Body Mass Index vs Body Roundness Index Body Mass Index (BMI) has long been the standard for assessing weight-related health risks. However, a newer measure, the Body Roundness Index (BRI), may provide a more accurate assessment of body fat distribution and associated health risks. by Mary B Grosvenor, MS, RD   and Lori A Smolin, PhD A healthy weight is the weight at which your health risks are lowest. But how do we determine what a healthy weight is for you? Your health care team probably uses your Body Mass Index (BMI). For over 40 years, this ratio of weight relative to height has been used to define healthy, underweight, overweight, and obese ranges and identify the health risks associated with these.[1] Recently however, the American Medical Association has stated that BMI alone is an imperfect measure.[2] Measuring waist circumference or calculating Body Roundness Index (BRI) have been proposed as better tools for evaluating the risks associated with body weight and fatness.  Body Weight, Body Fat, and Health  We are told to keep our weight within the recommended range to help prevent many of the chronic diseases that are rampant in the modern world.  However, it is not actually our weight, but rather how much of our weight is fat, that impacts our health risks. Having too much body fat, which is the definition of obesity, increases the risk of diabetes, high blood pressure, elevated blood cholesterol, heart disease, sleep apnea, and some types of cancer.  Where the fat is located also affects the risks; fat that accumulates around the liver and other organs in the abdomen, referred to as visceral fat, is associated with a higher incidence of these disorders than fat in the hips and thighs. These body types have been coined apple- and pear-shaped, respectively: an apple shape carries more risk than a pear shape.[3,4] So, if it is the amount of body fat that affects our health risk, why don’t we just measure body fat? The reason is that it is difficult.[5] Despite the availability of bathroom scales and monitors that give you a readout of your percent body fat, these devices don’t actually measure body fat. They measure current flow through body water and calculate body fat based on a supposition of the amount of water in the body. The measurements are affected by your age, when you last ate or exercised, whether your bladder is full or empty, and even how dry or moist your skin is, so they are not always accurate. More exact techniques such as underwater weighing and DXA scans are available, but these require trained professionals, invasive measures, and expensive equipment.  In the absence of an easy, reliable, cost-effective way to measure body fat, waist circumference measurement, and BRI offer simple, noninvasive ways to assess body fat and associated risks. Body Mass Index: Advantages and Limitations BMI is attributed to a 19th century mathematician who used a ratio of weight to height to define a “normal” man.  This concept was then picked up by the Metropolitan Life Insurance Company to assess body weight after they noted that more insurance claims were coming from their obese than their thinner policyholders.[1] In 1972, physiologist Ancel Keys refined the equation and coined the term “Body Mass Index” to evaluate body fatness. [6] Today BMI is the standard used by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) to assess body weight; a BMI between 18.5 and 24.9 kg/m2 carries the lowest weight-related health risks.[7] But BMI has its drawbacks. The data used to define the healthy and unhealthy weight ranges was primarily from non-Hispanic white men of European descent, so these ranges may not be accurate for women and people of other ethnicities and races. And, although BMI usually correlates with the amount of body fat, it does not actually measure the amount of fat or consider the location of body fat.[7] So, individuals with the same BMI may have dramatically different body compositions.  For example, a body builder may have a BMI in the obese range because of a larger-than-average amount of muscle. But they may have little body fat and therefore a low risk of obesity-related diseases. On the other hand, a person with a BMI in the normal range may have little muscle mass and a large percentage of body fat and therefore a higher disease risk than would be presumed by their BMI. Waist Circumference: Advantages and Limitations   A measurement of waist circumference can be used as a quick assessment of the amount of visceral fat. Visceral fat accumulation has been found to be a good predictor of metabolic syndrome, a cluster of conditions, including abdominal obesity, high blood pressure, high fasting blood sugar, and abnormal blood lipid levels that increase the risk of heart disease, stroke, and diabetes.[8] Visceral fat releases fatty acids, hormones, and other proinflammatory molecules into the blood stream. These are believed to cause low-grade inflammation that leads to other components of metabolic syndrome and the diseases associated with it.[9] Excess visceral fat, called abdominal obesity, has been associated with an increased risk of heart disease, type 2 diabetes, and all-cause mortality, independent of BMI.[10,11,12]  Based on this correlation, measuring waist circumference would seem to be an easy way to assess the risk associated with body weight. But, there no set standard for where to take the measurement; some protocols measure at the narrowest point of the waist, some measure at the umbilicus, some measure at the top of the iliac crest, and others use the midpoint between the lowest rib and the iliac crest.[13]The classification of abdominal obesity might differ depending on the measurement used.[12] In addition, the accuracy of measurements can be affected by factors such as stomach contents and breathing patterns and it can be particularly difficult to identify where to take measurements in those with a large  amount of body fat. [13,14] A final concern is the use if a single cut off point for risk assessment; abdominal obesity is defined as a waist circumference greater than 40 inches for men and 35 inches for women. This does not correct for the fact that taller individuals have larger waist circumferences, even when they do not have excess fat.[15]  Body Roundness Index: Advantages and Limitations  Body Roundness Index (BRI) was developed to provide a measure of body shape that would more accurately reflect the potential health risks associated with body fat. [15] The data used to formulate BRI included men and women of a variety of races and ethnicities. The BRI equation uses waist circumference and height to evaluate body shape and calculate body roundness, which is indicative of the amount of visceral body fat.  People with more visceral body fat will have a rounder body shape and a higher BRI. Those with narrow, lean bodies will have lower BRI values.[15] BRI has been found to be better than other anthropometric measures at assessing the risk of cardiovascular disease, metabolic syndrome, type 2 diabetes, and colorectal cancer.[16-19]   A specific BRI goal has not yet been defined but a BRI of 4.5 to 5.5 has been associated with the lowest all-cause mortality. Health risks increase by almost 50% in individuals with a BRI score of 6.9 or greater compared to those with a BRI between 4.5 to 5.5.[20] While the calculation for BRI is complicated, there are several accurate online calculators available including the two shown here: https://bri-calculator.com/#calculator https://www.omnicalculator.com/health/bri While BRI correlates better with total body fat and body fat distribution than BMI, this is not to say that BRI is a perfect measure of visceral fat or weight-related risks. One problem is that the BRI equation uses waist circumference, which as discussed above, can be difficult to measure accurately. This is a particular problem when doing self-measurements, which tend to underestimate actual waist circumference, particularly in women and those with large amount of body fat. [13,14].  Errors in waist measurement produce errors in the BRI number and thus the estimate of health risk.  Beyond Body Weight and Fat  So, what’s your healthiest weight? We know that how much fat you carry affects your health risks more than what you weigh, but actually measuring body fat is difficult. We also know that having a large waist circumference often indicates more visceral fat, which increases the risk for many chronic diseases. Although measures such as BMI, waist circumference, and BRI can provide important information about your potential health risks, none of these consider other factors that affect these risks such as genetics, diet, and physical activity. While we can’t change our genetics, we can make choices that affect our risks. A healthy diet and regular exercise may reduce the risks associated with excess visceral fat, while poor dietary choices combined with a lack of exercise may increase risk even in someone with a lower BRI.  Regardless of your weight and body shape, the lifestyle choices you make can reduce your risks of diabetes, heart disease, and a host of other chronic conditions. References [1]Pray R, Riskin S. The History and Faults of the Body Mass Index and Where to Look Next: A Literature Review. Cureus. 2023;15(11). doi: https://doi.org/10.7759/cureus.48230  [2]Berg S. AMA: Use of BMI alone is an imperfect clinical measure. American Medical Association. Published June 14, 2023. https://www.ama-assn.org/delivering-care/public-health/ama-use-bmi-alone-imperfect-clinical-measure ‌  [3] Hamer M, O’Donovan G, Stensel D, Stamatakis E. Normal-Weight Central Obesity and Risk for Mortality. Ann Intern Med. 2017;166(12):917. doi: https://doi.org/10.7326/l17-0022 ‌  [4] Correa-Rodríguez M, González-Ruíz K, Rincón-Pabón D, et al. Normal-Weight Obesity Is Associated with Increased Cardiometabolic Risk in Young Adults. Nutrients. 2020;12(4):1106. doi: https://doi.org/10.3390/nu12041106  [5] Tinsley G. The 10 Best Ways to Measure Your Body Fat Percentage. Healthline. Published April 29, 2018. https://www.healthline.com/nutrition/ways-to-measure-body-fat [6] Blackburn H, Jacobs D. Commentary: Origins and evolution of body mass index (BMI): continuing saga. International Journal of Epidemiology. 2014;43(3):665-669. doi: https://doi.org/10.1093/ije/dyu061 [7] Solan M. Body roundness may beat body mass for identifying risky fat. Harvard Health. Published September 2024. https://www.health.harvard.edu/staying-healthy/body-roundness-may-beat-body-mass-for-identifying-risky-fat [8] Lee YH, Park J, Min S, Kang O, Kwon H, Oh SW. Impact of Visceral Obesity on the Risk of Incident Metabolic Syndrome in Metabolically Healthy Normal Weight and Overweight Groups: A Longitudinal Cohort Study in Korea.  Korean Journal of Family Medicine . 2020;41(4):229-236. doi: https://doi.org/10.4082/kjfm.18.0122 [9]Varra FN, Michail Varras, Varra VK, Panagiotis Theodosis‑Nobelos. Molecular and pathophysiological relationship between obesity and chronic inflammation in the manifestation of metabolic dysfunctions and their inflammation‑mediating treatment options (Review). Molecular Medicine Reports. 2024;29(6). doi: https://doi.org/10.3892/mmr.2024.13219 ‌ [10]Zhang C, Rexrode KM, van Dam RM, Li TY, Hu FB. Abdominal obesity and the risk of all-cause, cardiovascular, and cancer mortality: sixteen years of follow-up in US women. Circulation. 2008;117(13):1658-1667. doi: https://doi.org/10.1161/CIRCULATIONAHA.107.739714 [11]Warren TY. Independent Association of Waist Circumference With Hypertension and Diabetes in African American Women, South Carolina, 2007–2009.  Preventing Chronic Disease . 2012;9. doi: https://doi.org/10.5888/pcd9.110170 [12] Ross R, Neeland IJ, Yamashita S, et al. Waist circumference as a vital sign in clinical practice: A consensus statement from the IAS and ICCR working group on visceral obesity. Nature Reviews Endocrinology. 2020;16(3):177-189. doi: https://doi.org/10.1038/s41574-019-0310-7 ‌ [13] Verweij LM, Terwee CB, Proper KI, Hulshof CT, van Mechelen W. Measurement error of waist circumference: gaps in knowledge.  Public Health Nutrition . 2012;16(2):281-288. doi: https://doi.org/10.1017/s1368980012002741 ‌ [14] Bigaard J, Spanggaard I, Thomsen BL, Overvad K, Tjønneland; A. Self-Reported and Technician-Measured Waist Circumferences Differ in Middle-Aged Men and Women. The Journal of Nutrition. 2005;135(9):2263-2270. doi: https://doi.org/10.1093/jn/135.9.2263 ‌ [15]Thomas DM, Bredlau C, Bosy-Westphal A, et al. Relationships between body roundness with body fat and visceral adipose tissue emerging from a new geometrical model. Obesity. 2013;21(11):2264-2271. doi: https://doi.org/10.1002/oby.20408 ‌ [16] Yang M, Liu J, Shen Q, et al. Body Roundness Index Trajectories and the Incidence of Cardiovascular Disease: Evidence From the China Health and Retirement Longitudinal Study. J Am Heart Assoc. Published online September 25, 2024. doi: https://doi.org/10.1161/jaha.124.034768 ‌ [17] Rico-Martín S, Calderon-Garcia JF, Purificación Sánchez‐Rey, Franco-Antonio C, Mariana Martínez Álvarez, Francisco J. Effectiveness of body roundness index in predicting metabolic syndrome: A systematic review and meta‐analysis. 2020;21(7). doi: https://doi.org/10.1111/obr.13023 ‌ [18] Wu L, Pu H, Zhang M, Hu H, Wan Q. Non-linear relationship between the body roundness index and incident type 2 diabetes in Japan: a secondary retrospective analysis. Journal of Translational Medicine. 2022;20(1). doi: https://doi.org/10.1186/s12967-022-03321-x [19] Gao W, Jin L, Li D, et al. The association between the body roundness index and the risk of colorectal cancer: a cross-sectional study. Lipids in Health and Disease. 2023;22(1):53. doi: https://doi.org/10.1186/s12944-023-01814-2 [20] Zhang X, Ma N, Lin Q, et al. Body Roundness Index and All-Cause Mortality Among US Adults. JAMA Network Open. 2024;7(6):e2415051. doi: https://doi.org/10.1001/jamanetworkopen.2024.15051

