Calcium Channel Blockers and Breast Cancer

More than 60 million Americans have high blood pressure (high BP), high BP is a major risk factor for a
heart attack or stroke.  This "disease", which is largely lifestyle in origin, is reaching epidemic proportions.

In past studies, calcium channel blockers have been shown to lower the risk of stroke, they have also been shown to produce an increased risk for heart attacks.


A new study indicates that women that use of calcium-channel blockers for 10 or more years had a  significantly higher risks, 2.5 times higher (250%), of both ductal breast cancer and lobular breast cancer. This connection did not vary much by the type of calcium-channel blocker used. In contrast, use of diuretics, beta-blockers, and ACE inhibitors were not associated with risk of breast cancer.  According to the National Cancer Institute more than 232,000 women will be diagnosed with breast cancer in the United States this year.

Cancer risks aside, calcium channel blockers still produce some mild side effects including constipation, allergic reactions, fluid retention, dizziness, headache, fatigue, and impotence (about 20% of users). More serious side effects include disturbances of heart rate or function, heart failure, and angina.

Examples of calcium-channel blockers include:

• amlodipine (Norvasc)
• diltiazem (Cardizem CD, Cartia, Dilacor Xr, Diltia Xt, Tiazac)
• felodipine (Plendil)
• lacidipine (Motens)
• lercanidipine (Zanidip)
• nicardipine (Cardene, Carden SR)
• nifedipine (Adalat CC, Procardia XL)
• nimodipine (Nimotop)
• nisoldipine (Sular)
• nitrendipine (Cardif, Nitrepin)
• verapamil (Calan, Covera-Hs, Isoptin, Verelan)

The Take Home Message

Although chemical intervention can effectively control blood pressure, the longer term risks associated with these drugs lead to other health concerns and complications.

So, what to do?  As I mentioned at the start of this article, high blood pressure is most often a result of lifestyle.  High blood pressure can respond nicely to conservative lifestyle changes.

These changes can include:

• Regular exercise/activity
• Weight management
• Nutritional supplementation:
• magnesium
• arginine
• and others
• Avoid NSAID's (over the counter pain relievers)
• Increase intake of antioxidant foods
• Reduce/stop smoking
• Relaxation practices
• Increasing intake of water (if there is no history of kidney disease)
• Chiropractic care to address postural problems that can compress the chest cavity

These are possible suggestions for natural control of your blood pressure.  Not all these possibilities are appropriate for everyone.  You should discuss these with a knowledgeable provider in natural therapies.  You should not stop your blood pressure medication without monitoring by your doctor.

For your better, long term, health,

Dr. Heller

Healing Foods: Turmeric (Curcumin)

For centuries folk medicine depended on natural, herbal and nutriceutical remedies.  With the advent of pharmaceutical medicine many of the old remedies and their benefits were lost by the wayside. Much to the detriment of society. However, with the ever growing lists of side effects of today's patent drugs, their lack of true healing and the epidemic of secondary chronic disorders that they leave behind, interest is once again being shown to the old ways, their benefits and their safety.

The following article, exerpted from greenmedinfo.com, reviews the benefits and the recent research behind the age old spice, turmeric.  Definitely an impressive resume' of benefits and a spice worth adding to your diet.
 *********************************************************
Turmeric is one the most thoroughly researched plants in existence today.  Its medicinal properties and components (primarily curcumin) have been the subject of over 5600 peer-reviewed and published biomedical studies.  In fact, our five-year long research project on this sacred plant has revealed over 600 potential preventive and therapeutic applications, as well as 175 distinct beneficial physiological effects.

Given the sheer density of research performed on this remarkable spice, it is no wonder that a growing number of studies have concluded that it compares favorably to a variety of conventional medications, including:

• Lipitor/Atorvastatin(cholesterol medication): A 2008 study published in the journal Drugs in R & D found that a standardized preparation of curcuminoids from Turmeric compared favorably to the drug atorvastatin (trade name Lipitor) on endothelial dysfunction, the underlying pathology of the blood vessels that drives atherosclerosis, in association with reductions in inflammation and oxidative stress in type 2 diabetic patients. [i] 
  
