Thursday, March 22, 2018

Tai chi as good as or better than aerobic exercise for managing chronic pain

Tai chi as good as or better than aerobic exercise for managing chronic pain
A graphic abstract to accompany The BMJ research paper: Tai chi as good as or better than aerobic exercise for managing chronic pain Credit: The BMJ
The ancient martial art of tai chi has similar or greater benefits than aerobic exercise for people with the chronic pain condition fibromyalgia, finds a trial published by The BMJ today.
The findings suggest it may be time to rethink what type of exercise is most effective for patients with chronic pain conditions.

22 mar 2018--Fibromyalgia is a long-term condition that causes widespread body pain. It may also lead to extreme tiredness, muscle stiffness, difficulty sleeping and depression. It affects around 2-4% of the adult population worldwide.
Aerobic exercise is currently recommended as a standard treatment, but many patients find it difficult to exercise due to fluctuations in symptoms.
Some trials have suggested that tai chi alleviates pain and improves physical and mental health in patients with fibromyalgia but concluded that larger and more rigorous trials are needed to confirm the results.
So to investigate further, a team of US researchers set out to compare the effectiveness of tai chi with aerobic exercise and to test whether this depends on its frequency or duration.
They identified 226 adults with fibromyalgia who had not participated in tai chi or other similar types of complementary and alternative medicine within the past six months. The average age of participants was 52 years, 92% were women, 61% were white, and average duration of body pain was nine years.
At the start of the trial, participants completed the fibromyalgia impact questionnaire (FIQR), which scores physical and psychological symptoms such as pain intensity, physical function, fatigue, depression, anxiety, and overall wellbeing.
Participants were then randomly assigned to either supervised aerobic exercise twice weekly for 24 weeks or to one of four tai chi interventions: 12 or 24 weeks of supervised tai chi completed once or twice weekly.
Changes in symptom scores were assessed at 12, 24 and 52 weeks and participants were able to continue routine drugs and usual visits to their physicians throughout the trial.
FIQR scores improved in all five treatment groups at each assessment, but the combined tai chi groups improved significantly more than the aerobic exercise group at 24 weeks. Tai chi also showed greater benefit when compared with aerobic exercise of the same intensity and duration (twice weekly for 24 weeks).
Those who received tai chi for 24 weeks showed greater improvements than those who received it for 12 weeks, but there was no significant increase in benefit for those who received tai chi twice weekly compared with once weekly.
The effects of tai chi were consistent across all instructors and no serious adverse events related to the interventions were reported. The findings also remained largely unchanged after further analyses to test the strength of the results.
The researchers point to several study limitations. For example, participants were aware of their treatment group assignment, and attendance differed between the two treatment groups, both of which could have influenced the results. However, key strengths include the large and diverse sample and longer follow-up than previous studies.
"Tai chi mind-body treatment results in similar or greater improvement in symptoms than aerobic exercise, the current most commonly prescribed non-drug treatment, for a variety of outcomes for patients with fibromyalgia," write the authors. "This mind-body approach may be considered a therapeutic option in the multidisciplinary management of fibromyalgia," they conclude.
In a linked opinion article, lead researcher Dr Chenchen Wang, says the public health problem of chronic pain calls for an "all hands on deck" approach to give patients feasible therapeutic options for the management of fibromyalgia. "It is time, therefore, for physicians to explore new approaches and rethink their strategies in order to provide the best care for patients with chronic pain conditions."
In a second opinion article, Amy Price, a trauma survivor with chronic pain, describes how tai chi has helped improve her balance, reduce anxiety, and manage pain.
She acknowledges that tai chi does not work for everyone with fibromyalgia, but says the advantage is that "it is low risk and minimally invasive, unlike surgery, and it will not harm your organs, like long term drug use." And there is also the chance that it might complement other interventions to help your body work better, she concludes.

More information: Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial,
Opinion: Time to rethink exercise for fibromyalgia care, … r-fibromyalgia-care/
Opinion: The unintended consequences of tai chi for fibromyalgia, … hi-for-fibromyalgia/

Provided by British Medical Journal

Wednesday, March 21, 2018

European Society of Cardiology guidelines on syncope launched today at EHRA 2018

European Society of Cardiology guidelines on syncope were launched today at EHRA 2018 and published online in the European Heart Journal.

