Madely Health Headlines Commentary for January 11, 2011

Reference:

Community Water Fluoridation: Questions and Answers

Preventing Dental Caries: Community Water Fluoridation

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2. Not much evidence that we all drink eight glasses of water per day
3. No evidence that Ginkgo Biloba prevents or slows cognitive decline

Dr. Yoni Freedhoff outlines in an article written in this month’s CMAJ how Health Canada is pushing a policy that will allow fortification of foods with vitamins and minerals without any evidence that it will improve public health. Moreover, there is a real risk of overconsumption of said additions to our food supply that can lead to harnful effects.

So, in effect, you will see junk food among others fortified with vitamins and minerals and marketed as an improved product. How utterly shameful.

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2. The vitals on vitamins
3. More vitals on vitamins

Ottawa Citizen journalist Dan Gardner castigates, and rightly so, how Olympic athletes sell out to corporations for oodles of cash without any consideration for the potential harm to public health outcomes. His column can be read here.

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Madely Health Headlines Commentary for December 9, 2009

Sources:

British researchers say little evidence Tamiflu works, but WHO says the drug is useful

Swine Flu Pandemic May Be Less Severe Than Expected

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I am not a fan of how newspapers use headlines to misrepresent stories to provke unwarranted fear, and heightened risk perception. Today, the Ottawa Citizen published two stories about seasonal and H1N1 vaccine. The first story, For Guillain-Barre survivors, flu shot stirs up unwelcome memories, emblazoned on the front page has all the elements of what is regrettably become the norm in newspaper headlines. Headlines are not under control of the journalist. The article was written by Sharon Kirkey.

Ottawa Citizen journalist Dan Gardner’s book, Risk: The Science and Politics of Fear discusses this journalistic approach to sensationalizing news called the Example Rule.

This rule is used to present rare occurrences as if they are common or lurking among us, misrepresenting true risk. Therefore, it was no great surprise to read the front-page headline of today’s Ottawa Citizen continuing this tradition. It outlines the history of a woman who develops a rare neurodegenerative disease called Guillain Barre Syndrome (GBS) and implies a link to the flu vaccine.

The medical content of the story accurately presented the risks of developing GBS, about 1-2 per 100, 000 people. There is some evidence that indicates that the flu vaccine may add an extra 1 per 1 million people. However, the headline clearly did not reflect this. It cites one Ontario study that the seasonal flu vaccine increases the relative risk of contracting GBS by 45 percent.

The absolute risk change of the 1 in a million increase was mentioned immediately following the 45 per cent claim. This former should have been the only statistic cited.

Relative risk is presented to emphasize dramatic change. It is used by media, pharmaceutical companies, food manufacturers, and the Natural Health industry among others to bolster their health claims.

Relative risk does not provide context for the change in risk and should not be included in health reporting. However, it is the number that will be cited by the reader when they discuss this issue with others, hence the problem of skewed risk perception.

The story ends with the woman who had GBS stating, “I made a promise to myself, that if I ever walk again, I will do whatever it takes to keep whatever doesn’t belong in my body out of it.” Although it is understood that traumatic experiences can influence one’s sense of risk, the statement is used to conjure up the idea that unnatural substances are implicated in the disease process and are to be avoided.

If that were the case, one could argue that we should avoid touching any manufactured product, walking down the street and being exposed to car exhaust’s polyaromatic hydrocarbons, and using chemical cleanser’s and agents among others. Exposure to some of these potentially harmful compounds is likely in the parts per million or billion as well. We do not routinely think about this because our sense of risk from these everyday products and activities is low.

News reporting should present information with context. The public should be treated with respect, which includes removing the fear mongering for the sake of selling newspapers, TV and radio shows and magazines. Globe and Mail health reporter Andre Picard has commented on this issue as well as Dr. Noni MacDoanald in an article written for the Canadian Medical Association Journal.

The second story written by Pauline Tam, Our best shot against swine flu?, deserves kudos to the reporter for excellent evidenced-based content and science writing.

Ms. Tam accurately represented the uncertainty that is inherent in medical research yet clearly emphasized the strength of evidence against many misperceptions about the flu vaccine.

She covered the issue about adjuvants or immune system boosters and reviewed how the adjuvant improves efficacy of the vaccine. The adjuvant, squalene, is produced by our liver and is found in many foods as natural oil.