  
• Corticosteroids (steroid medications): A 1999 study published in the journal Phytotherapy Research found that the primary polyphenol in turmeric, the saffron colored pigment known as curcumin, compared favorably to steroids in the management of chronic anterior uveitis, an inflammatory eye disease.[ii]  A 2008 study published in Critical Care Medicine found that curcumin compared favorably to the corticosteroid drug dexamethasone in the animal model as an alternative therapy for protecting lung transplantation-associated injury by down-regulating inflammatory genes.[iii] An earlier 2003 study published in Cancer Letters found the same drug also compared favorably to dexamethasone in a lung ischaemia-repurfusion injury model.[iv] 
  
• Prozac/Fluoxetine & Imipramine  (antidepressants): A 2011 study published in the journal Acta Poloniae Pharmaceutica found that curcumin compared favorably to both drugs in reducing depressive behavior in an animal model.[v]
  
• Aspirin (blood thinner): A 1986 in vitro and ex vivo study published in the journal Arzneimittelforschung found that curcumin has anti-platelet and prostacyclin modulating effects compared to aspirin, indicating it may have value in patients prone to vascular thrombosis and requiring anti-arthritis therapy.[vi] 
  
• Anti-inflammatory Drugs: A 2004 study published in the journal Oncogene found that curcumin (as well as resveratrol) were effective alternatives to the drugs aspirin, ibuprofen, sulindac, phenylbutazone, naproxen, indomethacin, diclofenac, dexamethasone, celecoxib, and tamoxifen in exerting anti-inflammatory and anti-proliferative activity against tumor cells.[vii]
  
• Oxaliplatin (chemotherapy drug): A 2007 study published in the International Journal of Cancer found that curcumin compares favorably with oxaliplatin as an antiproliferative agenet in colorectal cell lines.[viii]
  
• Metformin (diabetes drug): A 2009 study published in the journal Biochemitry and Biophysical Research Community explored how curcumin might be valuable in treating diabetes, finding that it activates AMPK (which increases glucose uptake) and suppresses gluconeogenic gene expression  (which suppresses glucose production in the liver) in hepatoma cells. Interestingly, they found curcumin to be 500 times to 100,000 times (in the form known as tetrahydrocurcuminoids(THC)) more potent than metformin in activating AMPK and its downstream target acetyl-CoA carboxylase (ACC). [ix]

Another way in which turmeric and its components reveal their remarkable therapeutic properties is in research on drug resistant- and multi-drug resistant cancers. 

We have found no less than 54 studies indicating that curcumin can induce cell death or sensitize drug-resistant cancer cell lines to conventional treatment.[x]

We have identified 27 studies on curcumin's ability to either induce cell death or sensitize multi-drug resistant cancer cell lines to conventional treatment.[xi]

Considering how strong a track record turmeric (curcumin) has, having been used as both food and medicine in a wide range of cultures, for thousands of years, a strong argument can be made for using curcumin as a drug alternative or adjuvant in cancer treatment.

Or, better yet, use certified organic (non-irradiated) turmeric in lower culinary doses on a daily basis so that heroic doses won't be necessary later in life after a serious disease sets in.  Nourishing yourself should be the goal of a healthy diet.

For the references go to the original article: 

For your better health,

Dr. Heller

All Sodas Increase Type 2 Diabetes Risk

Online health news, Medscape reported on Febuary 14, 2013 that a new study from France suggests that women who drink large amounts of diet soda are at increased risk for type 2 diabetes.

The study followed  66,118 women in France exploring links between diet and cancer.  What they found was that there were 1369 new cases of type 2 diabetes diagnosed during the follow-up period from 1993 to 2007.

In self-reported dietary consumption of soft drinks, the average intake of regular sodas was 328 mL/week, while for diet sodas it was higher, at 568 mL/week.   The study considers this high consumption.  For those of us here in the States let me convert that for you.  328 mL = about 11 oz. or slightly less than one can of regular soda/WEEK.  568 mL = 19 oz of diet soda/WEEK.  I'm guessing many of us know friends, family, co-workers or ourselves that consume more than this amount through the week.

The risk for type 2 diabetes was elevated among the women by about 30% with consumption of regular soda greater than 11 oz./week and more than doubled with consumption of diet soda greater than 19 oz./week.  These are risk factors after adjusting for other influencing variables.

Moral of the story?  Don't be fooled into thinking that diet means that it is better for you and that there are no health consequences with its consumption.