21 mar 2018--Syncope is a transient loss of consciousness caused by reduced blood flow to the brain. Approximately 50 per cent of people have one syncopal event during their lifetime. The most common type is vasovagal syncope, commonly known as fainting, triggered by fear, seeing blood, or prolonged standing, for example.
The challenge for doctors is to identify the minority of patients whose syncope is caused by a potentially deadly heart problem. The guidelines recommend a new algorithm for emergency departments to stratify patients and discharge those at low risk. Patients at intermediate or high risk should receive diagnostic tests in the emergency department or an outpatient syncope clinic.
Professor Michele Brignole, Task Force Chairperson, said: "The new pathway avoids costly hospitalisations while ensuring the patient is properly diagnosed and treated."
Most syncope does not increase the risk of death, but it can cause injury due to falls or be dangerous in certain occupations - such as airline pilots. The guidelines provide recommendations on how to prevent syncope, which include keeping hydrated, avoiding hot crowded environments, tensing the muscles, and lying down. Advice is given on driving for patients with syncope, although the risk of accidents is low.
The document emphasises the value of video recording in hospital or at home to improve diagnosis. It recommends that friends and relatives use their smartphones to film the attack and recovery.
Dr Angel Moya, Task Force Co-chairperson, said: "There are clinical clues, such as the duration of the loss of consciousness, whether the patient's eyes are open or closed, and jerky movements, that can help distinguish between syncope, epilepsy, or other conditions."
Another diagnostic tool is the implantable loop recorder, a small device inserted underneath the skin of the chest that records the heart's electrical signals. The guidelines recommend to extend its use for diagnosis in patients with unexplained falls, suspected epilepsy, or recurrent episodes of unexplained syncope and a low risk of sudden cardiac death.
A new section has been added to the guidelines, as an addendum, with practical instructions for doctors on how to perform and interpret diagnostic tests.
Professor Brignole said: "The Task Force that prepared the guidelines was truly multidisciplinary. A minority of cardiologists were joined by experts in emergency medicine, internal medicine and physiology, neurology and autonomic diseases, geriatric medicine, and nursing."
Dr Moya said: "Syncope is very common and is usually not life-threatening. We now have more tools to help us clarify the diagnosis and cause of syncope so that patients with benign forms can be reassured and those at risk of sudden cardiac death can receive treatment."

More information: Guidelines for the diagnosis and management of syncope (Version 2018). European Heart Journal.

Provided by European Society of Cardiology

Tuesday, March 20, 2018

Mobile application detecting atrial fibrillation reduces the risk of stroke

Mobile application detecting atrial fibrillation reduces the risk of stroke
The app can detect atrial fibrillation when it is held against the person's chest. Credit: Hanna Oksanen / University of Turku
A new smartphone application developed at the University of Turku, Finland, can detect atrial fibrillation that causes strokes. Atrial fibrillation can now be detected without any extra equipment. The mobile application can save lives all over the world as timely diagnosis of atrial fibrillation is crucial for effective stroke prevention.

20 mar 2018--The joint research project of the University of Turku and the Heart Centre of the Turku University Hospital involved 300 heart patients, half of whom had atrial fibrillation. The researchers managed to identify the patients with atrial fibrillation from the other group using the app.
The mobile application detected which patients had atrial fibrillation with 96 percent accuracy. In other words, the application recognised automatically near all cases with atrial fibrillation and the number of false alarms was very low.
"The results are also significant in that the group included different kinds of patients, some of whom had heart failure, coronary disease, and ventricular extrasystole at the same time. The research was conducted as a blind study, which means that the hospital sent us measurement data for analysis without any additional information," says Project Manager Tero Koivisto from the Department of Future Technologies.
The completed analyses were sent back to the hospital where their reliability was checked. This way, additional optimisation during the study on the basis of the data was not possible.
"At first, I was rather anxious about how well the algorithm will do in the blind study, especially because I felt that the patient group was particularly challenging. You could say that I was surprised myself how well it worked in the end," says Mr Koivisto.
The application has been under development for quite some time, requiring seven years of careful research. Detecting atrial fibrillation has been a worldwide medical challenge for years, but affordable solutions available for all have been lacking. When technology researchers at the University of Turku were designing new solutions in collaboration with cardiologists of Turku University Hospital back in 2011, they decided to investigate whether it was possible to detect atrial fibrillation from the micromovements in the chest using small accelerometers . They determined that it is possible.
"Most smartphones have an accelerometer. As nearly everyone has a smart phone, we decided to develop a simple application that could be used for detection. In the future, everyone who owns a smartphone can detect atrial fibrillation," says Mr Koivisto.
According to Chief Physician and Professor of Cardiology Juhani Airaksinen from Turku University Hospital, this is the first time that ordinary consumer electronics have achieved such reliable results that they can be actually beneficial for the patient's medical care. The results are also remarkable in that intermittent atrial fibrillation is not always detected even at the doctor's office.
"If everyone can measure with an ordinary smartphone whether they have atrial fibrillation, we have the possibility to direct patients straight to the doctor and further testing without any delay. Therefore, the potential for economic savings is significant," says Professor Airaksinen.
The researchers want to make the application available for all as quickly as possible, and they believe that it will also spread to the international market. According to Mr Koivisto, the commercialisation of the method is advancing quickly.
The results of the study was published in the Circulation journal.

