Friday, June 5, 2015

The Brain/Mind-Immune Connection is LITERAL


For quite some time, scientists and doctors in both integrative and functional medicine have been talking about how the brain and the immune system are interconnected. We've said that if someone goes through significant stress, the neuro-processing of this event can present as disease. Along those lines, we generally agree that if one has recurrent thoughts about shame stemming from poor self-esteem, then this may manifest in autoimmunity and/or inflammation as s/he rejects her/himself.

If that seems logical or intuitive to you, then you might be surprised when I tell you that this way of thinking has been dismissed by the broader medical community as "fluff." Sure, plenty of doctors accept that stress can provoke flareups of various illnesses, but not much weight is given to it, at least not to the point at which meditation and mindfulness are regularly prescribed alongside immunosupressants like prednisone. Furthermore, ask the average physician the mechanism behind stress causing disease, and they're likely to tell you it has something to do with the hormone cortisol being released. While long-term high levels of cortisol do have negative consequences, this hormone (which behaves like prednisone) is more likely our body's way of coping with the inflammation triggered by an overburdened mind.

Why is there a schism in thought and practice over the topic of how the mind affects health? I think part of the problem has to do with only having had indirect data to make the brain-immune connection. And yet, that data is pretty convincing, at least to me...


We know, for example, that when we condition the mind into a relaxed state with mediation, quantifiable changes occur in expression of immune-regulating proteins like NF-kB such that inflammation is toned down and cellular stress is decreased. Similarly, a study published in JAMA, found that people with rheumatoid arthritis benefit from writing in a journal about painful memories --to release them, if you will-- and that their symptom improvement was statistically significant, even at 4-month followup!

In a quest for a more direct brain/mind-immune connection, many have looked to the gut. Yes, you read that right. The intestinal system is laden with neuro-chemical factories and immune complexes. Numerous studies have shown how the bacterial colonies of the gut affect mood by communicating with the brain. And since we've already shown how mood can affect immunity, the signaling pathway between the brain and gastrointestinal immune centers was thought to occur along nerves, most likely the vagus nerve which controls our "rest and digest" mode and originates in the brainstem. To test this theory, researchers did experiments on mice. They showed that probiotic treatment with L. rhamnosus caused changes to the brain (namely increased GABA receptor stimulation), but this did not happen in mice who had their vagus nerve cut.

Researchers have even detailed the mechanism by which the mind starts to cause changes at the cellular level. In short, stress produces catecholamines (fight or flight chemicals), which trigger the body to prepare for an attack, allowing proteins like IkB to enter cell membranes and modulate the immune system.  This is, interestingly, most apparent when the brain perceives threat or isolation in a social setting (see here and here).

Still, all these connections seemed at best secondary because immune cells had not been described as being in direct contact with the brain. . .

Until now.

Previous concept on the left; New discovery on the right.
Photo credit University of Virginia Health System

Researchers at the University of Virginia have identified vessels from the lymphatic system (our immune defense) leading to the brain itself, thus making the mind-immune connection literal in the anatomic sense. Dr. Jonathan Kipnis PhD from the Dept. of Neuroscience said of this finding, "It changes entirely the way we perceive the neuro-immune interaction... We believe that for every neurological disease that has an immune component to it, these vessels play a major role." Right now they're thinking about how this applies to multiple sclerosis, among other neurological diseases, but since we have demonstrated above how the brain/mind has a significant role in most or all autoimmune diseases, I anticipate that the scope of these developments will broaden.

Either way, this is a huge win for the functional and integrative medicine communities because the brain/mind-immune connection has finally been confirmed in literal form. And with that confirmation, perhaps the approaches once regarded as "fluff" will become our first-line of defense.

Sunday, May 17, 2015

I'm Back, with Probiotics!

You guys, I needed a break.

I got on the vaccine bandwagon and it drained my soul for a while. That's why I was absent for so long.

I've said what I had to say. Now it's time to move on and explore other aspects of health and healing.

Today, I want to go back to good ol' probiotics. The good bugs. Personally, I have benefited from taking VSL#3 and Garden of Life products. I wanted to know who else would see improvements from taking these microbial supplements and if there's data to support that. Lo and behold, as I was sifting through the resources from an organization called Integrative Medicine for the Underserved, I found the upcoming guide.