What the body needs and what most of us don't get enough of is water.  Try replacing soda consumption with water consumption.  Carry a water bottle with you, keep one on your desk at work if possible, get frequent drinks during any breaks through the day, whatever it may take.  Many common health complaints from mental fog, to muscle aches to back pain to fainting have been related to dehydration (lack of water).

In the interest of your better health,

Dr. Heller




Photo Credit: © Pkruger | Stock Free Images & Dreamstime Stock Photos

New Year's Help For Smokers

Did you, a friend or family member make a New Year's resolution to improve your health?  Was one of those resolutions to quit smoking?  Well I want to pass along an interesting and hopefully helpful aid that I stumbled across. If this sounds of interest to you, keep reading.

Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services, said quitting smoking is one of the best things anyone can do to improve health.  

• Cigarette smoking causes an estimated 443,000 deaths each year, including approximately 49,400 deaths due to exposure to secondhand smoke.
• 8.6 million people live with a serious illness caused by smoking.
• On average, smokers die 13 to 14 years earlier than nonsmokers.
• Lung cancer is the leading cause of cancer death among both men and women in the United States, and 90% of lung cancer deaths among men and approximately 80% of lung cancer deaths among women are due to smoking.
• Smoking causes many other types of cancer, including cancers of the throat, mouth, nasal cavity, esophagus, stomach, pancreas, kidney, bladder, and cervix, as well as acute myeloid leukemia.
• People who smoke are up to two to four times more likely to suffer a heart attack than nonsmokers, and the risk increases with the number of cigarettes smoked. Smoking also causes most cases of chronic obstructive lung disease.
• Among youth who persist in smoking, a third will die prematurely from smoking.

Dr. Clancy noted that a new, comprehensive website available, gives one-stop access to the latest evidence-based methods on how to quit smoking.

The website — BeTobaccoFree.gov — has interactive features, mobile apps, tools and resources designed specifically for parents, educators and teens.

The site offers facts on smoking and second hand smoke, smokeless tobacco, educational/informational videos with former smokers and numerous tools under the "Quit Now" tab to help you or those you love;  all for FREE.       Click on this link to be taken to the website.

Best of luck on your New Year's health endeavors!

For your health,

Dr. Heller

Beware of Soda Consumption

According to the National Soft Drink Association (NSDA), consumption of soft drinks is now over 600 12-ounce servings (12 oz.) per person per year. Since the late 1970`s the soft drink consumption in the United States has doubled for females and tripled for males. The group with highest consumption is males between the ages of 12 - 29; they average 1/2 gallon a day or 160 gallons a year.

 Doctors, nutritionists and health clinics urge us to take control of our soft drink consumption to improve our health. It is highly recommended that each of us drink 6-8 glasses of water each day to keep your body well hydrated. Proper hydration of internal organs enables them to function properly, removing waste and toxins from the body. Hydration of the skin keeps it with good elasticity and will help keep you looking younger longer. Water is the best way to quench your thirst and keeping your body healthy.

 The graphic below shows the numerous negative impacts of soft drinks on the body.  If you have difficulty reading the graphic simply hold down the "ctrl" key and tap the "+" key" to zoom in.

Are Those Magic Beans?

If you are a coffee lover like myself, you may now have reason to treat yourself to another cup or three.   

A  recent Medscape Medical News slideshow reviews the potential medical and psychiatric benefits of coffee consumption.    These mental and medical benefits include reducing your risk of brain neuron degeneration and depression and cancer and cardiovascular disease.  I have recapped that slide show here:

A recent study published in the New England Journal of Medicine found that coffee consumption lowered all-cause mortality by over 10% at 13-year follow-up.^[1]

To say that caffeine, a substance known to increase blood pressure can benefit the cardiovascular system  may seem counterintuitive.  When caffeine is consumed as coffee, lengthy elevations of blood pressure are small and cardiovascular risks may be offset by other protective properties. Coffee beans contain antioxidant compounds that reduce formation of low-density lipoprotein (LDL) cholesterol. A reduced concentration of inflammatory indicators in the blood has also been seen with coffee consumption.^[2-7]  Several studies have indicated that moderate coffee intake was associated with a lower risk for coronary heart disease as far out as 10 years,^[3] and new data suggest that an average of 2 cups a day protects against heart failure.^[8]   This really should not surprise us since other studies have found the cardiovascular protective effects of antioxidant containing juices of fruits.