Nourish Your Microbiome for Gut Health and Whole-Body Wellness The food you eat fuels your body and supports trillions of gut microbes vital for digestion, immunity, and mental health. Learn how a diet rich in prebiotics, probiotics, and plants can boost your gut and overall health. by   Lori A Smolin, PhD and Mary B Grosvenor, MS, RD   What we eat nourishes our bodies. Food provides energy and nutrients to fuel our activity, builds and maintains our muscles, bones, and other structures, and regulates body processes. But the food we eat also nourishes the community of microorganisms that live in our gut. This microbiome includes over one thousand species of microbes and contains more genes than the entire human genome.[1] The numbers and species of organisms in this microscopic world depend in part on what we feed them. In turn, they affect our gastrointestinal (GI) tract and overall health. What should you eat to promote a healthy microbiome?  What is the Gut Microbiome?  The gut microbiome includes all the microorganisms that live in our GI tracts, as well as the metabolites they produce, and the environment in which they live. [2] We have long known that the gut microbiome benefits our health. It facilitates the absorption of nutrients and synthesizes vitamins, including vitamin B12 and vitamin K. It metabolizes phytochemicals, increasing their bioavailability and health-promoting effects.[3] It digests food components, such as fiber, which cannot be broken down by human enzymes, producing important metabolites, and protects us from pathogens and toxins. We now understand that the microbiome also has effects that extend beyond the GI tract, impacting functions throughout the body and protecting against conditions ranging from depression to obesity. [4,5] How Do Microbes in Our Gut Impact Overall Health? Many of the health effects of the microbiome are believed to be mediated through the metabolites and other molecules produced by the microbes.[6]  Some of these have their effect at the intestinal epithelium, while others travel via the lymph and blood to other parts of the body. Molecules that remain in the gut have local effects as well as far-reaching consequences. For example, short chain fatty acids, produced by the breakdown of dietary fiber, are used for energy by epithelial cells in the colon and make the colon contents more acidic, preventing harmful microbes from growing.[4] Short chain fatty acids in the gut also have widespread effects. They influence the maturation of immune cells, which then migrate to other parts of the body, [6] and they bind to endocrine cells in the gut epithelium causing the release of peptides that affect food intake and glucose metabolism.[7] Likewise, neurotransmitters produced by the microbiome generate local effects, and distant ones by signaling the central nervous system. [6,8] Molecules that leave the gut can impact systems throughout the body by directly signaling neural, endocrine, immunological, and metabolic pathways and by triggering the release of signaling molecules such as neurotransmitters and metabolic factors. [4,6] For example, substances produced by gut bacteria affect levels of neurotransmitters in the brain and thus impact brain function and cognition, [8] and trimethylamine N-oxide (TMAO), a molecule produced by the microbiome, can alter metabolic pathways, increasing the risk of cardiovascular disease.[9] Compounds produced by phytochemical metabolism in the gut provide antioxidant, anti-inflammatory, and anti-cancer effects throughout the body.[3] Through these varied interactions, the microbiome plays an important role in regulating metabolic health, and has the potential to decrease or increase the risk of diseases such as diabetes, cardiovascular disease, and cancer. [4, 5] A Healthy Microbiome There is no single definition of a healthy microbiome and no single microbiome configuration that is consistent with overall health, [10] but in general a healthy microbiome is a diverse, balanced community of microorganisms that promotes the health of the host in a variety of ways.[11] The microbiome stimulates the immune response, protects the host from pathogens, limits inflammation, and supports the nervous system.[5] Early in life the gut microbiome contributes to the development and maturation of the immune system. The GI tract is host to a large number of immune cells, which are in constant communication with the gut microbiome. [5] This interaction helps to train and modulate the immune response, ensuring it is strong enough to fight infection, but not so strong that it damages the host. The immune system must protect against infection by pathogens but allow the growth of beneficial bacteria, while not permitting them to overgrow or cross the intestinal epithelium.[12]  A healthy gut microbiome helps maintain the mucosal barrier, which prevents the entry of pathogens and toxins into the body. The gut microbiome also helps support and protect the nervous system through its communication with the brain via nerves in the gut, molecules carried in the blood, and its effect on the immune system. [13] Dysbiosis: When Bad Bacteria Prevail Dysbiosis occurs when there is an imbalance in the microbiota; this could be a decrease in the number of beneficial bacteria, an overgrowth of harmful bacteria, or a decrease in overall microbiome diversity. Individuals with dysbiosis may experience GI symptoms such as gas, diarrhea, bloating, and food intolerances; dysbiosis has also been proposed to have far reaching health implications.[14]  Products produced by “bad” bacteria harm health by disrupting the epithelial barrier, triggering inflammation, and potentially driving the initiation and progression of colorectal cancer.[5] Interactions between the microbiome and the immune system have been implicated in inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis. An unhealthy microbiome has also been linked to extra-intestinal autoimmune diseases such as rheumatoid arthritis, and diseases linked to chronic inflammation such as diabetes, obesity, cardiovascular disease, and cancers. [5,12,14]  The gut-brain connection has also led to research that links disturbances in the gut microbiota to mental illnesses such as anxiety, depression, and neurodegenerative diseases. [13,14]  Eating to Boost the Health of Your Microbiome  The composition of the intestinal microbiota is unique to each person. It is shaped by a variety of factors including diet, age, gender, medications, body weight, exercise, socio-economic conditions, sleep, stress, smoking, and alcohol use. About half of the variability between individuals’ microbiomes can be attributed to diet.[15] Studies show that consuming a Mediterranean dietary pattern based on vegetables, fruits, whole grains, legumes, and nuts with moderate intake of fish, poultry, eggs, and dairy products has a beneficial effect on the microbiome when compared to a Western dietary pattern more reliant on red and processed meats and other processed foods. [15] Choosing a diet based on the plant foods – vegetables, fruits, whole grains, legumes, and nuts – that are the foundation of the Mediterranean diet promotes a healthy microbiome by providing an abundance of prebiotics and phytochemicals. Prebiotics are high-fiber foods that serve as nourishment for beneficial gut bacteria, stimulating their growth and activity. Foods high in prebiotics include bananas, garlic, barley, wheat bran, oats, apples, onions, chickpeas, avocados, and almonds. The phytochemicals found in these plant foods pass into the colon where they function as prebiotics, modifying the composition of the microbiota by stimulating or inhibiting the growth of certain types of microbes. [3] A diet containing probiotics also supports a healthy microbiome. Probiotics are living microorganisms found in fermented dairy and plant-based foods such as yogurt, kefir, miso, tempeh, sauerkraut, pickles, kombucha, and kimchi. When consumed these bacteria add to the existing microbiota, but only live temporarily in the gut, so to be of benefit they need to be consumed regularly. Probiotics are also available as supplements, but there is little information on which strains and doses are beneficial and safe for specific health conditions.[16] Food sources of probiotics are likely a better option because they are less expensive, have a history of safe use, provide a greater number and variety of microbes, and bring with them essential nutrients.  In contrast, choosing a diet high in red and processed meats, and the saturated fats they contain, can negatively alter the composition of the microbiome. For example, diets high in animal protein and saturated fat have been found to decrease the number of beneficial bacteria and reduce microbial diversity. [17,18] The breakdown of red and processed meats also produces metabolites that increase inflammation.[17] These changes are associated with an increased risk of metabolic diseases such as obesity and diabetes. Bottom Line  A healthy microbiome is essential to a healthy body and what you eat can affect your microbiome. Adopting a dietary pattern that is based on whole plant-based foods such as fruits, vegetables, and whole grains, which provide prebiotics and phytochemicals, and includes fermented foods such as yogurt and pickled vegetables, which provide probiotics, while limiting red and processed meats, can bolster your microbiome and promote your overall wellbeing. [15, 19] References  [1] Rajilić-Stojanović M, de Vos WM. The first 1000 cultured species of the human gastrointestinal microbiota. FEMS Microbiology Reviews . 2014;38(5):996-1047. doi: https://doi.org/10.1111/1574-6976.12075 [2] Berg G, Rybakova D, Fischer D, et al. Microbiome definition re-visited: old concepts and new challenges. Microbiome. 2020;8(1). doi: https://doi.org/10.1186/s40168-020-00875-0 [3] 1.Santhiravel S, Bekhit AEDA, Mendis E, et al. The Impact of Plant Phytochemicals on the Gut Microbiota of Humans for a Balanced Life. International Journal of Molecular Sciences.  2022;23(15):8124. doi: https://doi.org/10.3390/ijms23158124 ‌ [4] Afzaal M, Saeed F, Shah YA, et al. Human gut microbiota in health and disease: Unveiling the relationship. Frontiers in Microbiology . 2022;13. doi: https://doi.org/10.3389/fmicb.2022.999001 ‌ [5] Hou K, Wu ZX, Chen XY, et al. Microbiota in Health and Diseases. Signal Transduction and Targeted Therapy . 2022;7. doi: https://doi.org/10.1038/s41392-022-00974-4 ‌ [6] Kuziel GA, Rakoff-Nahoum S. The gut microbiome. Current Biology . 2022;32(6):R257-R264. doi: https://doi.org/10.1016/j.cub.2022.02.023 ‌ [7] Cani PD. Human gut microbiome: hopes, threats and promises.  Gut . 2018;67(9):1716-1725. doi:10.1136/gutjnl-2018-316723.  [8] Miri S, Yeo J, Abubaker S, Riadh Hammami. Neuromicrobiology, an emerging neurometabolic facet of the gut microbiome? 