quickly ramping up practicing times due to an upcoming gig or recital, being out of shape & overweight, sitting at computers for a long time, playing computer games hour after hour.
   • Chemical Stressors: (things to knowingly, or unknowlingly put into your body), drugs and alcohol, prescription drugs, fast food, vaccines, toxic
     chemicals in your environment (like chemicals you're exposed to by work or at home), a bad water supply.
   • Emotional stressors: (stuff you're thinking about) getting that recording contract, composing and finishing songs by a deadline, record company execs being a pain is the most, family stresses, relationship stressors, job stresses other than your music career, death of loved ones, relocating, being on tour without family or loved ones nearby, and finally your negative thinking AKA "stinkin' thinkin'" I bet you never thought that all these things mentioned have a direct impact on your body!
4. Continued physical, chemical, and emotional stressors will short-circuit your nervous system and lead to things called "spinal subluxations". "A spinal what?" you ask? A subluxation is a misalignment of a spinal bone(s) that exerts stress on your nerve system. This leads to malfunction of the
   tissues that affected nerves supply, in some cases muscles, in some cases organs, and in some cases, both!
5. These continued stressors will eventually lead to symptoms due to repeated stress on the nerve system. Prolonged, uncared for stresses will lead to disease, disability, and eventually a shortened life-span.

So let's summarize in a real, practical situation that every musician can understand. You feel that you're in pretty good health, except for the fast food (chemical stress) that seems to be part of your lifestyle lately. You know that you're not eating right, but hey, there's this recording deal that you have to provide music for. You're spending 8 to 10 hours a day composing music, (physical stress) sitting at your guitar and piano. That certainly doesn't give you time to fix good meals. What's worse is that your girlfriend (or boyfriend) is hounding you because you don't spend enough time with them. (Emotional stress) Your dad recently had a heart attack, and your torn because you can't spend enough time with him right now. (emotional stress) You're finding that one or two beers isn't sufficing anymore. Drinking a six-pack is becoming part of your practice sessions. (chemical stress) To top things off, your back is beginning to hurt after playing guitar for more than a few hours, so you begin taking some ibuprofen every day to make it through the sessions. (chemical stress)

Now do you see what I'm getting at? Your health is a conglomerate of YOU. What you're eating, taking, saying, doing, and hearing. YOU ONLY DEVELOP AN INJURY WHEN THESE CONTINUED STRESS FACTORS BEGIN TO BREAK DOWN YOUR NERVOUS SYSTEM AND CAUSE YOUR MUSCLES, ORGANS, AND GLANDS TO DISEASE.

So, let's consider your injury, if you have one, at this point in time. Look back at this list of stressors and see which ones you've experienced lately.
And it doesn't have to be within the past month or two. This list can go back to birth! Complicated you say? You're right. When a person walks in my office with an RSI, we have to investigate that entire person's life to find out what stressors led him/her to this current symptom. In many cases, even though the pain is in the arm, the actual nerve stress that is leading to the symptom can stem from the brain stem, neck, upper back, and lower
back. You have to investigate the whole body.

So what can you do now that you understand this better? First, work at relieving stressors in your life. (That's not easy) Second, if you think your life stressors have taken their toll on your body, then visit a chiropractor to determine if your nervous system is shutting down, or is working at half-mast. Third, if you are having active RSI-type symptoms, don't wait - run, to a chiropractic office for a complete eval and treatment. And the last, feel free to asking me some advice if you meet some problems likes above...