One wonders why, given the focus by some groups on how natural products are better than synthetic, there is such controversy. It would make sense that the logic should remain consistent.

Ms. Tam also reviews the preservative thimerosal found in some multidose vaccines and cites evidence from numerous reputable sources regarding its safety profile.

What Ms. Tam accomplished it to foster critical analysis of health information and present it in context allowing the reader to make an informed decision and risk assessment. She shows medical research is always evolving and is not perfect (nor should it ever be if we are to continue to learn) and how it is a jigsaw puzzle of information pieces that are brought together to create the best picture to date about flu vaccine efficacy and indication for use.

Background:

The evidence-based website Up to Date cites this data:

Vaccination — Guillain-Barré syndrome has followed vaccinations, but this danger may be overstated.

Influenza vaccination — In the United States, an increased risk of GBS was associated with the swine influenza vaccine in 1976, although the severity of the risk has been controversial. Subsequently, no increased risk was observed up to 1991.

Individuals who received either the 1992-1993 or 1993-1994 influenza vaccinations were not at significantly increased risk for GBS, but combining the two seasons suggested that influenza vaccination resulted in approximately one additional case of GBS per million patients inoculated. This risk appears to be substantially less than the overall health risk posed by naturally occurring influenza.

The annual reporting rate of GBS following influenza vaccination in adults declined significantly from 1996-1997 through 2002-2003 in the US. Nevertheless, the long onset interval for post vaccination GBS compared with other post vaccination adverse events (median 13 days versus one day, respectively) is consistent with a possible causal association between GBS and influenza vaccine.

Other data are conflicting, but suggest that influenza vaccination is associated with a low or negligible risk of GBS. In a self-matched case control series from Ontario, Canada that identified 269 hospital admissions for GBS diagnosed within 42 weeks of receiving influenza vaccination, the estimated relative incidence of GBS during the primary risk interval (weeks two through seven after vaccination) compared with the control interval (weeks 20 through 43) was 1.45 (95% CI 1.05-1.99). However, a separate time-series analysis of 2173 hospitalized cases of GBS showed no statistically significant increase in hospitalizations for GBS after institution of the universal influenza vaccination program in 2000.

References:

Guillain-Barre syndrome following influenza vaccination.
Haber P; DeStefano F; Angulo FJ; Iskander J; Shadomy SV; Weintraub E; Chen RT
JAMA 2004 Nov 24;292(20):2478-81.

The Guillain-Barre syndrome.
Ropper AH
N Engl J Med 1992 Apr 23;326(17):1130-6

Guillain-Barre syndrome after influenza vaccination in adults: a population-based study.
Juurlink DN; Stukel TA; Kwong J; Kopp A; McGeer A; Upshur RE; Manuel DG; Moineddin R; Wilson K
Arch Intern Med. 2006 Nov 13;166(20):2217-21.

The Guillain-Barre syndrome and the 1992-1993 and 1993-1994 influenza vaccines.
Lasky T; Terracciano GJ; Magder L; Koski CL; Ballesteros M; Nash D; Clark S; Haber P; Stolley PD; Schonberger LB; Chen RT
N Engl J Med 1998 Dec 17;339(25):1797-802.

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Originally published in The Ottawa Citizen March 24, 2005

If your doctor offered the option of a blood test to determine what diseases your child will develop in their lifetime, what would you do? This option is soon to be a reality.

A report published in the January 2005 issue of the American Journal of Medical Genetics revealed that bipolar disorder and schizophrenia can now be diagnosed through a blood test using the science of genomics.

Genomics is the study of the genes that are being expressed (or actively working) in our cells. This field has developed from the human genome project; the mapping of the 30,000 human genes.

All our cells contain these genes, but not all are expressed. These genes provide the blueprints to produce proteins and other products for normal physiological function. These proteins can also tell us if there are specific diseases present.

Imagine if you were sent on a scouting mission to describe your neighbourhood. Each neighbourhood has its own unique landmarks and terrain with a variety of dwellings, gardens and roads. Your report is influenced by what you have seen, smelled and heard.

The body has a similar scout or sentinel called the white blood cell. A Canadian company, ChondroGene, has developed a diagnostic test that uses a process called the Sentinel Principle.