2023;14. doi: https://doi.org/10.3389/fmicb.2023.1098412 [9] Zhen J, Zhou Z, He M, et al. The gut microbial metabolite trimethylamine N-oxide and cardiovascular diseases.  Frontiers in Endocrinology . 2023;14. doi: https://doi.org/10.3389/fendo.2023.1085041‌ [10]  Shanahan F, Ghosh TS, O’Toole PW. The Healthy Microbiome (What is the definition of a healthy gut microbiome?).  Gastroenterology . 2020;160(2). doi: https://doi.org/10.1053/j.gastro.2020.09.057 [11] Van Hul M, Cani PD, Petitfils C , De Vos, WM, Tilg, H, El-Omar, EM. What defines a healthy gut microbiome?  Gut  2024;73 : 1893-1908. [12] Zheng, D., Liwinski, T. & Elinav, E. Interaction between microbiota and immunity in health and disease.  Cell Res  30, 492–506 (2020).  https://doi.org/10.1038/s41422-020-0332-7   ‌ [13] Loh JS, Mak WQ, Tan LKS, et al. Microbiota–gut–brain axis and its therapeutic applications in neurodegenerative diseases.  Signal Transduction and Targeted Therapy . 2024;9(1):1-53. doi: https://doi.org/10.1038/s41392-024-01743-1 [14] United Stated Department of Agriculture. Agricultural Research Service. Keeping a Healthy Gut.  https://www.ars.usda.gov/oc/utm/keeping-a-healthy-gut/ . Accessed December 9, 2024. [15] Merra G, Noce A, Marrone G, et al. Influence of Mediterranean Diet on Human Gut Microbiota.  Nutrients . 2021;13(1):7. doi: https://doi.org/10.3390/nu13010007 [16] NCCIH. Probiotics: Usefulness and Safety. NCCIH. Published 2016. https://www.nccih.nih.gov/health/probiotics-usefulness-and-safety [17] Beam A, Clinger E, Hao L. Effect of Diet and Dietary Components on the Composition of the Gut Microbiota. Nutrients.  2021 Aug 15;13(8):2795. doi:10.3390/nu13082795. ‌ [18] Wolters M, Ahrens J, Romaní-Pérez M, et al. Dietary fat, the gut microbiota, and metabolic health – A systematic review conducted within the MyNewGut project.  Clinical Nutrition . 2019;38(6):2504-2520. doi: https://doi.org/10.1016/j.clnu.2018.12.024 ‌ [19] Armet AM, Deehan EC, O’Sullivan AF, et al. Rethinking healthy eating in light of the gut microbiome.  Cell Host & Microbe . 2022;30(6):764-785. doi: https://doi.org/10.1016/j.chom.2022.04.016

A new study reveals a grim reality: hurricanes and tropical storms not only cause immediate devastation but also lead to a significant increase in mortality rates over the following 15 years. In a study published in October 2024, researchers looked at the late effects on mortality of tropical cyclones (hurricanes and tropical storms) affecting the continental U.S. from the years 1930 until 2015.  There were 501 storms during that time period and the researchers found that over a 15-year period a tropical cyclone generated 11,000 to 15,000 excess deaths in the affected areas.  Using wind speeds to classify storms as tropical cyclones, they looked at 20-year periods following tropical cyclones but found a mortality effect only during the first 15 years. The researchers noted that the mortality risk was greater in areas that rarely get tropical cyclones compared to areas that get them frequently.  Mortality risk after a tropical cyclone was also higher in black individuals than whites.      The authors estimated that the number of cyclones affecting the U.S currently imposes a burden of around 55,280–88,080 excess deaths per year. They suggested five possible reasons for this phenomenon:  Economic disruption  might change household economics.  As an example, a job loss from the storm might adversely affect health insurance, or retirement savings may be used to repair property damage.  Social network changes . As an example, younger working-age individuals leaving to find work in a different area after a tropical cyclone might decrease social support for older family members that remain behind.  State or local governments  restructuring budgets to support recovery after a tropical cyclone might necessitate a reduction of spending on healthcare infrastructure.  Ecological changes  could increase disease vectors, such as mosquitos, or flooding might expose populations to harmful chemicals. Increased physical and mental stress  from experiencing tropical cyclones may worsen long-term health.  One limitation of the study was not including data from individuals who left an area after a cyclone. They also did not take into account storm surges, flooding, or rainfall. Unknown confounding variables may also limit reliance on results.  Comments: The immediate tragedy of a severe weather event is clearly evident.  This study suggests that there are also long-term negative consequences as a result of these storms.  This study only looked at mortality, but it is also likely that there is also an increase of long-term non-fatal disease that may increase the public health burden after a tropical cyclone.   Click here to read another interesting article about the environment you may enjoy, The Effects of Plastics on Human Health.   Reference Young, R., Hsiang, S. Mortality caused by tropical cyclones in the United States. Nature  (2024). Retrieved from: https://www.nature.com/articles/s41586-024-07945-5#citeas

Dive into the world of pomegranates, the vibrant fruit with a rich history, powerful health benefits, and endless culinary possibilities. Culinary Medicine by Mary B Grosvenor, MS, RD   and Lori A Smolin, PhD Baskets of bright red pomegranates appear in grocery stores during the holiday season. This beautiful fruit has been part of the human diet for over five thousand years.[1] Throughout history they have been hailed for both their spiritual and their medical benefits, yet many of us still cannot figure out how we are supposed to eat them.  The Rich History and Symbolism of Pomegranates Pomegranates are a rounded hexagonal shaped fruit the size of a grapefruit that is classified botanically as a berry. They have a thick husk covering arrays of exquisitely arranged arils, which are the juice-filled sacs that surround the tiny white seeds; one pomegranate has about 600 arils. Originally cultivated near the Tigris and Euphrates Valley in what is now Iraq, they are now grown in India, Iran, Afghanistan, and Türkiye as well as California and some parts of Arizona.[2]  These luscious berries have played a spiritual role in many of the world's cultures and religions. In Greek mythology, pomegranates represent life, regeneration, and marriage.[3]  In Christianity, they are a symbol of resurrection and life everlasting. In ancient Rome, women wore headdresses of pomegranate leaves as a symbol of fertility.[4] They also symbolize fertility in Buddhism and Judaism. In biblical times, Moses promised his followers that they would find the fruit in the Promised Land.[5] In Islam, they represent the good things created by God. [2] Today, they are eaten as a part of Jewish Rosh Hashanah celebrations and in Iran during Yalda Night, a winter solstice celebration.[2]  Pomegranates as a Superfood: Nutritional and Medicinal Benefits Pomegranates have been called a superfood because of the nutrients and phytochemicals they provide. They are rich in fiber, vitamin C, folic acid, and potassium. They also contain a variety of polyphenols, including tannins and flavonoids. These phytochemicals provide potent anti-inflammatory and antioxidant effects; the antioxidant potential of pomegranate juice exceeds that of both red wine and green tea.[6,7,8]   Ancient cultures recognized the medicinal properties of pomegranates in treating a variety of disorders. In China and Mexico, pomegranates were used as a remedy for diarrhea and stomach aches. In traditional Islamic medicine, in addition to treating gastrointestinal problems, pomegranates were used for conditions ranging from infectious diseases to skin ailments.[9] Modern medicine continues to demonstrate a role for pomegranates in some of these conditions as well as to explore their anti-inflammatory and antioxidant effects in the prevention and management of chronic conditions such as heart disease, diabetes, and cancer. [6,8,10] Pomegranate juice has been shown to help keep blood pressure in the healthy range and to reduce the oxidation of LDL cholesterol, thereby potentially slowing the development of atherosclerosis.[6] Randomized control trials have shown that pomegranate juice increases insulin sensitivity, decreases insulin resistance, and lower blood glucoses.[10] In prostate cancer, pomegranate juice has been shown to inhibit the growth and promote the death of cancer cells. [6]The anti-inflammatory and antioxidant properties of pomegranates may also be beneficial in reducing the risks associated with skin, lung, and colon cancer.[6,11] But, how do you eat them?  Pomegranates may be a superfood, but they can be super challenging to eat. To learn how to prepare a pomegranate, start by picking a ripe one. Ripe pomegranates are a deep red color with slightly flattened sides; the skin should be soft and easily scratched.[12] The edible portion of a pomegranate includes the seeds and the juice-filled arils that surround them. To get to these, start by cutting off the top and bottom of the pomegranate and scoring the skin down the sides. Then split the fruit open with your hands, gently separating the sections. To detach the edible arils from the white membrane, place the sections in a bowl of water and push out the arils. The arils will sink while the membrane floats so it can be poured off. [5] Once you have opened a pomegranate, you can refrigerate it in a covered container for up to 5 days; a whole pomegranate can be refrigerated for up to 2 months.  There are lots of ways to eat a pomegranate. You can pop the arils directly into your mouth as a snack, add them to salads and fruit cups or sprinkle them on ice cream or other desserts. You can blenderize the arils to make juice. The juice can be used to make pomegranate glaze, jelly, and molasses. Pomegranate juice is used to create festive drinks: grenadine syrup is made from pomegranates.[12]  Pomegranate arils make a colorful garnish and the sweet and sour flavor makes them a versatile ingredient in meat, grain, and vegetable dishes as well as baked goods. So, experiment with this vibrant fruit to make your meals more colorful, flavorful, and healthful.  References [1] Pomegranates, from Antiquity to the present day | alimentarium. www.alimentarium.org . https://www.alimentarium.org/en/story/pomegranates-antiquity-present-day [2] Pomegranate. University of Wisconsin-Stevens Point. https://www.uwsp.edu/sbcb/tropical-conservatory/pomegranate/ [3] Langley P. Why a pomegranate? BMJ. 2000;321(7269):1153-1154. doi: https://doi.org/10.1136/bmj.321.7269.1153 [4] Brewer G. 5 things you didn’t know about pomegranates | Kew. www.kew.org . Published December 18, 2019. https://www.kew.org/read-and-watch/surprising-pomegranate-facts [5] Keller A. Pomegranates — Ancient Fruit with Modern Heart Health Benefits | Edible Paradise. Edibleparadise.com . Published 2014. https://edibleparadise.com/home-page-stories/pomegranates-ancient-fruit-with-modern-heart-health-benefits/ [6] Zarfeshany A, Asgary S, Javanmard SH. Potent health effects of pomegranate. Advanced Biomedical Research. 2014;3(1):100. doi: https://doi.org/10.4103/2277-9175.129371 [7] Bonesi M, Tundis R, Tundis R, Monica Rosa Loizzo. The Juice of Pomegranate (Punica granatum L.): Recent Studies on Its Bioactivities. Elsevier eBooks. Published online January 1, 2019:459-489. doi: https://doi.org/10.1016/b978-0-12-816681-9.00013-8 [8] Health benefits of pomegranates extend throughout the body. Uclahealth.org . Published March 18, 2022. https://www.uclahealth.org/news/article/health-benefits-of-pomegranates-extend-throughout-the-body [9] Mohammadi M, Boghrati Z, Emami SA, Akaberi M. Pomegranate: A review of the heavenly healer’s past, present, and future. Iranian Journal of Basic Medical Sciences. 2023;26(11):1245-1264. doi: https://doi.org/10.22038/IJBMS.2023.72816.15844 [10] Akaberi M, Zahra Boghrati, Amirhossein Sahebkar, Seyed Ahmad Emami. Therapeutic Potential of Pomegranate in Metabolic Disorders. Published online January 1, 2021:421-440. doi: https://doi.org/10.1007/978-3-030-73234-9_28 [11] Sharma P, McClees SF, Afaq F. Pomegranate for Prevention and Treatment of Cancer: An Update. Molecules : A Journal of Synthetic Chemistry and Natural Product Chemistry. 2017;22(1). doi: https://doi.org/10.3390/molecules22010177 [12] UF/IFAS. Pomegranate Recipes - Citrus Research and Education Center (CREC) - University of Florida, Institute of Food and Agricultural Sciences - UFL.edu . Published 2023. https://crec.ifas.ufl.edu/extension/pomegranates/pomegranate-recipes/ .