Gut Indications

Preterm infant‐ NEC
L. acidophilus, B. infantis, B bifidum NCD01453,L reuteri (55 million)
Childhood diarrhea ‐ prevention

Saccharomyces boulardii, Lactobacillus GG, combo (L. helveticus and S.thermophilus), L casei and L
acidophilus, L sporogenes (bacillus coagulans)
Infant ‐ prevent diarrhea
B. bifidum, S. thermophilus; E coli 083:K234:H31,
Childhood diarrhea ‐ treatment
Saccharomyces boulardii, Lactobacillus GG, Lactobacillus Reuteri SD2112,
Constipation in Children
L. casei rhamnosus Lcr35

Travelers' diarrhea prevention
L. acidophilus, B. bifidum,L. bulgaricus and S.thermophilus; Lactobacillus GG
Prevention antibiotic-assoc iated diarrhea

Saccharomyces boulardii, Lactobacillus GG, (combo Lactobacillus casei DN114 G01, L. bulgaricus, snf
Saccharomyces thermophilus)
Prevention C diff
Saccharomyces boulardii, Lactobacillus GG
Prevention recurrent C diff
Saccharomyces boulardii, Lactobacillus GG, bacteriotherapy
Adult diarrhea ‐ treatment
S. faecium, Enterococcus SF 68; S boulardii in amebic dysentery
Bifidobacterium lactis DN‐173 010, E. coli Nissle 1917, the supplement VSL#3 and Lactobacillus casei Shirota
H. pylori infection

L. acidophilus LB*, L. casei DN‐114 001*, (L. acidophilus La5, B.
lactis Bb12, L bulgaricus
and S. thermophilus)* L. johnsonni La1, Lactobacillus GG, L. casei subsp. casei DG

E. coli Nissle, S. boulardii
UC ‐ induce remission
E. coli Nissle, VSL #3,( B. breve Yakult, B. bifidumYakult, L. acidophilus less effective)
UC ‐ Maintenance
E. coli Nissle, VSL #3, also B breve/B bifidum/L acidophilus Yakult
Pouchitis ‐ prevent and maintain
VSL#3, L. acidophilus La‐5 and Bifidobacterium lactisBb12
Pouchitis ‐ induce remission

Bifidobacterium infantis B5624, VSL #3

Bifidobacterium animalis, Lactobacillus plantarum 299; +/‐ L. rhamnosus GG, L.
rhamnosus LC705, B.breve Bb99 and Propionibacterium freudenreichii ssp. Shermani JS
Radiation enteritis
VSL#3, L acidophilus, L rhamnosus
Extraintestinal Indications

Allergy to milk
Lactobacillus GG
Atopic eczema Prevention

Lactobacillus rhamnosus LPR and Bifidobacterium longum BL999 OR 0.17, L paracasei ST11 and B longum
BL999 OR 0.16, Escherichia coli
Atopic eczema Tx
L rhamnosus GG ATCC 53103, Bifidobacterium lactis; L. rhamnosus 19070‐2and L. reuteri DSM122460
Allergies (asthma, rhinitis, urticaria etc)

L. acidophilus P‐18806,L. delbruekii P‐18805 andS. thermophilus P‐18807; L. paracasei ‐33; +/‐ L. acidophilus
L‐92; B. longum BB3536
Lactobacillus reuteri DSM 17938
Infant, at birth for general prevention
E. coli‐decrease recurrent infections over next 10y!
Prevention respiratory infection
Bifidobacterium lactis HN019 w/prebiotic
Prevention respiratory infection adults

L. casei DN‐114 00, L. reuteri protectis ATCC55730, L. fermentum CECT 5716, L. fermentum VRI‐003;
Lactobacillus gasseri PA 16/8, Bifidobacterium longum SP 07/3, B. bifidumMF 20/5
L reuteri, Streptococcus salivarius WB21 in chewing gum
Vaginosis and vaginitis
L. acidophilus, L rhamnosus GR‐1, L. reuteri RC14
Prevent Preterm Birth?
Lactobacillus reuteri RC‐14 and Lactobacillus rhamnosus GR‐1
Decrease pre‐eclampsia
L. acidophilus LA‐5, B. lactis Bb12, and L. rhamnosus GG
Hepatic Encephalopathy

Chronic Liver disease ‐ NAFLD

Lactobacillus acidophilus , bifidus , rhamnosus , plantarum , salivarius , bulgaricus , lactis , casei , breve )
associated with prebiotics (FOS) and vitamins
Rheumatoid Arthritis
Bacillus coagulans (formerly Lactobacillus sporogenes)
Recurrent UTI
L. rhamnosus GR‐1; L. reuteri RC‐14

I wish these came with article references, but they don't. I'll also admit to being surprised by the listing of E.coli as a therapeutic agent and had to look up what this Nissle strain is all about here. What I read did NOT convince me to use this strain, in fact it looks potentially dangerous! 