More information: Jussi Jaakkola et al, Mobile Phone Detection of Atrial Fibrillation With Mechanocardiography: The MODE-AF Study (Mobile Phone Detection of Atrial Fibrillation), Circulation (2018). DOI: 10.1161/CIRCULATIONAHA.117.032804

Provided by University of Turku

Monday, March 19, 2018

Low-dose 'triple pill' lowers blood pressure more than usual care

A pill combining low doses of three blood pressure-lowering medications significantly increased the number of patients reaching blood pressure targets compared with usual care, researchers reported at the American College of Cardiology's 67th Annual Scientific Session. There was also no significant increase in adverse effects with the "Triple Pill."

19 mar 2018--"Most people—70 percent—reached blood pressure targets with the Triple Pill. The benefits were seen straight away and maintained until six months, whereas with usual care control rates were 55 percent at six months and even lower earlier in the trial," said Ruth Webster, MBBS, of The George Institute for Global Health at the University of New South Wales in Sydney, Australia, and lead author of the study. "Based on our findings, we conclude that this new method of using blood pressure-lowering drugs was more effective and just as safe as current approaches."
Despite the availability of effective blood pressure-lowering drugs, high blood pressure remains a major problem around the world, Webster said. Effectively treating high blood pressure can help to prevent heart attacks, strokes and kidney problems. Globally, however, many people with high blood pressure receive no treatment, and only about a third of those who are treated achieve recommended reductions in blood pressure. Achieving desired reductions in blood pressure often requires treatment with more than one medication, which increases the complexity of treatment, and patients often have difficulty adhering to regimens that involve taking multiple pills every day.
This study was the first large trial designed to test the theory that starting treatment with low doses of three drugs could achieve better blood pressure control compared with usual care and that combining these drugs in a single pill would make it easier both for doctors to prescribe treatment and for patients to adhere to it, Webster said.
The TRIUMPH trial, which was conducted in Sri Lanka, enrolled 700 patients whose average age was 56 years, 58 percent of whom were women. Trial participants had an average blood pressure of 154/90 mm Hg. Over half (59 percent) were receiving no treatment for high blood pressure before they enrolled in the trial. In addition to high blood pressure, 32 percent of participants had diabetes or chronic kidney disease.
Patients were randomly assigned to receive either the combination pill or usual care. The combination pill, or Triple Pill, consisted of the blood pressure medications telmisartan (20 mg), amlodipine (2.5 mg) and chlorthalidone (12.5 mg). These medications use different mechanisms to reduce blood pressure by relaxing the blood vessels, so the heart does not need to pump as hard to send blood throughout the body. Usual care meant that patients received their doctor's choice of blood pressure¬-lowering medication.
The trial's primary endpoint was the proportion of patients who achieved a blood pressure target of 140/90 mm Hg or less (130/80 mm Hg or less in those with diabetes or chronic kidney disease) at six months.
Compared with patients receiving usual care, a significantly higher proportion of patients receiving the Triple Pill achieved their target blood pressure at six months. The average reduction in blood pressure was 8.7 mm Hg for participants receiving the Triple Pill and 4.5 mm Hg for those receiving usual care. At six months, 83 percent of participants in the Triple Pill group were still receiving the combination pill and one-third of those in the usual-care group were receiving at least two blood pressure-lowering drugs.
The maximum difference between the two groups of patients was observed at six weeks after starting treatment, when 68 percent of those receiving the Triple Pill had achieved a blood pressure within their target range, compared with 44 percent of those receiving usual care. This represented a 53 percent reduction in the risk for high blood pressure for patients receiving the Triple Pill, Webster said.
Rates of participants having to change treatment due to side effects were not significantly different in the two groups (6.6 percent for the Triple Pill, 6.8 percent for usual care). This should allay concerns that use of the three-drug combination pill could lead to an unacceptable increase in adverse medication side effects, Webster said.
Each of the drugs used in the Triple Pill has been shown to be highly effective in reducing blood pressure and preventing deaths and illness due to heart disease and strokes, she said. Each drug represents a different class of blood pressure medication and previous studies have shown that combining such drugs results in synergistic effects.
"The most urgent need for innovative strategies to control blood pressure is in low- and middle-income countries," Webster said. "The Triple Pill approach is an opportunity to 'leap frog' over traditional approaches to care and adopt an innovative approach that has been shown to be effective."
The study's findings are also important for high-income countries, she said.
"A control rate of 70 percent would be a considerable improvement even in high-income settings. Most hypertension guidelines in these countries do not recommend combination blood pressure-lowering therapy for initial treatment in all people," she said. "Our findings should prompt reconsideration of recommendations around the use of combination therapy."
An inevitable consequence of a necessarily unblinded study (where both participants and their doctors know whether participants are assigned to the Triple Pill or usual care) is that doctors might manage patients differently depending on the assigned treatment. However, it is important to note this trial was designed to evaluate a new strategy of care in a real-world setting, Webster said.
To minimize the risk of bias in measuring the main outcomes, the number of patient visits was identical in both groups and all outcomes were standardized and objectively documented, she said.
The researchers are now conducting a follow-up qualitative study to find out what participants and their doctors thought about using the Triple Pill. And they are conducting a cost effectiveness evaluation to determine whether the Triple Pill is a cost-effective solution for blood pressure control.
Recommended targets for blood pressure control vary by country. In the U.S., guidance released in 2017 by the ACC and the American Heart Association recommends initiating treatment if blood pressure exceeds 130/80 mm Hg. European guidelines recommend that treatment should aim to achieve a blood pressure level of 140/90 mm Hg or less.