References for CME Article " What’s New in Adult Sexually Transmitted Infections Management and Prevention for 2024 " References [1] Sexually Transmitted Infections (STIs). CDC. Last Reviewed: January 30, 2024 Retrieved from: https://www.cdc.gov/std/statistics/2022/default.htm [2] National Overview of STIs in 2023. CDC. November 12, 2024. Retrieved from: https://www.cdc.gov/sti-statistics/annual/summary.html [3] Multi-drug resistant gonorrhoea. WHO. July 4, 2024. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/multi-drug-resistant-gonorrhoea [4] Zhu X et al. Ceftriaxone-Resistant Gonorrhea — China, 2022. CDC Morbidity and Mortality Weekly Report. March 28, 2024 / 73(12);255–259, Retrieved from: https://www.cdc.gov/mmwr/volumes/73/wr/mm7312a2.htm?s_cid=mm7312a2_w [5] Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. CDC-Morbidity and Mortality Weekly Report. December 18, 2020 / 69(50);1911–1916. Retrieved from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm [6] Positive Results Announced in Largest Pivotal Phase 3 Trial of a First-in-Class Oral Antibiotic to Treat Uncomplicated Gonorrhea. Businesswire.  November 01, 2023. Retrieved from: https://www.businesswire.com/news/home/20231101634842/en/Positive-Results-Announced-in-Largest-Pivotal-Phase-3-Trial-of-a-First-in-Class-Oral-Antibiotic-to-Treat-Uncomplicated-Gonorrhea [7] NIH Statement on Preliminary Efficacy Results of First-in-Class Gonorrhea Antibiotic Developed Through Public-Private Partnership. NIH. November 1, 2023. Retrieved from: https://www.niaid.nih.gov/news-events/nih-statement-preliminary-efficacy-results-first-class-gonorrhea-antibiotic-developed [8] Exploring a Meningitis Vaccine for Gonorrhea Prevention. NIH. May 10, 2024. https://www.niaid.nih.gov/news-events/meningitis-vaccine-gonorrhea-prevention [9] Johnson B. GSK’s gonorrhea vaccine receives fast-track designation to expedite clinical trials. Nature. 07 August 2023. Retrieved from: https://www.nature.com/articles/d41591-023-00069-9 [10] Roier S et al. A novel mechanism for the biogenesis of outer membrane vesicles in Gram-negative bacteria. Nat Commun. 2016;7:10515. Published 2016 Jan 25. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4737802/ [11] Gonococcal Infections Among Adolescents and Adults. CDC. Last Reviewed: September 21, 2022. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm [12] Syphilis. WHO. 21 May 2024. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/syphilis [13] Kojima N, Konda KA, Klausner JD. Notes on syphilis vaccine development. Front Immunol. 2022;13:952284. Published 2022 Jul 28. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9365935/ [14] Primary and Secondary Syphilis. CDC Sexually Transmitted Infections Treatment Guidelines, 2021. Last Reviewed: July 22, 2021. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/p-and-s-syphilis.htm [15] Syphilis During Pregnancy. CDC Sexually Transmitted Infections Treatment Guidelines, 2021. Last Reviewed: July 22, 2021. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/syphilis-pregnancy.htm [16] Syphilis. CDC. Last Reviewed: October 3, 2024. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/syphilis.htm [17] Bachmann LH, Mena L. Clinical Reminders during Bicillin L-A® Shortage. CDC. February 26, 2024, updated  September 9, 2024‎. Retrieved from: https://www.cdc.gov/sti/php/from-the-director/2023-07-20-mena-bicillin.html [18] Sexually transmitted infections (STIs). WHO. 21 May 2024. https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis) [19] Chlamydial Infections. CDC. Last Reviewed: July 22, 2021. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/chlamydia.htm [20] Legal Status of Expedited Partner Therapy (EPT). July 16, 2024. Retrieved from: https://www.cdc.gov/sti/php/ept-legal-status/?CDC_AAref_Val=https://www.cdc.gov/std/ept/legal/default.htm [21] Abraham S et al. Safety and immunogenicity of the chlamydia vaccine candidate CTH522 adjuvanted with CAF01 liposomes or aluminium hydroxide: a first-in-human, randomised, double-blind, placebo-controlled, phase 1 trial. The Lancet Infectious Diseases, Volume 19, Issue 10, 1091 - 1100. October 2019. Retrieved from: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(19)30279-8/abstract [22] Trichomoniasis. CDC. Last Reviewed: September 21, 2022. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm [23] Trichomoniasis. WHO. 16 October 2023. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/trichomoniasis [24] Nezhad G et al. Introduction of protein vaccine candidate based on AP65, AP33, and α-actinin proteins against Trichomonas vaginalis parasite: an immunoinformatics design. Parasites Vectors 17, 165 (2024). Retrieved from: https://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-024-06248-y [25] Johnson V. CRISPR-Editing EBT-101 Therapy Safe, Temporarily Suppresses HIV Infection. CGT Live. May 21, 2024. Retrieved from:  https://www.cgtlive.com/view/crispr-editing-ebt-101-therapy-safe-temporarily-suppresses-hiv-infection [26] Cox D, Barros Guinle MI.  This preventive drug could be a 'game changer' in ending the HIV epidemic. NPR, Goats and Soda - Stories of Life In a Changing World.  September 17, 2024. Retrieved from: https://www.npr.org/sections/goats-and-soda/2024/09/17/g-s1-23248/hiv-drug-aids-epidemic-lenacapavir [27] Bekker LG et al. Twice-Yearly Lenacapavir or Daily F/TAF for HIV Prevention in Cisgender Women. NEJM. July 24, 2024. https://www.nejm.org/doi/full/10.1056/NEJMoa2407001 [28] Herpes simplex virus. WHO. 13 September 2024. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/herpes-simplex-virus [29] About Genital Herpes. CDC. February 20, 2024. Retrieved from: https://www.cdc.gov/herpes/about/index.html [30] Nadia A et al. CRISPR-Cas9-mediated genome editing delivered by a single AAV9 vector inhibits HSV-1 reactivation in a latent rabbit keratitis model. Molecular Therapy Methods & Clinical Development, Volume 32, Issue 3. Retrieved from:  https://www.cell.com/molecular-therapy-family/methods/fulltext/S2329-0501(24)00119-0 [31] Human papillomavirus and cancer, WHO. 5 March 2024. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/human-papilloma-virus-and-cancer [32] Clinical Overview of HPV. CDC. July 9, 2024. Retrieved from: https://www.cdc.gov/hpv/hcp/clinical-overview/index.html [33] About HPV. CDC. July 3, 2024. Retrieved from: https://www.cdc.gov/hpv/about/index.html [34] HPV Vaccine Recommendations. CDC, July 9, 2024, Retrieved from: https://www.cdc.gov/hpv/hcp/vaccination-considerations/index.html [35] Mycoplasma genitalium. CDC. Last Reviewed: July 22, 2021. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm [36] Treatment of Mycoplasma genitalium infection in pregnancy: A systematic review of international guidelines. International Journal of Obstetrics & Gynecology. Volume166, Issue1, Pages 27-34. July 2024.  Retrieved from: https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/ijgo.15469 [37]Mycoplasma genitalium. Australian STI Management Guidelines for Use in Primary Care. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Last updated: April, 2024. Retrieved from: https://sti.guidelines.org.au/sexually-transmissible-infections/mycoplasma-genitalium/

The Connection Between Brain Anatomy and Political Ideology New study explores the role of the amygdala and anterior cingulate cortex in shaping political beliefs MEDICAL NEWS In a Dutch study published September 2024, researchers looked at whether amygdala or anterior cingulate cortex volume correlated with political ideology.  This was based on a previous study in the United Kingdom of young adults that found a correlation between larger right amygdala volumes and conservative political views as well as finding that larger anterior cingulate cortex volumes correlated with more liberal political views.  A previous U.S. study found a correlation between larger amygdala size and individuals believing that the existing social order was legitimate and desirable, and reported that individuals with larger amygdala sizes were less likely to participate in protest movements. In the Dutch study researchers reviewed 928 MRIs and correlated them to the subjects’ political party affiliation. They found a correlation of increasing right amygdala volume with political conservatism, but no relationship of anterior cingulate cortex volume to political ideology. Comments: The amygdala is an almond-like structure located within the cerebral hemispheres which is part of the limbic system. It regulates emotions, such as sadness, uncertainty, aggression, social cognition and fear.  It is thought to be involved in the processing of negative stimuli such as threats. The anterior cingulate cortex, also part of the limbic system, has a role in cognitive processes such as motivation, decision making, learning, cost-benefit calculation, and conflict and error monitoring.  It may also be involved in social behavior. It should be remembered that a correlation between two findings does not mean definitely that one caused the other.  Also, political party affiliation may not fully represent a person’s views.  Whether differences in brain anatomy are genetic or whether people with certain political views tend to use certain parts of their brains more often which causes them to enlarge, was not determined from these studies. While far from proven, it is a fascinating possibility that anatomical differences in the brain and the way an individual’s brain functions may partially explain political ideology preferences.    If you found this article interesting, you may also like reading- Increased Screen Time in Children is Associated with Worse Executive Functioning and Brain Wave Changes References Petalas DP et al. Is political ideology correlated with brain structure? A preregistered replication IScience. September 19, 2024. Retrieved from: https://www.cell.com/action/showPdf?pii=S2589-0042%2824%2901757-7 Kanai R et al. Current Biology. 21 677-680, April 26, 2011. Political Orientations Are Correlated with Brain Structure in Young Adults. Retrieved from: https://www.cell.com/current-biology/pdf/S0960-9822(11)00289-2.pdf Nam NH et al. Amygdala structure and the tendency to regard the social system as legitimate and desirable. Nature Human Behaviour. December 2017. Retrieved from: https://vanbavellab.hosting.nyu.edu/documents/Nam.etal.2018.NHB.pdf Apps MA, Rushworth MF, Chang SW. The Anterior Cingulate Gyrus and Social Cognition: Tracking the Motivation of Others. Neuron. 2016;90(4):692-707. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885021/