Dr. Wayne K. Marshall, president and CEO of ChondroGene, explained that when this sentinel cell passes through a diseased neighbourhood in the body, it will be influenced by the environment within and around the diseased tissue. Certain genes present within the white blood cell (RNA or ribonucleic acid) will turn on; in effect telling the story of where it has been. This story is also known as a biomarker, a unique molecular genetic profile of the diseased cells.

Dr. Marshall says this process can also detect early stages and the severity of other diseases, including arthritis, by using gene chips, a microscope-like slide that has thousands of genes imprinted onto it.

The RNA is extracted from the sentinel cell and placed on the gene chip. Through a sophisticated reaction process, the genes present in the RNA will attach themselves to specific genes on the chip. A computer program will read this chip and identify the disease it represents; each disease has a unique molecular signature or pattern.

Ongoing studies have looked at more than 7,000 patients and identified about 40 disease processes at various stages of development. Dr. Marshall says there are very distinct molecular signatures or gene combinations for the 40 diseases studied so far. To date, these diseases are represented by a combination of hundreds of genes.

Dr. Marshall states the next step is to look at reducing the number of key identifying genes to five or 10 to improve the early detection process.

The Sentinel Principle is being applied to four main areas: cancer, central nervous system disorders and psychiatric disorders, cardiovascular disease and arthritis. Many of these diseases do not have good diagnostic methods for early detection and treatment. The diagnosis of bipolar disorder and schizophrenia is wholly dependent on clinical signs and symptoms.

“The biggest problem we have is that we are not picking up these diseases until they are well established, and then the treatment is much more difficult and may not be as effective,” Dr. Marshall explained.

Preliminary data suggests that some of these diseases can be diagnosed prior to their expression. The genetic biomarkers of these diseases seem to be present even before the occurrence of disease symptoms.

Science fiction is becoming science fact. “There are several areas where we are focusing very aggressively right now, particularly in some cancers,” Dr. Marshall said.

“I believe that within the next 18 to 36 months we will have tests at least in a couple of disease areas where we can start to apply this principle. The beauty of this is that it is a principle that can be applied across any disease area.”

From a medical standpoint, this technology has the potential to help millions of people and reduce the burden on our health care system. The question is how others will use it.

Insurance companies may insist on this test and deny or restrict coverage on the basis of the client’s biomarkers. The information could prevent employment opportunities. Safeguarding this information would be paramount.

Nevertheless, this technology heralds a scientific avenue of new medical technologies that will explode into the mainstream of diagnosis and treatment. The intellectual steps taken to get here are inspiring.

© Dr. Barry Dworkin 2005

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Originally published in The Ottawa Citizen January 05, 2005

I thought it might be fun and interesting to present some of the medical stories of 2004 that did not make the front page, yet illustrate an undercurrent of fantastic potential.

Indeed, they reflect the exciting future of merging medical therapies and technologies. I believe they capture the essence of human imagination and the practical applications to improve human health.

• Scientists at the Weizmann Institute of Science have developed biological computers made up of DNA manipulating enzymes that use DNA as the software or instruction set. Trillions of these computers can exist in a drop of water. In test tube (in vitro) experiments, the computer was able to identify a prostate cancer cell and release short DNA strands. These strands incorporated themselves into the cancer cell’s DNA, shutting it down and killing it. In another experiment, they were able to detect lung cancer cells.

Successful development of these computers could lead to early detection and treatment of cancers and destroy them on a cell-by-cell basis, leaving healthy tissue alone.

• Scientists at the Shared Tissue Engineering Laboratory at the Medical University of South Carolina have modified old Hewlett-Packard and Canon inkjet printers to print human skin.

This idea was developed by Thomas Boland, an assistant bioengineering professor at Clemson University, when he observed that the time-consuming manual process of micro-patent printing of skin cells to create tissue was akin to how inkjet printers work. He filled the inkjet cartridges with animal cells or bio-ink. The printer was able to lay out a pattern of cells on a special layer of gel instead of paper.

Boland has already produced beating heart tissue and recreated bone tissue in mice. This leading edge of research may result in a new method of skin reconstruction and repair after burns or injuries. Normal skin taken from the burn victim can be prepared, cultivated and put into the bio-ink to reduce the risk of tissue rejection. The hope is that once this technology is perfected, they can move on to creating other organ tissue to be used in transplants and drug testing among other applications.