The vascular benefits of coffee are not lost on the brain. According to a 2011 review of studies, consuming between 1 and 6 cups a day reportedly cut stroke risk by 17%.^[9]   Coffee's impact on stroke risk in those with vascular disease is still in question, a review presented at the European Meeting on Hypertension 2012 found that 1 to 3 cups a day may protect against strokes caused by blockages in the general population.^[11]

Despite its association with increased blood pressure, coffee appears to benefit other aspects of what is known as “metabolic syndrome.”  This is a dangerous cluster of elevated blood pressure, high blood sugars, abnormal blood lipid levels, and increased body fat. Numerous studies have linked regular coffee drinking with improved glucose metabolism, insulin secretion, and a significantly reduced risk for type 2 diabetes.^[12-14]   Early data from an ongoing study also suggest that coffee consumption can promote weight loss. In this study, overweight patients treated with raw,  unroasted coffee beans in supplement form lost an average of 17 pounds over 22 weeks.  The authors suspect that this effect may be due in part to coffee containing a plant compound with antioxidant properties thought to reduce blood sugar absorption.^[15]

With so many food products thought to increase cancer risk – soda, grilled meat, any thing pickled – at least we can rest easy when it comes to coffee (according to recent data, anyway). Evidence suggests that moderate to heavy coffee consumption can reduce the risk for numerous cancers, including endometrial (> 4 cups/day),^[16] prostate (6 cups/day),^[17] head and neck (4 cups/day),^[18,19] basal cell carcinoma (> 3 cups/day),^[20] and estrogen receptor-negative breast cancer (> 5 cups/day).^[21]   These benefits are thought to be in no small part due to coffee's antioxidant and antimutagenic properties.^[16,18]

Many of us find that morning cup of coffee to be effective for  alertness , but new research also links coffee with longer lasting effects on cognitive well-being.   One study showed that patients with mild thought and memory impairment and blood levels of caffeine of > 1200 ng/mL – which is about 3 to 5 cups of coffee a day – avoided progression to dementia over the following 2 to 4 years. ^[22]    Other data showed that 3 cups of coffee a day may help prevent the neurologic  damage caused by Parkinson’s Disease.   

A 2011 study suggests that coffee consumption might also benefit our mental health^[26]: Women who drank 2 to 3 cups of coffee per day had a 15% decreased risk for depression compared with those who drank less than 1 cup per week. For those who drank 4 cups or more per day, a 20% decreased risk was seen.  The effect of coffee on mood in the short term may be due to altered serotonin and dopamine activity, and on the antioxidant activity in the long term.^[26-29]

Evidence suggests that coffee consumption slows the  progression of liver disease.  Patients with alcoholic cirrhosis and hepatitis C reduced the risk of developing primary liver cancer.^[30-33]

Other research suggests that coffee consumption may help dry-eye syndrome by increasing tear production,^[35] that it may reduce the risk for gout,^[36] and potentially fight infections.^[37] Coffee and hot tea consumption were found to be protective against one of the medical community's most concerning bugs, methicillin-resistant Staphylococcus aureus (MRSA) ^[37], typically pronounced Mursa.   It is unclear whether the beverages have antimicrobial activity through out the body, but study participants who reported any consumption of either were approximately half as likely to have MRSA in their nasal passages.

Now, with all the validated benefits of coffee we may have a tendency to see it as a health panacea, but coffee is not a totally innocuous beverage.  Coffee consumption certainly has negative medical and psychiatric effects to consider. Besides the previously mentioned increase in blood pressure, coffee can cause or worsen anxiety, insomnia, and tremor and has the potential to  increase glaucoma risk^[38] for those so predisposed.  Also, due to the potential severity of its symptoms, “caffeine withdrawal syndrome” is under consideration for inclusion in the forthcoming DSM-5^[39] , a manual published by the American Psychiatric Association (APA) that includes all currently recognized mental health disorders.

As always be aware of the total affects of what you put into your body.  Enjoy and good health to you.