You'll note that the information is marked by alphabetical grades. These are defined as shown below.


My goal this year is to become more fluent in being able to name these organisms, recommend them, and have the data to back all that up. That information will go under the probiotics label on the right. The more we learn about how the human microbiome affects health and disease, the more I see that this knowledge is crucial to providing comprehensive care that can provide both short and long-term benefits.

Tuesday, February 10, 2015

Going Viral: How the Internet Plays into the Anti-Vaxx Movement

Be careful, son. Don't want to hear about this on Facebook!

Mommy/Parent Shaming
Back in the day if something terrible happened to a child that event would, at most, be covered by the news and serve as a warning to others to reconsider their parenting practices.Then life would go back to its mix of routine and the unexpected.

Nowadays, if Johnny doesn't have sufficient hand dexterity by the time preschool rolls around it's because his mother didn't create enough 'sensory play' activities in the home. This is a warning sent out in pins, posts, tweets, and e-mails. You name it. And when something truly horrific occurs, the breaking news covering it is only the start of an onslaught of public commentary. Read: Heartless criticism:

Rare tumor? Well, I would never let my kid eat non-organic food, I bet that's why this child got cancer. 
Kidnapped on the way home? I never let my kids go anywhere alone. Ever. 
School shooting? That's what happens when you don't home-school. 
Where was the mother when this child had a freak accident?

And so on.

It's all there on the internet for people to pick apart and most of that turns into finger-pointing straight at the mother. Is it any wonder then that many mothers are absolutely terrified of making a "bad" choice? -- One in which a negative result is possible.

Though extremely rare, there are risks involved with vaccines and as soon as some parents hear that they can't bring themselves to go along with the injection. They are paralyzed by fear and perceived judgement. What if it's their child who is 1 in 17,000,000? They can just see it now:

She actually agreed to stick toxic* chemicals in her baby and now s/he's injured? What kind of mother does that?

Which bring us to our next internet side-effect...

Passivism by way of Naturalism
How do you get out of making tough choices? Keep it natural, baby.

Yes, letting nature take its course is the coping mechanism many parents are opting for today. Because they don't actually see it as a choice (though it most certainly is one). They believe that by abstaining from modern interventions with their children they can wash their hands from blame should something not turn out right.

In other words, if a child gets a rash from elderberry, that's cool. Whatever. That ol' Mother Earth is a tricky one! If the child gets a rash from penicillin, well, the parents took a risk and should have known better.

How did we end up here?

As I said, people were already looking for a way out. A way to distance themselves from the scary things that can happen when you're in charge of tiny precious lives. You take that desire and couple it with an internet fraught with "all natural" promotions telling viewers there's no risk** involved, and BAM. You've got parents who want to believe essential oils can cure anything, it's herbs or nothing (not even prescribed medications), and that immunity by infection is the way to go.

Now listen. If measles becomes commonplace again, it will be ONE HUNDRED THOUSAND TIMES more likely for one's child to have a serious negative outcome from this disease than from getting the vaccine. Let me repeat: ONE HUNDRED THOUSAND TIMES. But that's a gosh-darn-awful risk some people are willing to take to avoid guilt in the one in a MILLION chance something "unnatural" might happen to their child as a result of their decision-making.

Why do some parents throw statistics out the window?

The Paranoia will Destroy Ya'
I have the perfect case study. I know a fellow who runs on fear. He watches the news late into the night and makes decisions throughout the day based on paranoia alone. He'd seen a story on his Facebook feed once about how a child was difficult to extricate from her carseat after the vehicle slipped off the road and into murky water, but luckily the parent had scissors nearby to cut the safety belts. He shared this post multiple times and, sure enough, the next day he had heavy duty shears in the glove compartment and the trunk. He tells me this as he's putting his under-2 year old in a front facing carseat in the front passenger chair of his pickup truck.