• People are more aware of malaria lately. More than 500 million people contract the disease, and one million children die each year. Resistance to conventional medications is a growing problem. A new discovery may lead to a new means of treating this parasitic infection.

Teams from Northwestern University in the U.S. and Walter and Eliza Hall Institute of Medical Research in Melbourne, Australia, have identified a protein called PfEMP1 that helps the parasite stick to red blood cells. It is thought that this and other proteins unique to the malaria parasite could be targeted with a vaccine, effectively immunizing against the disease.

• Another protein uncovered by researchers at the University of Texas MD Anderson Cancer Center may provide a breakthrough in the treatment of psoriasis. The protein STAT3 is involved in wound healing and in the development of skin cancer. STAT3 becomes activated to repair damaged skin and shuts down once the healing process is complete. However, in the case of psoriasis, activated levels of STAT3 were high; the skin cells do not stop reproducing. Indeed, a special mouse bred to produce activated STAT3 always developed psoriasis.

Researchers injected a drug containing a small piece of DNA designed to shut off STAT3 in these mice; the psoriasis cleared. This has the potential to provide relief to millions of people.

• A new phase 2 study released by ConjuChem, a Montreal-based pharmaceutical company, shows promise for the treatment of type 2 diabetes. They have created a technology that prevents the rapid breakdown of protein-based (peptide) hormones by the digestive system. By creating a carrier molecule called DAC(TM), they can link this to known hormones, enhancing their effectiveness.

In the study, they used such a hormone called GLP-1. This naturally occurring peptide normalizes blood sugar levels in five ways: It stimulates insulin secretion; it delays the stomach from emptying food into the intestine; it stimulates the pancreas to create more insulin-producing Beta cells; increases the Beta cell’s sensitivity to glucose; and it reduces insulin resistance so each molecule of insulin has a greater effect than before. Without the benefit of DAC(TM) Technology, GLP-1 lasts only about five minutes.

We continue to see the integration of imagination and science creating possibilities once considered science fiction. Undoubtedly we will be reading more of these stories. The wonder never ceases: marvellous.

All the best in the new year.

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3. Medical advances restore vision for the future

Originally published in The Ottawa Citizen February 3, 2004

Original Title: The betterment of the family

Last of two parts

Deborah decided she had had enough of smoking marijuana. Last week’s column reviewed how her addiction affected her psychosocial development. Deborah was pondering why she continued to smoke four to 10 joints a day to the detriment of her health, desires and life goals.

The Adolescent Toolkit provides a solid framework to provide insights into the reasons behind particular behaviours. Deborah returned with her answers to these three questions in early November:

What do you like and dislike about yourself?

What are your good and bad qualities?

What are your definitions of a friendship and relationship?

Her answers that follow reflect years of unrecognized inconsistencies and conflicts.

Deborah embraces her adventurous and creative spirit. She is musically and athletically inclined. She takes pride in her trustworthiness and organizational skills, and fulfils her responsibilities at work. Her independence lets her successfully adapt to new situations. She feels she is self-sufficient and does not have to depend upon others for assistance. Empathy, compassion and generosity are cornerstones in her friendships.

She dislikes confrontation, avoids contentious problems and buries her emotions to minimize interpersonal conflicts. She admits she “cares too much about what people think of me.” There are some regrets when she says, “I never really followed my passions/goals/dreams. I gave up at everything too soon. I got relatively good at lots of things, but not great at anything.”

Her behaviour and reactions to conflict parallel the actions of her 15-year-old self. Indeed, many of her social skills stalled at age 15 because of her drug use. She hates that her cannabis use takes priority over her friends and family. “I’m smart enough to know better, but not smart enough to quit.”

Her definitions of friendship and relationships reflect the normal idealism of the teen years. There is a tendency to focus on the positive attributes of each and omit any consideration of the potential conflicts, hardships and frustrations inherent in close relationships. Her desire to avoid confrontation combined with a need to be liked by people paralyses her ability to make decisions in her best interest. Her fear of rejection makes it difficult for her to say “no.”

When people decide on a course of action that runs contrary to their conscience and sense of propriety, they can become angry with themselves. This anger can damage a person’s self-respect. Others will pick up on this; some will take advantage of this vulnerability. We all know people who share these characteristics.