Provided by American College of Cardiology

Sunday, March 18, 2018

Most patients comfortable with sexual orientation and gender identity questions

Most patients comfortable with sexual orientation and gender identity questions
Credit: Mayo Clinic
New Mayo Clinic research suggests up to 97 percent of patients are comfortable with their health care provider asking sexual orientation and gender identity questions. Before this research, it was unclear if the questions - which researchers say are important to reduce health disparities among LGBTI patients - would offend patients. The findings were published today in Health Services Research.

18 mar 2018--"Our results should help ease the concerns of providers who want to deliver the highest-quality care for their patients but may not ask sexual orientation or gender identity questions for fear of distressing or offending their patients," says Joan Griffin, Ph.D., a health services researcher at Mayo Clinic who is a co-author. Dr. Griffin is the Robert D. and Patricia E. Kern Scientific Director for Care Experience at Mayo Clinic.
Although multiple governmental reports have recommended asking these questions, there was little evidence about patient acceptance of these questions, the researchers say.

Why is this research important?

Sexual and gender minorities are at an increased risk for a number of health threats, including higher rates of alcohol and tobacco use, and psychological distress. They are also less likely to seek medical care, according to the Centers for Disease Control and Prevention. However, to decrease health inequities for these patients, health care providers first need to identify them.
Previous research showed many health care providers assumed sexual orientation and gender identity questions would offend patients.
"In previous studies, there was more concern from health care providers about using the questions, but nobody had asked patients about their thoughts," Dr. Griffin says. "Therefore, we were not sure what to expect from patients, but we were not surprised that patients were less concerned about the questions than the providers in other studies thought they would be."
Patients will receive the questions at Mayo Clinic as it switches to a single, integrated electronic health record and billing system. The system was implemented across Mayo Clinic Health System in 2017 and is scheduled to launch on Mayo Clinic's Rochester campus in May, and on Mayo Clinic's Arizona and Florida campuses in October.
"At Mayo Clinic, the needs of the patient come first. These questions will help Mayo Clinic identify the unique, unmet needs of LGBTI patients and highlight that equitable care for all people is a top priority," Dr. Griffin says.

The questions

The researchers conducted the study at three Mayo Clinic sites in Minnesota between June 29, 2015, and Feb. 29, 2016. The sites were chosen for their diversity in patient populations. One site is a women's health clinic serving local, regional and national patients. Another serves regional and national patients 65 and older. And the third site is in a rural community of less than 10,000 people. They gave 491 new patients routine intake forms, or intake forms with sexual orientation and gender identity questions. Both groups received feedback forms that inquired about the intake questions. Responses between the two groups then were compared.
Mayo Clinic's new sexual orientation and gender identity questions are:
  • What sex were you assigned at birth on your original birth certificate? (male, female or choose not to answer)
  • What is your current gender identity? (male, female, female-to-male/transgender male/trans man, male-to-female/transgender female/trans woman, gender queer/neither exclusively male nor female, additional gender category/other [describe] or choose not to answer)
  • Do you think of yourself as ... (lesbian/gay/homosexual, straight/heterosexual, bisexual, something else [describe], don't know or choose not to answer)
  • What is your preferred gender pronoun? (he/him, she/her, something else [describe] or choose not to answer)
Implementing in medical practice

The researchers say that, while their study looked at multiple patient populations, more research may be needed to capture other concerns.
"These findings may generalize to relatively similar areas in the country, especially the Midwest, but there may be differences in other regions in the U.S. or by cultural groups that we did not capture in our sample," Dr. Griffin says.
As institutions adopt sexual orientation and gender identity questions, a simple explanation of why the information is being collected may increase patient participation, the researchers suggest. Patients also may benefit from being reminded of their health care institution's nondiscrimination and confidentiality policies, they say.

Provided by Mayo Clinic

Saturday, March 17, 2018

Gerontologists tackle social isolation, increasingly a public health concern

Social connectivity and meaningful social engagement must be promoted as integral components of healthy aging, according to a new collection of articles in the latest issue of Public Policy & Aging Report (PP&AR) from The Gerontological Society of America (GSA). Several authors also detail a series of initiatives that, if replicated, hold promise for decreasing isolation among older adults.