CLEARLY car accidents that cause immediate child fatalities -- especially when kids are not properly restrained -- are more common than seat belts causing harm. We all know this. But successful public health recommendations do not garner all the 'Likes.' Sensationalized, rare events do.

What's more, I believe the phrase "What your  fill in the blank  doesn't want you to know" is destroying our society. It too is fueled by paranoia. Specific to this topic, enough people have clicked on articles informing them that their doctor is profiting from each vaccination and that these injections are making everyone sicker for job security. Your local newspaper won't tell you that, but truth-seekers of the inter-webs unite, right?!

DIY Everything
People, we've lost our reverence for the professionals.

Not only do we think they're hiding things from us left and right, we're no longer impressed with the years of training that went into their careers.

DIY blogs have told us we don't need no education. And I get it, there have been things I learned online that helped me to do simple jobs around the house that I would have otherwise wasted my money on had I hired them out. But I want to think I know where to stop. Like, heavy electrical work. I won't risk getting electrocuted or burning down my house just because some guy is telling me he's got an easier "life hack." I'd much rather call a pro for that.

The same is true for medicine and public health. Unfortunately, so many are caught up in the DIY spirit that they write long, incredibly long blog posts claiming that hours/days/weeks/years on the internet makes them a statistician. But I've yet to read a single one of them use ANOVA analysis, compare t-scores, discuss confounding variables or null hypotheses. If that doesn't sound the alarm like "extra" parts left over from a DIY mechanic job, I don't know what else to say.

Down with the Internet?
No, and I'm sorry if this entry reads like an attack on technology. My goal here is to recognize how the anti-vaxx movement is spreading. Once we see the patterns that perpetuate false information or exploit common fears among parents we need to do what we can to fix this. It's about education and reassurance. It's even about better marketing ourselves. In my own efforts, I've tried adding PubMed articles to my Pinterest page, but there's been little interest in that. But I write an article about Gwyneth Paltrow's vagina and my readership soars. Now I'm just waiting for Kim Kardashian to get a vaccination in her derriere and, my pride aside, you know this blog will run with that.

That's how important this is.

Now SHARE this blog with all your friends or I'll tell everyone you gave your kids non-organic kale... And then tweet about it.

*This is not true. And if you're worried about preservatives, most vaccines do not carry them and where they exist there is often a preservative-free option. 
**This is also false. I've known plenty of people who ended up in emergency rooms after taking herbs without talking with a healthcare provider first. 

Friday, February 6, 2015

Ethics: Religious Exemption from Vaccinations

(from NEJM original)

Where I live, the only way to be truly exempt from vaccinating your children as it pertains to school and day care admittance is to have an actual allergy or receive a waver due to religious beliefs from one's physician. As you can imagine, there's plenty of people who fake a deeply held religious conviction in order to obtain this piece of paper.

The other day I overheard a woman asking her doctor about that exemption. She freely admitted that she claimed religious convictions against vaccines so as not to expose her children to what she perceived as unnecessary risks associated with the injections. But now she's worried. Like everyone else, she's hearing about outbreaks of measles. She said measles didn't seem that bad, but she got to thinking about some of the other preventable diseases like polio. This lady did NOT want her kids getting that crippling disease. So she asked her physician if the religious exemption was an all or nothing setup. In other words, could she make her "religious beliefs" a la carte: MMR is an abomination; the polio vaccine is kosher?

Well, praise God!

I'm not sure what was said in response to this inquiry, but I'm curious to know what you think about vaccine exemptions. I know many are entirely against them. Others will concede that we must still leave room for religious liberty among those who are true in these beliefs. Another might ask, which faith actually preaches this? Important to me from a public health standpoint is the following question:

Is basing exemption on religion keeping people from getting vaccines they would have otherwise requested? 

The ideal is for people to get fully immunized, of course, but I'd rather have them get some than no vaccinations at all. What's your take on this situation now that I've shared with you what some are thinking?

Tuesday, February 3, 2015

My Experience with DIY Fecal Transplant

Step 1: Get yourself a SINGLE use blender.

There's an article going around talking about stool donation. It gets a lot of laughs. None from me.