Drug abuse is a means for some to escape from problems. This escapism became so ingrained in Deborah that it buried her true spirit. People always do things for a reason. For Deborah, her inability to face the fact that she was giving in to her false self (not following her conscience), not having the tools to change her approach to problems and her anger were compelling reasons to escape. This insight is the first small push forward to change her life. Using this knowledge she began to assert herself in an atmosphere of support from friends and family.

My advice to her in late November was to use her excellent organizational skills to create a new “life agenda.” Deborah’s agenda included spending more time with her family, losing weight, exercising, singing, helping her sons with their homework, practising her bass guitar every day, participating in theatre, photography, developing an outreach program to help adolescents in rural area high schools, and buying a motorcycle.

By Dec. 4, she stopped her daytime smoking. She returned with a prepared calendar of events that included her goals, family activities and a cannabis cessation date of Dec. 19.

Upon her return on Jan. 9, she was smoking one joint every four to five days instead of the usual 16 to 40: remarkable progress. She was spending more time with her sister, mother, children and friends. Her urge to smoke was waning. Indeed smoking was no longer a pleasurable experience. Other, more meaningful, humanizing activities were soul-cleansing. Indeed, Deborah said, “I thought I was happy when I smoked, but the difference is night and day.”

Sometimes you have to take that first difficult step by brute force of will. No one else can do this for you. Counselling and psychotherapy have their place, but ultimately the agent for change comes from within. There are no magic answers, only support, dignity and honour to guide us all. Deborah returns next month for a follow-up visit.

Life continues.

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Originally published in The Ottawa Citizen December 30, 2003
Original Title: The top medical news stories of the year

The December issue of the Harvard Health Letter reviews the top 10 significant medical achievements and events for 2003 and their potential impact.

Here is my take on the Harvard list. In many cases, I have included the relevant website address where you can read previous columns I have written on the subjects.

1. Adult and childhood obesity is the world’s No. 1 health issue. There is increasing recognition that lifestyle, eating habits and food choices play an important role in the development of obesity for many, but not all, individuals. There are ongoing studies examining various hormonal abnormalities within the brain that lead to obesity as well. (Check out my previous column at http://members.rogers.com/barrydworkin/childhood_obesity.html.)

2. The SARS threat was eventually contained. Many lessons about infectious disease control and prevention measures were learned. New protocols and models were developed for future infectious disease emergencies.

3. The discovery that Apo1 Milano protein probably prevents heart attacks. The Cleveland Clinic in Ohio injected the protein into heart disease patients. Within five weeks, years of cholesterol plaque buildup in the coronary arteries disappeared. More studies are to follow.

4. New blood pressure guidelines dramatically reduced the cutoff for the diagnosis of hypertension. An old drug, a diuretic, was recommended as a first-line treatment choice. However, most Canadians with hypertension are untreated or do not follow their medication regimen. (See http://members.rogers.com/barrydworkin/needless_suffering.html.)

5. Recommendations for preventive services and medical guidelines are not being followed as well as they should be, according to a study. (http://members.rogers.com/barrydworkin/get_a_checkup.html.)

6. The natural effects of aging are slowing. More integrated public health measures, lifestyle choices and medical advances combined with social and economic support for older people have turned back the aging clock by at least five years.

7. Hormone replacement therapy was dealt another blow when the Women’s Health Initiative study showed the risk for dementia increased for women taking estrogen-plus-progestin pills.

8. Low-carb diets return with a vengeance. Two New England Journal of Medicine studies showed the Atkins diet, in the short term, was a safe way to lose weight (except with some medical conditions). (http://members.rogers.com/barrydworkin/low_carb_diet.html.)

9. A study this year announced that Letrozole, an aromatase inhibitor, reduced breast cancer recurrence by half. Women who took letrozole for an average of 2.4 years after the usual five years of Tamoxifen therapy had a 43-per-cent relative reduction rate of cancer recurrence compared to placebo. However, the absolute reduction was one recurrence per 100 women per year. (See http://members.rogers.com/barrydworkin/breast_cancer_treatment.html.)

10. Early strides into the genomic era. Companies are developing devices that read specific DNA sequences for various genetically inherited diseases and conditions. Potential risks for colon and breast cancer, among others, could be detected in a drop of blood taken from a child and treatments could be tailored for each person’s genes.

As for the future, I expect we’re certain to face more infectious disease outbreaks. There is concern that SARS will return and that a flu pandemic will appear within the next decade.