17 mar 2018--More than 8 million people over age 50 are socially isolated. That means they may not have the support of a social network of friends, family, or community. The toll on their health can be devastating: social isolation has been linked to higher blood pressure, increased susceptibility to the flu and other infectious diseases, greater risk of heart disease, and earlier onset of dementia.
"As we age, social connections can be an important contributor to our well-being," said GSA Executive Director and CEO James Appleby, BSPharm, MPH. "Now through our Public Policy & Aging Report, I am proud that GSA is adding momentum to research in this topic area—ultimately leading to new evidence-based insights that can be translated into sound policy and practice."
Appleby sits on the Executive Council of Connect2Affect, an initiative led by AARP Foundation that is committed to helping end isolation and build the social connections that older adults need to thrive.
Lisa Marsh Ryerson, president of AARP Foundation, contributed the first article to the PP&AR's lineup. In addition to describing the efforts of Connect2Affect, she reports on several new ventures underway at the Foundation.
One involves a collaboration with the USC Center for Body Computing, with generous support from UnitedHealthcare, to study whether providing free Lyft rides to medical and non-medical appointments can improve health and well-being in older adults. A second involves testing whether an interactive device with built-in speech recognition and the ability to provide voice responses will make it easy, fast, and fun for older adults to get reminders and community information, and to discover and deepen new relationships. The Foundation is also supporting a project that evaluates the effectiveness of phone-based outreach in reducing feelings of loneliness and the incidence of poor health among low-income older adults.
A subsequent article by Julianne Holt-Lunstand, PhD, of Brigham Young University, demonstrates the need for such innovations. She concludes that there is now substantial evidence that being socially connected significantly reduces the risk for premature mortality, and that lacking social connectedness significantly increases risk. Moreover, these risks exceed those associated with many risk factors that receive substantial public health resources: obesity, air pollution, smoking, and physical inactivity.
The new issue of PP&AR, which contains 10 articles and an opening editorial, is titled "Lack of Social Connectedness and Its Consequences" and can be accessed at

Provided by The Gerontological Society of America

Thursday, March 15, 2018

Hundreds of genes linked to intelligence in global study

A depiction of the double helical structure of DNA. Its four coding units (A, T, C, G) are color-coded in pink, orange, purple and yellow. Credit: NHGRI
More than 500 genes linked to intelligence have been identified in the largest study of its kind. Scientists compared variation in DNA in more than 240,000 people from around the world, to discover which genes are associated with intelligence. Researchers identified 538 genes that play a role in intellectual ability. They also found 187 regions in the human genome that are linked to thinking skills.

15 mar 2018--Scientists say the study sheds new light on the biological building blocks of people's differences in intelligence. The research was carried out by the Universities of Edinburgh and Southampton, and Harvard University.
Genes found to be linked to intelligence also appeared to influence other biological processes, researchers say. Some genes linked to intellectual ability are also associated with living longer, scientists found. They also found that genes linked with problem solving powers were associated with the process by which neurons carry signals from one place to another in the brain.
Using these genetic discoveries, scientists next predicted seven per cent of intelligence differences in an independent group of individuals using their DNA alone. "Our study identified a large number of genes linked to intelligence. Importantly, we were also able to identify some of the biological processes that genetic variation appears to influence to produce such differences in intelligence, and we were also able to predict intelligence in another group using only their DNA," says Dr. David Hill.
"We know that environments and genes both contribute to the differences we observe in people's intelligence. This study adds to what we know about which genes influence intelligence, and suggests that health and intelligence are related in part because some of the same genes influence them," says Professor Ian Deary.
The study used data from the UK Biobank, a major genetic study into the role of nature and nurture in health and disease.
It is published in the journal Molecular Psychiatry.

More information: W. D. Hill et al. A combined analysis of genetically correlated traits identifies 187 loci and a role for neurogenesis and myelination in intelligence, Molecular Psychiatry (2018). DOI: 10.1038/s41380-017-0001-5

Provided by University of Edinburgh

Wednesday, March 14, 2018

Exploring the role of cognitive factors in a new instrument for elders' financial capacity

Although the general public and mental health professionals seem to disregard incapacity regarding financial issues and relevant decision making in mild cognitive impairment (MCI), and focus only on severe dementia cases, a PhD study in Greece reveals that noticeable deficits do exist in the handling of financial issues in elders suffering from MCI.