I remember the first time I heard about fecal transplant. It was in a noontime seminar about up and coming treatment options for patients. This was back in 2007, during my intern year. I thought I couldn't possibly be hearing things right. As it became clear that, yes, people would be opting to take someone else's feces and let their gastroenterologist spray their intestines with the stuff, I couldn't help but think, "What in the world would make someone do that?!"

Now I know. 

Fast forward to 2014. I'm lying on my side on the floor of my shower with an enema perfectly positioned as it drips a slurry of my friend's stool and saline. I brought a bunch of magazines with me to get my mind off of what was actually happening. I thought I'd be more grossed out, but if anything I felt relieved and excited about the future.

How did I end up here?

Now we step back to 2012. I came home to the perfect life. My college sweetheart and I were married for almost a decade. We welcomed a beautiful baby girl into our family, joining her handsome big brother. We closed on a new-to-us house. I was squared away to return to a job with coworkers I adore. The ecstasy of it all lasted just a few days. It started with cramping. Then I saw colon tissue in the toilet. I was doubled over, thinking I'd leave my children motherless. On August 6th, 2012, the room began to spin when I was diagnosed with a disease known as ulcerative colitis (UC).

Never fear, my gastroenterologist said. I could take a pill multiple times a day for the rest of my life and be fine. Just fine.

The pills didn't work.

Then the injections didn't work.

The following two years were one disappointment immediately followed by another letdown, punctuated by profound physical as well as emotional suffering. Play that on repeat.

I tried to keep it together. Pushed myself to go to work. Tried to hide my symptoms. Wedding ring was either dangling around my finger from starvation, or tight when the steroids kicked in. Baby would cry for food as I chewed on my pillow in agony. I'd snap at my son for age-appropriate behavior because I was tired of being tired.

It felt like everything in my life had been stripped away from me.

Clearly I was desperate to try something, anything to get myself better. But how does an educated woman (a doctor, no less) specifically end up deciding she's going to give at-home fecal transplant a try?


Gut dysbiosis (bad bacteria) is everywhere in the literature when it comes to explaining the origins of UC. And fecal transplant would serve to outnumber and replace the bad bacteria, but I had only ever heard of it being used for another condition called C. diff colitis.

One day I was reading an article about how happy, healthy colons have a high population of bacteria that produce an anti-inflammatory messenger called interleukin-10. As one with an inflammatory bowel disease I thought, if only I could recolonize my colon with those good bugs. I brought this up with my current gastroenterologist and she said people like Dr. Borody in Australia perform fecal transplants for UC patients using rationale such as this. I was intrigued to say the least and wondered out loud if I needed to look into plane tickets -- There's a good joke in here somewhere about the land down under and my rectum. -- But my gastroenterologist explained that it's not rocket science and that, while she couldn't officially sign off on anything, if it were her she'd look into options at home.

Yes, some plant gardens, others lay floor tiles, my DIY project was to be fecal transplant. Instead of being grossed out, my husband was totally on board and he found everything there is to know about at-home fecal transplant from a website called Power of Poop. The process is surprisingly simple, really. The hardest part is...

Finding a Donor

A lot more goes into the criteria than you might think. Sure, you want someone who is healthy, eats well, and doesn't have risk factors that could lead to the transmission of, say, hepatitis. But aside from that, researchers are just starting to discover the potential of transplanted stool and the possibilities are remarkable. Did you know that a stool from a thin donor can make a fat recipient thin? And vice versa. Given that much of our neurotransmitters are made in the colon (it is thought of as the "second brain"), it's believed that changes in mood (for better or worse) can be transmitted as well.

With all that in mind, I came up with the following criteria for a stool donor:
  • Same gender (I felt this would increase our odds of matching up.)
  • Incredibly healthy 
  • Clean life
  • Thin 
  • Pleasant demeanor
  • Stomach o' steel. Proven by a history of having enteritis and bouncing back, or never getting food poisoning. 
  • No family history of inflammatory bowel disease
  • Accessible
  • Willing

Out of 500+ friends on Facebook, only 4 met my criteria. 2 became pregnant and I didn't want to bother them, nor did I want those hormones. 1 was just starting a new practice out-of-state. So that left the chosen one.

How do you go about asking your friend for their poop? Well, if this person knows anything about the hell you've endured, they'll actually volunteer. Such was the case for me.

Did it work?

Mostly, yes. First understand that the conditions were not ideal. I was just getting over a flare so the "landing site" for the transplant to take hold was spotty. Due to some logistical constraints (my donor was moving out of state), we were only able to do this one time. The poster child for FMT did this for WEEKS.