For your better health,

Dr. Heller

References

1.        Freedman ND, Park Y, Abnet CC, et al. Association of coffee drinking with total and cause-specific mortality. N Engl J Med. 2012;366:1891-1904. Abstract

2.        Larsson SC, Orsini N. Coffee consumption and risk of stroke: a dose-response meta-analysis of prospective studies. Am J Epidemiol. 2011;174:993-1001. Abstract

3.        Wu JN, Ho SC, Zhou C, et al. Coffee consumption and risk of coronary heart diseases: a meta-analysis of 21 prospective cohort studies. Int J Cardiol. 2009;137:216-225. Abstract

4.        Natella F, Nardini M, Belelli F, et al. Coffee drinking induces incorporation of phenolic acids into LDL and increases the resistance of LDL to ex vivo oxidation in humans. Am J Clin Nutr. 2007;86:604-609. Abstract

5.        Gómez-Ruiz JA, Leake DS, Ames JM. In vitro antioxidant activity of coffee compounds and their metabolites. J Agric Food Chem. 2007;55:6962-6969. Abstract

6.        Nardini M, D'Aquino M, Tomassi G, et al. Inhibition of human low-density lipoprotein oxidation by caffeic acid and other hydroxycinnamic acid derivatives. Free Radic Biol Med. 1995;19:541-552. Abstract

7.        Montagnana M, Favaloro EJ, Lippi G. Coffee intake and cardiovascular disease: virtue does not take center stage. Semin Thromb Hemost. 2012;38:164-177. Abstract

8.        Mostofsky E, Rice MS, Levitan EB, Mittleman MA. Habitual coffee consumption and risk of heart failure: a dose–response meta-analysis. Circ Heart Fail. 2012;DOI:10.1161/CIRCHEARTFAILURE.112.967299. http://circheartfailure.ahajournals.org

9.        Larsson SC, Orsini N. Coffee consumption and risk of stroke: a dose-response meta-analysis of prospective studies. Am J Epidemiol. 2011;174:993-1001. Abstract

10.     Larsson SC, Virtamo J, Wolk A. Coffee consumption and risk of stroke in women. Stroke. 2011;42:908-912. Abstract

11.     D'Elia L, Cairella G, Garbagnati F, et al. Moderate coffee consumption is associated with lower risk of stroke: meta-analysis of prospective studies. J Hypertension. 2012;30 (e-Supplement A):e107.

12.     Huxley R, Lee CM, Barzi F, et al. Coffee, decaffeinated coffee, and tea consumption in relation to incident type 2 diabetes mellitus: a systematic review with meta-analysis. Arch Intern Med. 2009;169:2053-2063. Abstract

13.     Sartorelli DS, Fagherazzi G, Balkau B, et al. Differential effects of coffee on the risk of type 2 diabetes according to meal consumption in a French cohort of women: the E3N/EPIC cohort study. Am J Clin Nutr. 2010;91:1002-112. Abstract

14.     Floegel A, Pischon T, Bermann MM, et al. Coffee consumption and risk of chronic disease in the European Prospective Investigation into Cancer and Nutrition (EPIC)–Germany study. Am J Clin Nutr. 2012;95:901-908. Abstract

15.     Vinson JA, Burnham B, Nagendran MV, et al. Randomized double-blind placebo-controlled crossover study to evaluate the efficacy and safety of a green coffee bean extract in overweight subjects. Program and abstracts of the 243rd American Chemical Society National Meeting and Exposition; March 25-29, 2012; San Diego, California. Abstract 92.

16.     Je Y, Hankison SE, Tworoger SS, et al. A prospective cohort study of coffee consumption and risk of endometrial cancer over a 26-year follow-up. Cancer Epidemiol Biomarkers Prev. 2011;20:1-9.

17.     Wilson KM, Kasperzyk JL, Rider JR, et al. Coffee consumption and prostate cancer risk and progression in the Health Professionals Follow-up Study. J Natl Cancer Inst. 2011;8;103:876-884.

18.     Turati F, Galeone C, La Vecchia C, et al. Coffee and cancers of the upper digestive and respiratory tracts: meta-analyses of observational studies. Ann Oncol. 2011;22:536-544. Abstract

19.     Galeone C, Tavani A, Pelucchi C, et al. Coffee and tea intake and risk of head and neck cancer: pooled analysis in the international head and neck cancer epidemiology consortium. Cancer Epidemiol Biomarkers Prev. 2010;19:1723-1736. Abstract

20.     Song F, Qureshi AA, Han J. Increased caffeine intake is associated with reduced risk of Basal cell carcinoma of the skin. Cancer Res. 2012;72:3282-3289. Abstract

21.     Li J, Seibold P, Chang-Claude J, et al. Coffee consumption modifies risk of estrogen-receptor negative breast cancer. Breast Cancer Res. 2011;13:R49.