14 mar 2018--An extended sample of 719 elders from Northern Greece, including healthy participants and patients with different types of cognitive deficits, such as amnestic mild cognitive impairment (aMCI), mild, moderate, and severe Alzheimer's dementia (AD), mild Parkinson's disease dementia (PDD), mild vascular dementia (VD), moderate frontotemporal dementia (FTD), and moderate mixed dementia (MD), were examined with a new instrument specifically designed in the Greek cultural context, entitled Legal Capacity for Property Law Transactions Assessment Scale (LCPLTAS) and a battery of classic neuropsychological tests concerning various cognitive functions.
The proposed instrument is based on Marson's theoretical model of financial capacity and consists of seven domains: basic monetary skills, cash transactions, bank statement management, bill payment, financial conceptual knowledge, financial decision making, and knowledge of personal assets. In addition, both participants and their family members/caregivers were examined with a structured interview and a questionnaire that assessed everyday financial experiences/problems and their personal beliefs about the elders' everyday financial capacity. An assessment of capacity was made by mental health experts. The generally accepted psychometric approach for the classification and determination of capacity status (incapable, marginally capable, and capable) was used for LCPLTAS and was established in relation to normal control performance. Cutoff scores for distinguishing capable from marginally capable status, and marginally capable from incapable status was set at 1.5 SDs and 2.5 SDs, respectively, below the control group mean for LCPLTAS
Significantly different profiles in the scores and subscores of LCPLTAS for all the groups of dementia patients were found. Α general incapacity finding holds true not only for all the dementia groups who obtained scores more than 2.5 SDs lower than healthy controls, but also for the MCI patients group who scored around 2.0 SDs lower than healthy participants.
The severity of the deficits in the scores and subscores of LCPLTAS depend on the severity of the cognitive deficits in the classic neuropsychological tests, and more specifically on Mini Mental State Examination (MMSE) total score. Logistic regression showed that specific neuropsychological tests, such as the MMSE, Geriatric Depression Scale (GDS) and Trail Making Part B predicted competence on LCPLTAS for the patients. Persons with MCI and dementia had lower financial knowledge scores than those without cognitive impairment, with MMSE scores below 27, suggestive of an indication of financial incapacity.
Cross-cultural replication studies are needed, as this research serves as a first step in the direction of providing a short form of a reliable and valid tool for use in the Greek elderly population. In addition, it seems necessary to further investigate in detail the biological and brain underpinnings of financial incapacity in MCI patients. Finally, normative data for the child and teenage population, as well as patients with other neurological disorders that may affect judgment for financial issues, is a promising area of future research, as normative data are generally lacking, not only in Greece, but internationally, while there is a plethora of relevant financial cases at courts which rely on other neuropsychological tests and not on relevant tests that aim specifically the financial capacity.

More information: Vaitsa Giannouli et al, Exploring the Role of Cognitive Factors in a New Instrument for Elders' Financial Capacity Assessment, Journal of Alzheimer's Disease (2018). DOI: 10.3233/JAD-170812

Provided by IOS Press

Sunday, March 11, 2018

Overdiagnosis—when finding cancer can do more harm than good

Overdiagnosis—when finding cancer can do more harm than good

Not all cancers are equal.

11 mar 2018--Some grow fast and spread quickly, while others grow so slowly (or even not at all) that if they went undetected they wouldn't cause any problems. Even if left untreated, a person wouldn't be harmed by their cancer.
When these harmless cancers are found they're said to be 'overdiagnosed'. This happens more often with certain types of cancer, and is usually tied to particular types of cancer screening that test people without symptoms, such as breast screening.
The problem is that when these types of cancer are diagnosed early it's impossible to tell the potentially harmful ones from the harmless ones. Everyone is then usually offered treatment. And this means that some will be exposed to the potential side effects of treatment, and worry of a cancer diagnosis, when they didn't need to be. This is called overtreatment.
Overdiagnosis is one of the key things to consider when working out the balance of possible benefits and harms of cancer screening. Keep in mind, overdiagnosed cancers aren't the same as when a test finds something abnormal that turns out not to be cancer (so-called false positive test results), another risk of screening and many other types of test. An overdiagnosed cancer is a true cancer, but it's one that wouldn't have caused harm in that person's lifetime.
So the challenge then becomes shifting our thinking of cancer as always needing urgent treatment to a disease that sometimes we can live with, or be unaware of and unaffected by.
Over the last few decades overdiagnosis has been receiving more attention. And with new cancer detection technology on the horizon, ranging from blood tests to wristbands, it's important that we learn more about it and work out how to minimise it.

What's the evidence?

Some of the earliest evidence around overdiagnosis came from autopsy studies. Experts found undiagnosed cancers in people who had died from a cause other than cancer. This showed in some cases people can live out their life without ever knowing a cancer is there, or being harmed by it.
Professor Gilbert Welch, from the Dartmouth Institute for Health Policy and Clinical Practice in the US, is a pioneer in raising awareness of the challenge of overdiagnosis. And he says that overdiagnosis isn't something that doctors or researchers usually directly observe. "The occasional exception is when we do nothing for a diagnosed cancer and the patient goes on to die of something else," he says.
Other evidence for the phenomenon has come from digging into cancer statistics, particularly when comparing the number of people diagnosed with a cancer (incidence) with those that die from it (mortality).
"The easiest evidence to understand is when incidence shoots up following early diagnosis and mortality stays the same," says Welch. "Here South Korea serves as the poster child."

Thyroid cancer in South Korea – a true epidemic?

South Korea introduced free screening programmes for a range of cancers in 1999, with thyroid cancer screening also available for a small fee. A decade later, the incidence of thyroid cancer in South Korea had increased dramatically.