Discover the surprising connection between belly fat and chronic pain. A new study reveals how excess abdominal fat can contribute to widespread musculoskeletal pain. MEDICAL NEWS A study using the United Kingdom Biobank data looked at 32,409 participants, who had abdominal MRIs, for any association with increased abdominal fat tissue and widespread or multisite chronic pain syndromes.  It looked at MRI findings of the amount of abdominal visceral adipose tissue (VAT-fat around the abdominal organs) and subcutaneous abdominal adipose tissue (SAT-fat just under the abdominal wall skin) and complaints of neck/shoulder, back, hip, knee or all over the body chronic pain.  The subjects were about evenly divided between women and men, with a mean age of 55 years. The researchers found an association of both VAT and SAT with the number of chronic musculoskeletal pain sites in both women and men.  They reported that higher amounts of VAT and SAT correlated to higher numbers of chronic musculoskeletal pain sites.  For women each standard deviation increase in VAT was correlated to a two times higher risk of having more sites of chronic musculoskeletal pain, while for men, each standard deviation increase in VAT was associated with a 34% increased risk of having more sites of chronic musculoskeletal pain.  For women, each standard deviation increase in SAT was associated with a 60% increased risk of having more chronic musculoskeletal pain sites and for men, a 39% increased risk.  The authors adjusted for age, height, ethnicity, household income, highest education level, alcohol frequency, smoking status, physical activity, comorbid conditions, sleep duration, psychological problems and follow-up time, but still found that the association between increased VAT and SAT and the number of chronic musculoskeletal pain persisted.  The researchers stated that the results suggested that excessive abdominal adipose tissue may be implicated in the pathogenesis of chronic musculoskeletal pain.  The fact that women had higher correlations between abdominal fat and chronic musculoskeletal pain site might reflect different fat distribution or hormonal effects. Theories as to why this may occur include: VAT and SAT have been linked to increased levels of cytokines such as interleukin-6 and C-reactive protein and adipokines such as leptin.  These are markers of body inflammation which have been proposed as a possible cause of musculoskeletal pain.  Chronic inflammation may also affect peripheral nerves, which may possibly be another cause of chronic pain. Comments: In this first ever large study of MRI measured abdominal fat volume, an association between higher levels of both VAT and SAT to increased number of sites of musculoskeletal pain were found in both men and women.  The authors tried to control for socioeconomic and activity levels and still found this association held. Weaknesses of the study include the fact that although an association (or correlation) was found between abdominal fat tissue and the number of chronic musculoskeletal pain sites, it doesn’t prove that abdominal fat is in fact a cause of chronic musculoskeletal pain.  In addition, 97% of the subjects were white so it may not be applicable to other ethnic groups.  In this type of study there can also be unmeasured confounding variables which might affect results. This study adds an additional potential risk factor for chronic pain of increased abdominal fat, as documented by MRI.  Further study is needed, but this data does suggest that weight loss leading to decreased fat deposits might possibly decrease chronic musculoskeletal pain via a metabolic mechanism. If you found this article interesting, you may also like reading -   Eating Red Meat May Increase the Risk of Diabetes Reference Kifle ZD, Tian J, Aitken D, et al. MRI-derived abdominal adipose tissue is associated with multisite and widespread chronic pain. Regional Anesthesia & Pain Medicine Published Online First: 10 September 2024. Retrieved from: https://rapm.bmj.com/content/rapm/early/2024/08/06/rapm-2024-105535.full.pdf

Explore research on how multifocal lenses affect fall risks and balance, with implications for patient care. MEDICAL NEWS Presbyopia, which occurs during aging, is the loss of the eye’s ability to focus on nearby objects, due to the lens getting less flexible and not focusing light correctly on the retina. When this occurs, people who have problems seeing both near and far may be prescribed multifocal lenses (bifocals, trifocals or progressive lenses). It seems counterintuitive that multifocal lenses, which are supposed to improve vision, actually can increase the risk of falls. Key Findings from Clinical Studies on Multifocal Lenses and Fall Risk A trial of 156 subjects, aged 63 to 100, compared people who wore multifocal eyeglasses to those that didn’t. It was reported that multifocal eyeglass wearers were 2.29 times more likely to fall than the controls. A second study found that multifocal lens wearers made contact with more obstacles when walking than they did when they were wearing single-vision glasses. Depth perception and distant edge-contrast sensitivity (the ability to perceive outlines of distant objects and distinguish them from the background) have been found to be decreased with multifocal lenses compared to single-vision glasses. Visual distortion may occur because the lower part of a multifocal lens is meant for reading and can actually blur more distant objects, making falls more likely. Another issue is how well people can adjust their head angle relative to the glasses to allow vision in the middle of the lens rather than the lower part when walking or climbing stairs. One suggested remedy for individuals where falls are a problem is the use of two sets of glasses, a multifocal lens pair for general use and a single-vision pair to use when walking. A study found that multifocal lens wearing subjects had an 8% reduction in falls when they were given single-vision distance glasses to use when walking and for outdoor activities, compared to a control group. If someone with both near and far vision difficulty requires cataract surgery, another possible remedy, to avoid the use of multifocal lens glasses post-operatively, is to insert a multifocal intraocular lens. Multifocal intraocular lens implants have not been found to increase falls when compared to monofocal intraocular lens implants. Other Ophthalmology articles in our FibonacciBLOG : " A look at four common eye maladies: Arcus Senilis, Ectropion, Pterygium, and Pinguecula "  by Evan Mostafa, MD and George J.Florakis, MD " Sudden Vision Loss: An Approach to Acute Vision Loss " by   Eleni Florakis and George J. Florakis, MD " Amblyopia - AKA Lazy Eye " by Emily Groenendaal, MD, and George J Florakis, M.D.   References Timmis MA, Johnson L, Elliott DB, Buckley JG. Use of single-vision distance spectacles improves landing control during step descent in well-adapted multifocal lens-wearers. Invest Ophthalmol Vis Sci. 2010;51(8):3903-3908. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/20207976/ Lord SR, Dayhew J, Howland A. Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. J Am Geriatr Soc. 2002;50(11):1760-1766. Retrieved from: https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1046/j.1532-5415.2002.50502.x Chang D. Multifocal Spectacle and Monovision Treatment of Presbyopia and Falls in the Elderly. Journal of Refractive Surgery. 06/01/2021. Retrieved from: https://journals.healio.com/doi/epdf/10.3928/1081597X-20210408-02 Supuk E, Alderson A, Davey CJ, et al. Dizziness, but not falls rate, improves after routine cataract surgery: the role of refractive and spectacle changes. Ophthalmic Physiol Opt. 2016;36(2):183-190. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949987/ Haran MJ, Cameron ID, Ivers RQ, et al. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial [published correction appears in BMJ. 2016 May 27;353:i3041. doi: 10.1136/bmj.i3041]. BMJ. 2010;340:c2265. Published 2010 May 25. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876235/ Renz E, Hackney M, Hall C. Foot clearance and variability in mono- and multifocal intraocular lens users during stair navigation. J Rehabil Res Dev. 2016;53(6):933-944. Retrieved from: https://www.rehab.research.va.gov/jour/2016/536/pdf/JRRD-2015-02-0030.pdf Gadzhanova S, Gillam M, Roughead E. Risk of falls and injuries requiring hospitalisation after first-eye cataract surgery in elderly Australians. Acta Ophthalmol. 2020;98(4):e495-e498. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31654472/

A broad view and summary of a scary, sudden, and seemingly complex disorder. Ophthalmology An Approach to Acute Vision Loss by Eleni Florakis and George J. Florakis, MD Acute vision loss can be very distressing to both patients and physicians and extremely important to diagnose in a timely manner. There are many different causes of acute vision loss which can occur anywhere along the visual tract, from the cornea to the occipital lobe [1]. Acute vision loss may be benign and reversible, but it may also represent a more malignant, irreversible process. Prompt diagnosis is necessary to treat and potentially save the patient’s vision and/or life. As with any new presenting symptom, the first step is to obtain a thorough history and physical. Acute vision loss can be caused by many different etiologies including ocular, vascular, and neurological pathologies. A detailed medical history may help determine whether one of these categories of pathology should be considered. Medical History Some risk factors that might make one think about a primary ocular pathology include contact lens use, severe myopia, and recent eye surgery or trauma. On the other hand, cardiovascular risk factors such as diabetes, hypertension, and hyperlipidemia may increase the risk of a vascular etiology such as retinal artery or vein occlusion, cardiac emboli, carotid disease or vertebrobasilar occlusive disease. Hematologic disorders including sickle cell anemia, Waldenstrommacroglobulinemia, or multiple myeloma can lead to a hyperviscosity syndrome, and may also indicate a vascular etiology [2]. A personal history of multiple sclerosis should prompt an assessment of the optic nerve since optic neuritis occurs at some point in about 50 percent of patients with multiple sclerosis [3]. Methanol toxicity which can present as blurred “snowfield” like visual changes, or may manifest as a dense centrocecal scotoma (Complete or partial central vision loss in a horizontal oval distribution extending between the point of fixation and the blindspot), should be considered in patients with a history of drug ingestion, fire breathing using methanol, or consumption of home distilled spirits. If diagnosed early, methanol toxicity can be treated by inhibiting the metabolism of methanol with fomepizole and preventing permanent vision loss from optic atrophy [4]. A history of transient ischemic attack or stroke may point towards a neurologic etiology. Many systemic medications are associated with ocular side effects, and the patient’s medication list should be reviewed. Somemedicationsassociated with acute vision loss include anticholinergics (which can present as loss of accommodation or angle closure glaucoma), sildenafil (ischemic optic neuropathy), sulfonamides (myopia), and topiramate (acute angle closure glaucoma). Most of these medications will produce visual symptoms gradually when prescribed in high doses and/or with prolonged use (except for those that induce acute angle closure glaucoma)[3]. Some examples of anticholinergic medications include atropine, benztropine mesylate, darifenacin, dicyclomine, fesoterodine, oxybutynin, tolterodine, scopolamine, and over the counter antihistamines such as diphenhydramine, brompheniramine, chlorpheniramine and meclizine. History of Present Illness The history of present illness may be helpful in making the correct diagnosis. Location, quality, and timing of the vision loss is important to inquire about, as well as whether the vision loss is monocular or binocular and associated with any other symptoms including ocular pain. The patient may describe blurry vision usually associated with a media-related ocular issue (the optic media includes the cornea, aqueous humor, lens, and vitreous body), a dimming of the vision indicative of avascular issue, reduction in the visual field suggestive of a retinal or neurological issue, or a showering of black dots which may be perceived by the patient in a vitreous hemorrhage. If the patient describes a floating or moving scotoma, this may also suggest a vitreous pathology. Fixed scotomas (partial or complete vision loss in the field of vision) would indicate the pathology is in structures that are fixed relative to the globe (corneal, lenticular, retinal, optic nerve, or from neurological damage). Sudden vision blur that only lasts a few seconds may be indicative of tear film abnormalities. The tear film is a thin fluid layer covering the eye, and transient decreased vision due to an issue in the tear film may clear with blinking. Vision loss that only lasts a few seconds may also be due to papilledema, or vitreous debris. Vision loss that lasts less than 10 minutes may be associated with carotid or vertebrobasilar artery disease, cardiac emboli, or with initial symptoms of giant cell arteritis. Vision loss that lasts a couple of hours may suggest transient acute closure glaucoma, ophthalmic migraine, retinal artery/vein occlusion, retinal detachment, or optic neuritis [5]. If the vision loss lasts over 24 hours,diagnoses include acute angle closure