Technology continues apace. New vaccines for the prevention of cervical cancer are in the testing phase. Virtual colonoscopies, PET scanners and other non-invasive technologies are opening up new and safer means of improving early detection and diagnosis of certain cancers.

The question is whether society will be prepared to pay for these advances.

© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen December 19, 2003
Original Title: Cycling the virtual highway

WARNING: Before you read any further, I have to confess that I am a cycle nut. Forgive my indulgence in sharing my love of this world with you in one column.

The exercise, scenery, skill and exhilaration one experiences while on their road or mountain bike is one of the joys of life. Some of them are works of art and a testament to the beauty of engineering. However, with the arrival of winter, save for a few diehards, we bring our machines into the house. Some will hang them up for the season; others will mount their bike onto a stand in front of the TV turning it into a stationary bike.

I tried the TV thing but it just did not provide the same workout experience. One of the frustrations of many cyclists is the potential to lose some if not all their training and fitness gained throughout the summer months. Indeed, there are gyms that offer various aerobic machines including bikes but it remains a second cousin to the real deal.

My Christmas gift suggestion for this year will appeal to the cyclist on many levels. If you love technology, computers and music in addition to your bike, these gifts are the cure for cycling withdrawal syndrome (I have no financial stake in these company’s products nor have I been asked to review them).

Tacx (www.tacx.nl), a Netherlands company, has created the T1900 I-Magic Virtual Reality Trainer that transports you into a fully functional 3-D world. The I-Magic comes with a mounting stand that accommodates any road bike or mountain bike with a front fork. It has a steering attachment that allows you to go off-road in the virtual world before you.

The rear wheel abuts against a silver electronic roller that responds to the virtual terrain. Climb a hill and the resistance increases, catch a draft from a cyclist in front of you and the resistance decreases. A small sensor unit attached to the front handlebars records your heart rate data, cadence and speed. The sensor unit attaches via a USB connection to your computer.

The Analyzer software provides a second-by-second review of your cadence, power, speed and heart rate. The Tacx website’s BikeNet page allows you to share your time trials and courses with others by uploading your data. Conversely, you can download another cyclist’s course and time into your program. Once downloaded, your competitor will appear on the screen; the race is on!

You can change your camera angle from a first-person perspective to an overhead helicopter view to just behind your rider. A collision option adds to the realism. Obstacles and other riders can knock you off your bike.

A virtual reality cycling league (www.i-magicleague.com) now has 100 members competing in nine rounds of courses ranging from a cycling oval to mountainous terrain. Ambient sounds of the country including the mooing cows pipe through as you ride.

Fitcentric (www.fitcentric.com) sells NetAthlon, a software package that includes both real and imaginary world bike terrains. These terrains are also available for runners. If you ever wanted to cycle the 2000 Olympic Sydney triathlon cycle course, the 112 mile Hawaiian Iron Man Kailua Pier Kona, the Colorado Springs Olympic Velodrome, the banks of the Charles River in Boston, the Boston Marathon course, BMX courses, eco-adventures and alpine trails, now is your chance. Pop in your MP3′s, point your summer fan at your face and you have an indoor cycling experience that cannot be beat.

You can create other virtual cyclists to join you as a pacer for your workout.

Fitcentric offers an online site where cyclists can meet and compete in real time against one another. The software accommodates a headset allowing you to talk to your virtual cycling partner as you ride. The GameSpy website (www.gamespy.com) also offers the means to compete against others if you both share the same courses.

Fitcentric also offers courses for treadmills and the latest versions of the Concept rowing machines.

The I-magic’s list price was $999 this summer. Rebec and Kroes on Bank Street sells the unit. The Fitcentric software sells for about $80 US for three courses. Additional courses run between $10 to $25 US each.

The minimum computer specifications are a 500 MHz Pentium 3 with 128 MB of RAM and USB and a 32MB Nvidia GeForce or ATI Radeon graphics card.

After buying it and using it for over three months, I can unequivocally state that it will provide even the most experienced cyclist with as much of a challenge and workout as they desire.

Cycling through Hawaii or Sydney, Australia in the dead of winter has a certain appeal and you maintain your fitness to boot! All the best on this holiday season and a Happy New Year.

© Dr. Barry Dworkin 2003

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