Overdiagnosis—when finding cancer can do more harm than good

If the number of cases of thyroid cancer were really increasing, and if we assume they're all cancers that needed to be found and treated, we'd also expect an increase in the number of people dying from thyroid cancer.
That didn't happen.
There are two possible explanations for this:
  1. Thyroid cancer treatment improved dramatically at the same time as more people were being diagnosed, so lots more people were surviving the disease.
  2. The cancers that were being picked up through screening were overdiagnosed.
The second explanation is far more likely. In other words, simply scanning more thyroids picked up more of the slow-growing, harmless cancers that didn't need to be found and treated in the first place.
Importantly, overdiagnosis can mean cancer survival statistics don't always accurately represent the progress we're making. For example, if more harmless cancers are found and treated, many more people will survive the disease they've been diagnosed with. So it can be tricky to untangle the true impact of things like better treatments.
But some cancers are much more prone to overdiagnosis than others, such as breast and prostate cancers.

Breast screening: saving lives and balancing harms

Breast screening picks up early stage cancers that are more likely to be treated successfully. But it also comes with potential harms, including overdiagnosis, because many of those early invasive breast cancers wouldn't have gone on to cause trouble. Women need this information so they can make a fully informed decision about whether or not to go for screening.
Research has shown that for each woman whose life is saved through breast cancer screening, around three will be diagnosed with a breast cancer that would have never caused harm or death.
A cancer diagnosis causes distress. And because breast screening and diagnostic tests can't yet tell the dangerous cancers that need treating from the harmless ones that don't, some people will experience that distress unnecessarily. So to be on the safe side, treatment will be recommended to all patients, which can also lead to unnecessary side effects.
"For every woman who is prevented from dying from breast cancer, three others will be diagnosed that wouldn't have otherwise if they didn't participate in breast screening," explains Professor Peter Sasieni, Cancer Research UK's expert in cancer screening and epidemiology from King's College London.
"Those three will be treated and will probably have surgery, radiotherapy and possibly hormonal therapy."
"I think the language we use to talk about cancer is a big problem in society," he adds. "I think most people still think of a cancer diagnosis as a death sentence."

Overdiagnosis—when finding cancer can do more harm than good

"The Holy Grail is finding something that tells us which cancers are harmless and which aren't, and then we can distinguish between them and ignore the harmless ones."
Screening can save lives by diagnosing cancer at an earlier stage and, in some cases, preventing it from developing in the first place. But the decision to introduce new screening programmes has to be carefully thought through.

Prostate cancer: why there's no UK screening programme

Prostate specific antigen (PSA) is a molecule made by the prostate and detected in blood samples. A man's PSA level can be raised for many reasons, including an enlarged prostate, infection and prostate cancer.
Clinical guidelines recommend PSA testing in men with prostate cancer to monitor if their disease gets worse. And men with low-risk prostate cancer that hasn't spread can be monitored with regular PSA testing as an alternative to surgery or radiotherapy.
But there are longstanding debates around if the PSA test should be used for screening to look for prostate cancer in men with no symptoms.
There's no national prostate cancer screening programme in the UK, because the PSA test isn't reliable enough. A large study from 2013 looked at the results of different trials comparing men who had prostate screening and those who didn't. The study showed that screening didn't save any lives, and the men who took part in screening were more likely to be overdiagnosed.
The latest findings from a major Cancer Research UK-funded PSA trial included over 400,000 men and has backed up that a one-off PSA test doesn't save lives.

Seek and you shall find

No screening test is perfect and there's always a trade-off between lives saved and the harms of overdiagnosis and overtreatment. It's up to researchers to improve tests and tip the balance.
We're in exciting times when it comes to the potential for technology and innovation to diagnose cancer earlier. We need to be able to find and diagnose cancers early because when cancer is found at an earlier stage it's easier to treat.
But the flip side is that new tests and more sensitive tech can come with a higher risk of picking up cancers that would never have gone on to cause harm. So it's vital that researchers consider not only how to find cancer earlier, but also how to reduce overdiagnosis and ensure we're picking up the cancers that need treating.
Lung cancer screening is an example of where this can happen.
Most lung cancers are diagnosed at a late stage (stage 4), and this is largely to blame for lung cancer survival being so poor. Diagnosing more cancers early (stage 1 and 2) is crucial to save lives. And screening might be a way of doing this.

Overdiagnosis—when finding cancer can do more harm than good

The US National Lung Screening Trial compared chest x-rays with low dose CT scans to pick up lung cancers. In other words, whether CT as a more advanced imaging technology has greater potential than standard chest x-rays to diagnose lung cancer in people without symptoms and stop people dying from the disease.
The researchers looked at over 53,000 people aged between 55 and 74 at high risk of lung cancer based on their smoking history. Half were screened with chest x-rays and the others had CT scans.
The group that had CT scans were 20% less likely to die of lung cancer than those who had chest x-rays, suggesting CTs can save more lives. But compared with the x-ray group, the risk of having a lung cancer overdiagnosed in the CT group was around 18%. That's nearly 1 in 5 people who were diagnosed with a lung cancer that wouldn't have gone on to cause any harm at all in their lifetime. Researchers working on lung screening know this is something to be addressed as they test what might balance the harms and benefits of lung screening.
"It's important to emphasize that harms of overdiagnosis can coexist with the benefit of a mortality reduction – they aren't mutually exclusive," says Welch.
There isn't a national lung cancer screening programme in the UK because it's not clear if the potential benefits would outweigh the potential harms. The largest European trial investigating lung cancer screening is still underway. The latest results, expected out in the next year, will hopefully shed more light on these issues.