glaucoma, vitreous hemorrhage, retinal detachment, retinal artery occlusion, retinal vein occlusion, optic neuritis, ischemic optic neuropathy, and cerebrovascular accident [6]. Monocular vision loss is often associated with local eye pathologies such as glaucoma, uveitis, retinitis or neurological diseases like optic neuritis or anterior ischemic optic neuropathy. Alternatively, binocular vision loss usually affects structures further back in the visual pathway including the optic chiasma, lateral geniculate body, occipital radiations, and the occipital cortex [7]. There are many different symptoms that are commonly associated with vision loss and can point one towards a specific diagnosis. Visual flashes of lights or floating shadows are indicative of a retinal detachment. A combination of tearing, halos around lights, nausea, and vomiting may be associated with acute angle closure glaucoma. Jaw/tongue claudication, temporal headache, proximal muscle pain and stiffness, diplopia, weight loss, and night sweats are symptoms of giant cell arteritis. Headache with vision loss may be associated with a migraine, giant cell arteritis, or pituitary apoplexy(infarction or hemorrhage of the pituitary). Presyncope symptoms may cause transient vision loss from postural hypotension. Neurologic symptoms should be reviewed for stroke or pituitary apoplexy [8]. The presence or absence of ocular pain can also help point one towards a specific diagnosis. Ocular pain with eye movement can be suggestive of retrobulbar optic neuritis, and if the pain is exacerbated by exercise or elevated body temperature it is known as Uhthoff’s phenomenon. Localized ocular pain may suggest a corneal pathology (ulcer or abrasion), anterior chamber inflammation, or increased intraocular pressure [9]. Painful visual impairment can also be seen in optic neuritis, Tolosa Hunt syndrome (painful weakness of the eye muscles due to granulomatous inflammation of the cavernous sinus), orbital apex syndrome (dysfunction of the optic and cranial nerves due to a process that affects the optic canal and superior orbital fissure/orbital apex), pituitary apoplexy, and glaucoma. On the other hand, diseases of the optic tracts such as anterior ischemic optic neuropathy, the optic radiations (part of the visual tract that connects the optic tracts to the visual cortex in the occipital lobe), or the occipital cortex tend to be painless [10]. Physical Exam After a history is obtained, a thorough ocular exam should be conducted. This includes inspection, visual acuity, visual fields, tonometry, pupil examination, evaluation of extraocular movement, slit lamp examination, fluorescein application, color vision examination, red reflex examination, and fundus examination. During inspection, ptosis, proptosis, injection or chemosis should be assessed. Ptosis may indicate a neurologic process, while proptosis may signify a structural process. Injection or chemosis may indicate an ocular or retrobulbar pathology. Visual acuity and fields should be completed to confirm and specify the extent of vision loss acquired from the history. Tonometry should be performed to see if the patient has an elevated intraocular pressure which would be indicative of glaucoma. Patients with acute angle closure glaucoma present with an elevated intraocular pressure along with a cloudy/steamy cornea, a mid-dilated pupil and conjunctival injection on exam. Thus, a pupil examination, which includes evaluation of symmetry, reactivity to light, and pupillary reflex testing, is also helpful. An abnormal pupil examination may also be indicative of a neurologic process. Pupillary reaction testing should include the swinging-flashlight test to look for consensual pupillary reflexes. During the swinging-flashlight test, a light is shined into one eye and then rapidly moved to the other eye. When the light is shined into one eye, both pupils should constrict. While the light is being moved into the other eye both pupils should expand and constrict again when the light is shined into the opposite eye. If the pupils respond asymmetrically to the light stimuli, the patient would be diagnosed with a relative afferent pupillary defect (RAPD) . A RAPD indicates a monocular optic nerve disease or abnormality of the retina. Exceptions include surgical, traumatic or pharmacologically altered pupils. Topical fluorescein application is used to diagnose keratitis, corneal abrasion, and corneal edema. Color vision testing helps detect optic neuropathy. A patient with optic neuropathy will perceive the color red to be either absent or duller in the affected eye. An abnormal red reflex exam indicates media opacities such as a cataract or vitreous hemorrhage or intraocular pathology such as retinal detachment or tumor [3,5]. Fundus examination may demonstrate retinal hemorrhaging and/or retinal whitening seen in retinal detachments, or cotton-wool spots which are indicative of vascular disease causing retinal arteriole obstruction and resulting damage to nerve fibers. Arteriolar narrowing or tortuosity , optic tumor , and/or venous engorgement should also be looked for . Fundus examination may also reveal optic disc swelling and pallor seen in optic neuropathy, or an increase in the cup-to-disc ratio characteristic of chronically increased intraocular pressure. The macula examination may reveal a cherry-red spot typically seen in retinal ischemia. If there are signs of giant cell arteritis which include temporal artery tenderness or induration, pale retina, or papilledema, and the patient is complaining of temporal headaches, jaw claudication, proximal myalgias or stiffness, an erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and platelet count should be ordered. If giant cell arteritis is suspected, the patient should be started on high dose steroids immediately to preserve any remaining vision. Any vision loss that already occurred is most likely irreversible. Treatment for giant cell arteritis includes methylprednisolone 1000 mg IV daily for one to three days, followed by prednisone 60 mg/day for two to four weeks [3,5]. Depending on the history and ocular examination, other aspects of the physical exam may need to be performed to narrow the differential diagnosis. These may include checking the patient’s blood pressure, blood sugar levels, (can be high or low with pituitary apoplexy), auscultating the carotid arteries for bruits, the heart for murmurs, and a careful examination of the cranial nerves. Deficits of the optic nerve , oculomotor nerve (controls movement of the eye and pupil), trochlear nerve (controls torsional movement of the eye), and the ophthalmic branch of the trigeminal (provides sensory stimuli) and abducens nerves (controls lateral movement of the eye) may indicate an orbital mass since all these nerves are located within the orbit. Alternatively, deficits in the maxillary branches of the trigeminal nerve , which runs through the cavernous sinus, and supplies sensation to the mid-third of face along with central retinal vein occlusion may indicate cavernous sinus thrombosis (a clot in the cavernous sinus which is life-threatening) [5]. Treatment Once the diagnosis is determined, treatment should commence immediately. In certain scenarios such as giant cell arteritis, immediate treatment can save the patient’s remaining vision. Other emergent cases that should be treated in an urgent manner include central retinal artery occlusion (CRAO), acutely elevated intraocular pressure, and pituitary apoplexy. In CRAO, it is presumed that vision loss may be reversible if blood flow is restored in approximately 100 minutes, before ganglion cell death occurs. Some interventions include attempting to lower the intraocular pressure with digital massage, paracentesis, or pharmacologic agents. Unfortunately, many of these proposed interventions have not been established in randomized trials due to the low likelihood of collecting enough subjects to do a large study [3]. Acutely elevated intraocular pressure (IOP) due to angle-closure glaucoma should also be treated urgently since irreversible vision loss many occur within hours if the IOP remains above 40 mmHg. Initial management should include pressure-lowering eye drops such as0.5% timolol maleate (Timoptic), 1-2% Brominidine (Alphagan), and 2% pilocarpine(Isopto Carpine) one drop each, one minute apart. The order in which these drops are administered is not of importance. Note that Timoptic is contraindicated in patients with ronchial asthma, severe COPD, sinus bradycardia, second- or third-degree AV block and overt cardiac failure. Alphagan is contraindicated in patients with Raynaud’sphenomenon or Buerger’s disease, and Isopto Carpine is contraindicated in patients with inflammation of the cornea or iris or detachment of the retina. If these ocular medications cannot be given, acetazolamide administered either orally or intravenously may also help to acutely reduce intraocular pressure. Please note that acetazolamide is contraindicated if the patient is allergic to sulfa and or has sickle cell disease. Once the pressure is lowered, definitive treatment, such as laser or surgical peripheral iridotomy, should be performed [3]. Pituitary apoplexy should always be considered whenever a patient presents with a headache associated with sudden blindness and/or ophthalmoplegia (inability to move the eye due to paralysis of the extraocular muscles). Patients with pituitary apoplexy may also present with nausea and vomiting and neck stiffness. These patients are at risk of abrupt and rapid neurological decline which can lead to depressed level of consciousness and even death if not diagnosed and treated properly. CT or MRI (preferably MRI) can reveal the diagnosis via demonstration of hemorrhage into the pituitary. Treatment includes high-dose systemic corticosteroids to avoid adrenal insufficiency and possible neurosurgical intervention. Electrolyte, glucose, and hormone levels must be evaluated as well as an emergent consultation with an endocrinologist [4]. In other cases, immediate treatment may not be necessary but semi-urgent referral may be needed to prevent permanent vision loss. For example, if not treated with antibiotics, microbial keratitis can lead to permanent scarring or corneal perforation. Cultures may be needed which takes some time to process. Another example includes macula-involving retinal detachment which should be surgically repaired within a week so that the patient has the best visual outcome as opposed to macular sparing retinal detachments which need to be treated more urgently [3]. Historically, these were both treated with urgency until it was found that urgent surgical repair of macular involving retinal detachments did not yield any increased visual benefit. Unfortunately, for other etiologies such as vascular disorders, treatment is unlikely to salvage the affected eye, but it can decrease the risk of the same process occurring in the contralateral eye or of a complication caused by the same process (e.g. ischemic stroke requiring anticoagulation) [2]. Thus, it is still important to diagnose and treat in a timely manner. Referrals to specialties other than ophthalmology may also be warranted depending on the diagnosis. For example, cardiologists should be consulted in patients with retinal artery occlusion since the most common cause of death in these patients is cardiac disease. A cardiac source such as a mural thrombus, valvular heart disease, patent foramen ovale, or arrythmia may be identified and possibly corrected. Patients who present with neurological symptoms including weakness, numbness, paresthesia, dysarthria, dysphagia, or headache should be sent to an emergency department immediately, where an emergent neurology consult can be obtained [4]. Conclusion In conclusion, acute vision loss can present in a vast variety of ways and in many different clinical contexts. A thorough history and physical is necessary to determine the underlying cause. Other tests and referrals to different specialties may be required for diagnosis and/or treatment. Timely