My results were the following: My disease went from running the entire length of my descending colon to just affecting the most distal parts. Afterward, instead of having a gnawing sensation in my gut whenever something stressful happened, I simply felt unease. No physical association with it.

I've gotten to a better spot now with my UC, thank God. So if you're wondering if I'd do it again, the answer is something my 2007 self would never believe: Yes, many times over.

Why did I share my story?

Listen, I understand that this is always going to sound gross. But if I can take away some of the stigma and demystify the process, I'm happy to poo it. I mean, do it. -- OK, I lied when I said it doesn't make me laugh. -- Go ahead and chuckle, too, while you now understand fecal transplant can mean the difference between life and a lack thereof.

Friday, January 30, 2015

Gwyneth Paltrow Wants You to Steam Clean Your Vagina*

People, I kid you not.

Sales for her $90 t-shirt must have inspired the Oscar winning actress to branch out into medicinal therapies, of course.

Now, I knew about her vegan lifestyle and how Hollywood is obsessed with cleanses. But the V-steamer? Was not prepared. The premise is this: You sit on something that sends steam up through the vagina and purportedly (read: does not) travels up through the cervix and into the uterus.

I'm not going to go on about how ridiculous this is in practice. - Russell Saunders does a great job of that here. - But I will ask the question, Why will people trust Gwyneth Paltrow over their OB/Gyne who has completed medical school and a rigorous training in residency? Because I'll tell you right now, no MD/DO would sign-off on this.

The obvious answer is celebrity status trumps all. But does it also have to do with this notion that those with expendable incomes have access to the "real" or "actual" cures for disease? Take Magic Johnson, for example. Many people believe he did so well with HIV because he could afford the magic bullet that is kept hidden from mere commoners. Is there any truth to that? Who knows?

What we do know is that wealthy folks like Gwyneth Paltrow can afford to visit health spas regularly and buy organic. That just seems so cleansing and holistic. And we like those words. We like them a lot. But is there evidence to support this notion that money can buy health? For starters we know that being poor is linked to more time spent feeling unwell and higher infant mortality (source). But that's not what I'm getting at. I'm looking squarely at therapeutic options rich people have that others don't.

In my own life, I've come to understand that if you get sacked with an autoimmune disease it's best not to be poor. For real. I was fortunate to have good health insurance through my husband's employer, without it I'd be paying four THOUSAND dollars a month for Humira. Even that conventional drug wasn't enough so I looked into other options. I  began meeting with a naturopath who took cash only and I shelled out hundreds of dollars more. And while I can't say that she cured me, I did get valuable information from tests not normally ordered by allopathic doctors. Hoping that the internet would be the great equalizer, I looked to see if others could get access to alternative medicine professionals through online consulting and the answer is yes, but at an even heftier price. Egads.

So do we say phooey? "I don't need no stinkin' organic kale and crystal healing anyway." I wish that were entirely true. Some studies show that parents who can afford to purchase "clean" and organic products for their children can significantly decrease or prevent harmful chemicals in their blood compared to children who use conventional household items and eat regular diets [1-2]. Likewise, those who have the time and money to hire a nanny while s/he attends a yoga retreat can in fact lower their inflammation (source).

Yes, what I'm saying is that -- coochie-cleansers and detox diets aside -- there are helpful tools in disease prevention and management that can be prohibitive due to cost. And if you know anything about me, you know Dr. D is all about social justice. I cannot stand health disparities like this. What am I gonna do about it? I have some ideas, actually...

I, a board certified physician, will share evidenced-based products or techniques that actually help people obtain better health. I will find and share these thing in the most economical way possible. And you know what? Being raised in the inner-city of Chicago taught me a thing or two about getting more for less. I can and will deliver on this promise.

But if you have money and vagina(s) to burn, then this just isn't for you.

*Otherwise known as that post where Monique talks about the socio-economic aspects of modern healthcare. 

[1] Curl CL, et al. Organophosphorus pesticide exposure of urban and suburban preschool children 
with organic and conventional diets. Env Health Perspect. 2003;111:377-82
[2] Duty SM, et al. Personal care product use predicts urinary concentrations of some phthalate monoesters. Environ Health Perspect. 2005 Nov;113(11):1530-5