What next?

Screening can help spot cancer early and save lives.
And the UK's national screening programmes exist because research has shown that the benefits outweigh the harms for the population at large.
But for an individual person, the decision to be screened or not should be an informed choice.
"Currently, in order to have the benefits of screening, there has to be some overdiagnosis," says Sasieni.
If you're unsure about what to do if you get an invitation for screening, visit our website or speak to your doctor.
Research into better tests and improved technology will help pick up cancers earlier.
The challenge then is finding out how to tell the dangerous cancers from the harmless ones. But with overdiagnosis moving further in to the spotlight, and with our strong commitment to diagnosing cancers earlier, researchers are better placed than ever to tackle this.

Provided by Cancer Research UK

Saturday, March 10, 2018

Exercise can slow the aging process – a professor explains how

Exercise can slow the aging process – a professor explains how
Credit: Shutterstock
The tradition of sending a telegram to every British citizen on their 100th birthday was started just over 100 years ago by George V, who sent out just nine letters. Last year, the Queen had to sign over 16,000 birthday letters. The UK has an ageing society, with falling birth rates and increasing life expectancy. Improvements in public health and medicine have helped to achieve this amazing effect on lifespan.

10 mar 2018--But for far too many, old age is endured and not enjoyed, being associated with disease and physical and mental frailty. Today's baby boomers may be less likely than previous generations to accept that old age is a time for taking it easy, getting to know your GP and developing a taste for the settee, slippers and daytime TV.
My latest research project, conducted with colleagues at the University of Birmingham and Professor Stephen Harridge at King's College London, aims to understand which aspects of human ageing are inevitable, and which are a result of our modern lifestyles – and therefore under our control.
Staying strong
Prehistoric hunter-gatherer tribes were highly active, spending a lot of time and energy sourcing their food. If they weren't successful, they would also spend days with or little or no food. By contrast, today we are a highly sedentary society; one study by the Heart Foundation revealed that most adults spend 15 hours a day sitting down. Together with eight hours of sleep, this leaves just one hour for physical activity.
Exercise can slow the aging process – a professor explains how
An MRI scan of the thigh: as people age, muscle mass declines and turns to fat. Credit: Janet Lord/University of Birmingham., Author provided
As we get older, our physical activity levels decline even further. In our research, we have tried to determine how much this low level of physical activity contributes to the ageing of many body systems, including muscle, bone and the immune system.
We examined 125 male and female cyclists, aged 55 to 79, who had maintained a high level of cycling throughout most of their adult lives. These were not Olympians, but very keen cyclists who were able to cycle 100km in under 6.5 hours for the men, and 60km in under 5.5 hours for the women.
We have previously looked at several body systems that we know decline with age, such as muscle and bone. At mid-life, people start losing muscle mass and strength at a rate of 1% to 2% per year, making it harder to carry out their normal activities such as climbing stairs. Our bones also become thinner with age and this can eventually lead to diseases such as osteoporosis.
We showed that the cyclists did not lose  or strength as they aged, and their bones only became slightly thinner. We then went on to examine a body system that was not so obviously influenced by physical activity – the immune system.
Exercise can slow the aging process – a professor explains how
The thymus shrinks with age, affecting immune system function. Credit: Janet Lord/University of Birmingham, Author provided
Start 'em young
The immune system declines with age, making older adults more susceptible to infections such as flu and pneumonia. They also respond less well to vaccines, so this preventive measure doesn't offer the same protection which it can to younger people. When we compared the immune system of the cyclists to older adults who had not done regular exercise, and to young people in their twenties we found that their immune systems looked most like the young persons'.
In particular, we found that the cyclists still made lots of new immune T cells, produced by an organ called the thymus, which normally starts to shrink after we reach puberty. The older cyclists seemed to have a thymus that was making as many new T cells as the young people's. The lifelong cycling seemed to have slowed down the ageing of their immune systems.
We investigated why this happened and found that the cyclists had high levels of a hormone called interleukin 7 in their blood, which helps to stop the thymus shrinking. Interleukin 7 is made by many cells in the body, including muscle cells, so we think that active muscles will make more of this hormone and keep the immune system, and especially the thymus, young.
So it is possible to take back control of your body, and prevent its deterioration with age. The UK's chief medical officer Sally Davies suggests that people do at least 150 minutes of aerobic exercise per week. We don't know if this is enough to protect your immune system, but it's a good place to start.
Our physical activity levels start to decline from the age of 25 in the UK, so don't leave exercise until old age – start now.
This article was originally published on The Conversation. Read the original article.The Conversation

Provided by The Conversation