identification of the primary pathology is crucial to enable the clinician to treat the underlying disease process, prevent further vision loss, possibly restore full vision and to prevent any other systemic sequelae. Review Hints from the PMH Consider: Primary ocular pathology - if contact lens use, severe myopia, or recent eye surgery or trauma. Vascular etiology ( retinal artery or vein occlusion, cardiac emboli, carotid occlusive disease or vertebrobasilar disease )- if cardiovascular risk factors such as diabetes, hypertension, and hyperlipidemia are present. Hyperviscosity syndrome and vascular etiology - from hematologic disorders including sickle cell anemia, Waldenstrom macroglobulinemia, or multiple myeloma). Optic neuritis – if there is a history of multiplesclerosis. Methanol toxicity -if patient has a history of drug ingestion, fire breathing, or consumption of home distilled spirits. Neurologic pathology - if history of transient ischemic attack or stroke . Medication related - if patient is taking an ananticholinergic (loss of accommodation or angle closure glaucoma), sildenafil (ischemic optic neuropathy), sulfonamide (myopia), or topiramate (acute angle closure glaucoma). Hints from the HPI Blurry vision – usually a media-related ocular issue (the optic mediai ncludes the cornea, aqueous humor, lens, and vitreous body) Dimming of the vision –may be indicative of a vascular issue Reduction in the visual field -suggestive of a retinal or neurologica lissue Showering of black dots -vitreous hemorrhage Floating, moving scotoma - may suggest a vitreous pathology Sudden vision loss that only lasts a few seconds -may be indicative of tear film abnormalities, papilledema, optic disc drusen, or vitreous debris. Binocular vision loss -usually affects structures further back in the visual pathway including the optic chiasma, lateral geniculate body, occipital radiations, and the occipital cortex Flashes of lights or floating shadows - indicative of a retinal detachment Headache - migraine, giant cell arteritis, or pituitary apoplexy (infarction or hemorrhage of the pituitary) Ocular pain with eye movement - suggestive of retrobulbar optic neuritis (especially if exacerbated by exercise or elevated body temperature called Uhthoff’s phenomenon) Localized ocular pain - may suggest a corneal pathology (ulcer or abrasion), anterior chamber inflammation, or increased intraocular pressure Painful visual impairment - also be seen in optic neuritis, Tolosa Hunt Syndrome (granulomatous inflammation of the cavernous sinus), orbital apex syndrome, pituitary apoplexy, and glaucoma. Hints from the Physical Ptosis -may indicate a neurologic process Proptosis -may signify a structural process Injection or chemosis -may indicate an ocular or retrobulbar pathology Relative afferent pupillary defect (RAPD) -indicates a monocular optic nerve disease or abnormality of the retina. Topical fluorescein application -used to diagnose keratitis, corneal abrasion, and corneal edema. Color vision testing -helps detect optic neuropathy. Abnormal red reflex exam -indicates media opacities such as a cataract or vitreous hemorrhage or intraocular pathology such as retinal detachment ortumor Fundus examination retinal hemorrhaging and/or retinal whitening -seen in retinal detachments cotton-wool spots - indicative of vascular disease (e.g. ischemia from retinal arteriole obstruction and subsequent nerve fiber layer infarct) optic disc pallor – optic neuropathy increase in the cup-to-disc ratio -increased in chronically elevated intraocular pressure increase in the cup-to-disc ratio -chronically increased intraocular pressure macula cherry-red spot -retinal ischemia deficits of the optic nerve, oculomotor nerve, trochlear nerve, and the ophthalmic branch of the trigeminal and abducens nerves -may indicate an orbital mass since all these nerves are located within the orbit. deficits in the maxillary branches of the trigeminal nerve along with central retinal vein occlusion -may indicate cavernous sinus thrombosis. Two Diseases You Shouldn’t Forget Giant cell arteritis - jaw/tongue claudication, temporal headache, proximal muscle pain and stiffness, diplopia, weight loss, and night sweats Pituitary apoplexy -headache associated with sudden blindness and/or ophthalmoplegia, and possibly nausea, vomiting, and neck stiffness Other Ophthalmology articles in this blog: “ Amblyopia - AKA Lazy Eye ” by Emily Groenendaal, MD, and George J Florakis, M.D. " A look at four common eye maladies: Arcus Senilis, Ectropion, Pterygium, and Pinguecula " by Evan Mostafa, MD and George J.Florakis, MD " Multifocal Lenses: Use of Bifocal, Trifocal and Progressive Eyeglasses Can Increase the Risk of Falling " References Muth CC. Sudden Vision Loss. JAMA. 2017 Aug 8;318(6):584. doi: 10.1001/jama.2017.7950. PMID: 28787508. Brady C. “Acute Vision Loss.” Merck Manual, 2021 May, https://www.merckmanuals.com/professional/eye-disorders/symptoms-of-ophthalmologic-disorders/acute-vision-loss . Leveque T. “Approach to the adult with acute persistent visual loss.” Up To Date, https://somepomed.org/articulos/contents/mobipreview.htm?9/51/10032#H33 . “Sudden Visual Loss.” American Academy of Ophthalmology, 2021, Neuro-Ophthalmologic Emergencies: Sudden Visual Loss (aao.org) , https://www.aao.org/focalpointssnippetdetail.aspx?id=9afe10a9-5569-4903-986b-b0c5ddbc389e. Goold L, Durkin S, Crompton J. Sudden Loss of Vision. Australian Family Physician. 2009 Oct; 38(10): 764-768. Bagheri N, Mehta S. Acute Vision Loss. Prim Care. 2015 Sep;42(3):347-61. doi: 10.1016/j.pop.2015.05.010. PMID: 26319342. Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. Visual Field Deficits. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10912/ Santhakumaran, S. Approach to Acute Vision Loss. McGill Journal of Medicine. 2021 Apr;19(2). Doi: 10.26443/mjm.v19i1.492 . Prasad S, Galetta SL. Approach to the patient with acute monocular visual loss. Neurol Clin Pract. 2012 Mar;2(1):14-23. doi: 10.1212/CPJ.0b013e31824cb084. PMID: 29443297; PMCID: PMC5766020. Khadilkar S, Dhonde P. “Approach to Acute Visual Loss.” http://apiindia.org/wp-content/uploads/pdf/medicine_update_2012/neurology_02.pdf . Zhang LY, Zhang J, Kim RK, Matthews JL, Rudich DS, Greer DM, Lesser RL, Amin H. Risk of Acute Ischemic Stroke in Patients With Monocular Vision Loss of Vascular Etiology. J Neuroophthalmol. 2018 Sep;38(3):328-333. doi: 10.1097/WNO.0000000000000613. PMID: 29369960. Vázquez FJ, Sobenko N, Schutz N, Altszul M, Lagruta I, Mateos MV, Fantl D. Acute loss of vision as the initial symptom of multiple myeloma. Clin Lymphoma Myeloma Leuk. 2012 Apr;12(2):148-50. doi: 10.1016/j.clml.2011.11.005. Epub 2012 Jan 24. PMID: 22277575. Graves JS, Galetta SL. Acute visual loss and other neuro-ophthalmologic emergencies: management. Neurol Clin. 2012 Feb;30(1):75-99, viii. doi: 10.1016/j.ncl.2011.09.012. PMID: 22284056. Meekins JM. Acute Blindness. Top Companion Anim Med. 2015 Sep;30(3):118-25. doi: 10.1053/j.tcam.2015.07.005. Epub 2015 Jul 9. PMID: 26494503. Vortmann M, Schneider JI. Acute monocular visual loss. Emerg Med Clin North Am. 2008 Feb;26(1):73-96, vi. doi: 10.1016/j.emc.2007.11.005. PMID: 18249258. Chamberlain MC, Chalmers L. Acute binocular blindness. Cancer. 2007 May 1;109(9):1851-4. doi: 10.1002/cncr.22619. PMID: 17366556. Gorman RL, Ahlstrom B, Kobrin-Merritts D. Acute blindness. Am J Emerg Med. 1986 Sep;4(5):459-63. doi: 10.1016/0735-6757(86)90221-4. PMID: 3741564. Li S, Tang G, Fan SJ, Zhai G, Lv J, Zhang H, Lu W, Jiang J, Lv A, Wang N, Cao K, Zhao J, Vu V, Mu D, Pan X, Feng H, Hsia YC, Han Y. Factors associated with blindness three months following treatment for acute primary angle glaucoma. Br J Ophthalmol. 2021 Apr;105(4):502-506. doi: 10.1136/bjophthalmol-2020-316259. Epub 2020 Aug 7. PMID: 32769077. Bidot S, Biotti D. Cécité monoculaire transitoire : causes vasculaires et diagnostics différentiels [Transient monocular blindness: Vascular causes and differential diagnoses]. J Fr Ophtalmol. 2018 May;41(5):453-461. French. doi: 10.1016/j.jfo.2017.06.027. PMID: 29776764. Augstburger E, Héron E, Abanou A, Habas C, Baudouin C, Labbé A. Acute ischemic optic nerve disease: Pathophysiology, clinical features and management. J Fr Ophtalmol. 2020 Feb;43(2):e41-e54. doi: 10.1016/j.jfo.2019.12.002. Epub 2020 Jan 15. PMID: 31952875. Originally published 1/2022

Amblyopia occurs when vision in one or both eyes does not develop properly during childhood. It presents in 3%-5% of children and is usually unilateral; the extent of damage depends on severity, age of onset, and length of time before treatment. The affected eye triggers an abnormal brain response in development. The brain ignores the bad eye and with time this further erodes the visual acuity of the bad eye. You could call this a "Catch-22". Ophthalmology InShort by Emily Groenendaal, MD, and George J Florakis, M.D. Amblyopia is an asymmetric visual acuity secondary to a disturbance of normal visual development. It presents in 3%-5% of children and is usually unilateral; the extent of damage depends on severity, age of onset, and length of time before treatment. Signs and Symptoms Signs and symptoms of amblyopia include asymmetric and/ or reduced visual acuity typically in one eye that is more than expected from any underlying condition and persistent after treatment. Other signs and symptoms include poor depth perception or clumsiness, and misalignment of the eye. Causes and Risk Factors Children are at higher risk for amblyopia if there is a family history of strabismus or amblyopia. Other risk factors in the child include media opacities, uni- or bilateral strabismus, anisometropia (asymmetric refraction, especially hyperopic), ametropia (high hyperopia or myopia), ptosis, corneal opacities, cataract(s), vitreous hemorrhage, leukocoria, or eyelid hemangioma, combined anisometropia and strabismus, Down syndrome, and premature birth. The risk is high only during a child’s period of critical development; it decreases when the child is 8-10 years old. Diagnostic Evaluation and Differential Diagnosis To diagnose amblyopia, evaluate acuity and refractive error on more than one occasion, starting with the amblyopic eye. Decreased or asymmetric acuity can present without amblyopia. The differential diagnosis also includes tumors, lesions, optic nerve atrophy or hypoplasia, retinal detachment, or glaucoma. Treatment and Recommended Follow-Up Treatment of amblyopia should first address the underlying condition (ie, strabismus surgery, refractive surgery for anisometropia, cataract, ptosis, vitrectomy, or corneal surgery). Prescription glasses can improve symptoms secondary to strabismus and anisometropia. An amblyopic eye can be strengthened or stabilized by temporarily disrupting the vision of the sound eye. Occlusion therapy (patching the sound eye) is most common, and the length of full-time wear depends on the underlying cause of the amblyopia and the patient’s age. Pharmacologic agents (eg,atropine) can also be used in the sound eye. Tape can be placed on the spectacle lens of the sound eye, or a blurry contact lens can be inserted into the sound eye. Follow-up appointments during treatment should range from 1-3 months; after treatment, follow-up appointments are necessary to ensure no regression. Pearl to Know Most children with unilateral amblyopia do not complain about it; they only notice it when one of their eyes is occluded. An amblyopic eye visualizes individual letters better than it does a whole line of letters. Other Ophthalmology articles in this blog: " A look at four common eye maladies: Arcus Senilis, Ectropion, Pterygium, and Pinguecula " by Evan Mostafa, MD and George J.Florakis, MD " Sudden Vision Loss: An Approach to Acute Vision Loss " by Eleni Florakis and George J. Florakis, MD " Multifocal Lenses: Use of Bifocal, Trifocal and Progressive Eyeglasses Can Increase the Risk of Falling " More medical terms in the FibonacciMD.app Compendium (our medical encyclopedia)