22.     Cao C, Loewenstein DA, Lin X, et al. High blood caffeine levels in MCI linked to lack of progression to dementia. J Alzheimer Dis. 2012;30:559-572.

23.     Hamza TH, Chen H, Hill-Burns EM, et al. Genome-wide gene-environment study identifies glutamate receptor gene GRIN2A as a Parkinson's disease modifier gene via interaction with coffee. PLoS Genet. 2011;7: e1002237.

24.     Ross W, Duda J, Abbott R, et al. Association of coffee caffeine consumption with brain Lewy pathology in the Honolulu-Asia Aging Study. Program and abstracts of the 64th Annual Meeting of the American Academy of Neurology; April 21-28, 2012; New Orleans, Louisiana. Abstract #S42.005.

25.     Duru C. Caffeine is a modifier of age at onset in Huntington's disease. Program and abstracts of the 15th International Congress of Parkinson's Disease and Movement Disorders; June 5-9, 2011; Toronto, Ontario, Canada. Abstract 180.

26.     Lucas M, Mirzaei F, Pan A, et al. Coffee, caffeine, and risk of depression among women. Arch Intern Med. 2011;171:1571-1578. Abstract

27.     Pasco JA, Nicholson GC, Williams LJ, et al. Association of high-sensitivity C-reactive protein with de novo major depression. Br J Psychiatry. 2010;197:372-377. Abstract

28.     Ng F, Berk M, Dean O, Bush AI. Oxidative stress in psychiatric disorders: evidence base and therapeutic implications. Int J Neuropsychopharmacol. 2008;11:851-876. Abstract

29.     O'Connor A. Coffee drinking linked to less depression in women. New York Times. February 13, 2012. http://well.blogs.nytimes.com/2011/09/26/coffee-drinking-linked-to-less-depression-in-women/ Accessed January 11, 2012.

30.     Molloy JW, Calcagno CJ, Williams CD, Jones FJ, Torres DM, Harrison SA. Association of coffee and caffeine consumption with fatty liver disease, nonalcoholic steatohepatitis, and degree of hepatic fibrosis. Hepatology. 2012;55:429-436. Abstract

31.     Gallus S, Tavani A, Negri E, La Vecchia C. Does coffee protect against liver cirrhosis? Ann Epidemiol. 2002;12:202-205.

32.     Molloy JW, Calcagno CJ, Williams CD, et al. Association of coffee and caffeine consumption with fatty liver disease, nonalcoholic steatohepatitis, and degree of hepatic fibrosis. Hepatology. 2012;55:429-436. Abstract

33.     Modi AA, Feld JJ, Park Y, et al. Increased caffeine consumption is associated with reduced hepatic fibrosis. Hepatology. 2010;51:201-209. Abstract

34.     Birerdinc A, Stepanova M, Pawloski L, Younossi M. Caffeine is protective in patients with non-alcoholic fatty liver disease. Aliment Pharmacol Ther. 2012;3576-82.

35.     Arita R, Yanagi Y, Honda N, Maeda S, et al. Caffeine increases tear volume depending on polymorphisms within the adenosine A2a receptor gene and cytochrome P450 1A2. Ophthalmology. 2012;119:972-978. Abstract

36.     Choi HK, Willett W, Curhan G. Coffee consumption and risk of incident gout in men: A prospective study. Arthritis Rheum. 2007;56:2049-2055. Abstract

37.     Matheson EM, Mainous AG, Everett CJ, King DE. Tea and coffee consumption and MRSA nasal carriage. Ann Fam Med. 2011;9:299-304. Abstract

38.     Pasquale L. Program and abstracts of the American Glaucoma Society 22nd Annual Meeting; March 1-4, 2012; New York, New York. Abstracts 23 and 83.

39.     Compton WM, Budney AJ, Hasin D. New approaches to substance and related diagnoses in the DSM-5. Program and abstracts of the American Academy of Addiction Psychiatry (AAAP) 22nd Annual Meeting and Symposium; December 8-11, 2011; Scottsdale, Arizona. Workshop B2. Presented December 9, 2011.