How Arm Position Affects Blood Pressure Accuracy Accurate blood pressure readings are crucial for diagnosing hypertension, a major risk factor for heart disease. Recent studies show that incorrect arm positioning can lead to inaccurate readings, potentially affecting millions of people. Learn how to position the arm correctly to ensure reliable blood pressure measurements. Medical News Study Findings on Arm Position and Blood Pressure Overestimation In a study published in October 2024, investigators measured the effects of arm position on blood pressure (BP) measurements.  Guidelines for blood pressure measurement recommend that the arm be supported on a desk or table and the middle of the blood pressure cuff be at heart level.  However, other positions such as the arm being unsupported at the side or resting on the lap are frequently used in measurements. 133 subjects, aged 18 to 80, had their blood pressure measured all three ways.  The researchers reported that supporting the arm on the lap overestimated systolic BP by a mean of 3.9 mmHg (1 mmHg is the pressure generated by a 1-millimeter-high column of mercury) and diastolic BP by mean of 4.0 mmHg.  An arm unsupported at the subject’s side overestimated systolic BP by a mean of 6.5 mm Hg and diastolic BP by a mean of 4.4 mmHg. Why Arm Position Affects Blood Pressure Accuracy There may be several reasons why arm position may affect blood pressure.  The distance between the heart and the cuff increases when the arm is positioned in the lap or at the side compared to being supported on a desk.  When the arm is positioned below the heart this may lead to an increase in hydrostatic pressure (force exerted by gravitational pull) in the arm’s brachial artery.  There may also be decreased venous return of blood with the arm down compared to a supported arm and compensatory vasoconstriction ( the narrowing or constriction of blood vessels by small muscles in their walls) may lead to an increase in vascular resistance and an increase in BP.  Finally, an unsupported arm may cause some muscular contraction, which might cause transient increases in BP. The authors suggested that non-adherence to correct blood pressure measuring guidelines could result in up to 16% of US adults, equating to 40 million individuals, being misclassified as hypertensive when using a systolic blood pressure cutoff of 140 mm Hg and higher. Beyond Arm Position: Other Factors Affecting Blood Pressure Readings In this study, the method by which blood pressure was measured caused significant overestimations in both systolic and diastolic pressure.  In another study, by some of the same authors, it was reported that using a regular-sized blood pressure cuff on a small-armed individual underestimated systolic blood pressure by 3.6 mmHg.  Use of a regular-sized blood pressure cuff overestimated systolic blood pressure by 4.8 mmHg on subjects who required a large-sized blood pressure cuff, and use of a regular-sized cuff on someone who required an extra-large-sized blood pressure cuff overestimated systolic blood pressure by 19.5 mmHg.  There are a number of other factors that can affect blood pressure results, such as crossing the legs while taking measurement, talking during measurement, or the so-called white-coat effect of blood pressure elevation just being in the presence of a health care professional.     Hypertension is a significant risk factor for stroke and heart disease, and treating it with medication can reduce that risk.  Other studies have found even greater differences in blood pressure readings depending on arm position.  Measuring blood pressure correctly with the correct positioning and the right-sized cuff should increase diagnostic accuracy and allow more precise patient selection for treatment.  Repetition of borderline blood pressure elevations or having patients take their blood pressure at home may also improve accuracy.    References Liu H, Zhao D, Sabit A, et al. Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial. JAMA Intern Med. Published online October 07, 2024. Retrieved from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2824754?guestAccessKey=f167dda3-8cad-4f34-99ca-79865446c64f Ishigami J, Charleston J, Miller ER, Matsushita K, Appel LJ, Brady TM. Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023;183(10):1061–1068. Retrieved from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2807853 Kallioinen N et al.  Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review. J Hypertens. 2017;35(3):421-441. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5278896/#T2

Brussel Sprouts were Once a Culinary Outcast, Now a Trendy Superfood Discover the History, Health Benefits, & Cooking Tips Culinary Medicine by Mary B Grosvenor, MS, RD and Lori A Smolin, PhD From America’s most disliked to most trendy vegetable Today, Brussels sprouts are among the trendiest vegetables. You can find them on the menu in eating establishments ranging from pubs to posh restaurants.[1] But this was not always so. President Franklin Roosevelt jokingly refused to return to England until Lady Churchill agreed to stop serving him boiled Brussels sprouts.[2] Those of us who grew up in the 20th century probably remember Brussels sprouts as soggy, smelly mini cabbages that our mothers served us as children. As recently as 2008, they were named America’s most hated vegetable.[3] What has shifted the popularity of these little cabbages? And more importantly can you transform your appetite for them? Brussels, Belgium, and Boiling Brussels sprouts get their name from the city in Belgium where they became popular beginning in the 16th century. There are a number of varieties; most are green but there is also a purple variety. Brussels sprouts grow on upright stalks; the round buds we eat have layers of leaves resembling a tiny cabbage. They are a member of Brassicaceae family of vegetables, also called crucifers because their flowers look like a crucifix or cross. Other crucifers include cabbage, broccoli, cauliflower, Bok choy, kale, arugula, and mustard greens.[4] In addition to the appearance of their flowers, these vegetables share a distinctive sulfur smell and slightly bitter taste, particularly when overboiled.[5] Benefits of Brussels Sprouts Brussels sprouts pack a nutritional punch. A cup of cooked sprouts provides 100% of the RDA for vitamin C and over 200% of the vitamin K recommendation along with about forty calories, less than a gram of fat, and three grams each of protein and fiber. The fiber in Brussels sprouts has been shown to promote the growth of healthy bacteria in the gut microbiome.[6] Brussels sprouts also contain a number of phytochemicals including carotenoids and polyphenols, which have antioxidant and anti-inflammatory properties, and glucosinolates, which have been shown to have cancer protective properties in humans.[7,8] Glucosinolates are sulfur-containing compounds found primarily in cruciferous vegetables that are responsible for the odor and bitter flavor in Brussels sprouts and other cruciferous vegetables. Changing Tastes: Ours and the Brussels So, what has changed our appetite for this ancient healthy vegetable? Some of the palatability of Brussels sprouts is individual. Our taste for them may be tainted by our early experiences, such as a childhood of overboiled Brussels, but it is also affected by genetic differences in how we perceive bitter tastes; there are tasters and non-tasters. Non-tasters are less sensitive to the glucosinolate compounds in Brussels sprouts, so they taste less bitter.[9] Some of the increased appeal for sprouts is also because the Brussels themselves are different from those of 30 years ago. In the 1990s, a Dutch scientist developed a less bitter tasting sprout by cross-pollinating older, milder tasting varieties with newer, high-yielding ones.[10] Another contributor to our changed relationship with Brussels sprouts is how we prepare them. The overboiled sprouts of 30 years ago, which emitted the distinctive sulfur smell, have been replaced in restaurants and home kitchens by crispy roasted and sauteed sprouts.[11] The Bitter and the Sweet So, if you are not already a fan, give Brussels sprouts a chance. If it is the bitterness that bothers you, buy sprouts that are small and bright green. Remove the outer leaves, which tend to be bitter, and then blanch them for a few minutes before roasting or sautéing. Be careful not to overcook your sprouts; cooking them just long enough to be tender limits the release of the sulfur smell. Adding other ingredients can bring out the best in Brussels. You can reduce the bitterness with sugars like maple syrup, honey, or brown sugar, which help to caramelize the sprouts and bring out their own sweetness. Cooking them in fat such as olive oil or avocado oil adds crispness and balances the bitter flavor. [12] Drizzle them with olive oil, broil them to a crispy brown, or top them with pistachios. You can even eat them raw by shredding them in salads. But Roosevelt was right, do not serve them soggy. Other Culinary Medicine articles about Brussel Sprouts Did you know Brussels sprouts are high in Folate? read more about folate in Why Folic Acid, Folate, & Vitamin B9? Brussels sprouts, packed with antioxidants like vitamin C and polyphenols, help combat inflammation by neutralizing harmful free radicals. read more in Eating to Reduce Inflammation Brussels sprouts are a high potassium food. If you have Hyperkalemia you should avoid. Read more in Elevated Potassium - Hyperkalemia References [1] Brenner L. Cooks Without Borders. Cooks Without Borders. Published November 13, 2022. Accessed October 30, 2024. https://cookswithoutborders.com/new-story/brussels-sprouts-popularity-rise [2] Zimmerman A. The Sprout Incident of FDR and Lady Churchill | Bibliomania. The Library of Congress. Published January 12, 2024. https://blogs.loc.gov/bibliomania/2024/01/12/the-sprout-incident-of-fdr-and-lady-churchill/ [3] Guttman V. Brussels sprouts: America’s most hated vegetable. Slate Magazine. Published January 21, 2011. https://slate.com/human-interest/2011/01/brussels-sprouts-america-s-most-hated-vegetable.html [4] Cleveland Clinic. This Is Why Mom Said to Eat Your Broccoli (and Other Cruciferous Veggies). https://health.clevelandclinic.org/crunchy-and-cruciferous-youll-love-this-special-family-of-veggies [5] Science of Flavor: Cruciferous Vegetables. The Nutrition Source. Published November 21, 2016. Accessed October 30, 2024. https://nutritionsource.hsph.harvard.edu/2016/11/21/science-of-flavor-cruciferous-vegetables-brussels-sprouts/ [6] Bouranis JA, Beaver LM, Jiang D, Choi J, Wong CP, Davis EW, Williams DE, Sharpton TJ, Stevens JF, Ho E. Interplay between Cruciferous Vegetables and the Gut Microbiome: A Multi-Omic Approach. Nutrients. 2022 Dec 22;15(1):42. doi: 10.3390/nu15010042. PMID: 36615700; PMCID: PMC9824405 [7] Ağagündüz D, Şahin TÖ, Yılmaz B, Ekenci KD, Duyar Özer Ş, Capasso R. Cruciferous Vegetables and Their Bioactive Metabolites: from Prevention to Novel Therapies of Colorectal Cancer. Evid Based Complement Alternat Med. 2022 Apr 11;2022:1534083. doi: 10.1155/2022/1534083. PMID: 35449807; PMCID: PMC9017484. [8] Glucosinolate - an overview | ScienceDirect Topics. www.sciencedirect.com . https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/glucosinolate [9] Bachmanov AA, Beauchamp GK. Taste Receptor Genes. Annual Review of Nutrition. 2007;27(1):389-414. doi: https://doi.org/10.1146/annurev.nutr.26.061505.111329 [10] From Culinary Dud to Stud: How Dutch Plant Breeders Built Our Brussels Sprouts Boom. NPR.org . https://www.npr.org/sections/thesalt/2019/10/30/773457637/from-culinary-dud-to-stud-how-dutch-plant-breeders-built-our-brussels-sprouts-bo . [11] Harvard Health the Nutrition Source. Science of Flavor: Cruciferous Vegetables. The Nutrition Source. Published November 21, 2016. https://nutritionsource.hsph.harvard.edu/2016/11/21/science-of-flavor-cruciferous-vegetables-brussels-sprouts/ [12] MSN. How to fix the bitter taste of Brussels sprouts. Published 2024. https://www.msn.com/en-us/foodanddrink/cookingschool/how-to-fix-the-bitter-taste-in-brussels-sprouts/ar-BB1hg6cG Accessed November 6, 2024