Wednesday, April 30, 2008

Study finds increases in nursing home, assisted living costs

30 april 2008--Costs for nursing homes, assisted living facilities and some in-home care services have increased for a fifth consecutive year, and could rise further if a shortage of long-term care workers isn't resolved, a new study indicates.
The survey by Genworth Financial Inc., released Tuesday, comes as baby boomers are approaching retirement amid worries that they haven't saved enough to cover day-to-day expenses as well as long-term medical care costs.
The study found that the average annual cost for a private room in a nursing home rose to $76,460, or $209 per day, this year, a 17 percent increase over the $65,185 cost in 2004. Nursing home costs this year ranged from $515 per day in Alaska to $125 per day in Louisiana, the study found.
The cost for assisted living facilities, meanwhile, averaged $36,090 nationally, up 25 percent from $28,763 in 2004. Costs ranged from $4,921 per month in New Jersey to $1,981 per month in Arkansas, the study said.
In-home care costs for non-Medicare certified workers were essentially flat, at a national average hourly rate of $18 for homemaker services and $19 for home health aide services. But the cost of a Medicare-certified home health aide rose to an average $38 an hour, up at a 7 percent annual growth rate over the past four years.
The study by Genworth Financial, which is based in Richmond, Va., looked at data from more than 10,000 nursing homes, assisted living facilities, and home care providers nationwide. The company sells insurance, including long-term care products.
Buck Stinson, president of Genworth Financial's long-term care insurance business, said the results indicate that "the expense of just a few years of long-term care in a facility or at home can very quickly wipe out a lifetime of savings."
He noted, for example, that an elderly person typically spends 2- 1/2 years in a nursing home, or more than $190,000 on average at today's costs.
He said that individuals, especially the baby boomers born between 1946 and 1964, "need to do more thinking about their own retirement plan and how they're going to age."
Stinson also said there was a need to find ways to "recruit close to 200,000 people a year to keep pace with the aging demographic." A companion Genworth Financial study found that low wages and benefits as well as a lack of training and career-advancement potential have made it difficult to attract workers to the elder care industry and retain them.
The study for the first time also looked at adult day health care and found an average daily cost of $59. That would work out to about $15,000 a year for participation five days a week.
Adult day health care, sometimes at a community-based center, can monitor medication, provide therapy and ensure that people with cognitive problems are watched and don't wander off.
Stinson said these centers were proving popular with families who have elderly parents living in their homes and need daytime support so they can continue jobs, take care of children or just get a break from caregiving.
"It's a convenient outlet ... and obviously less expensive than a full-time facility, so it makes economic sense," Stinson said.
Aging: Depression Tied to Alzheimer’s

30 april 2008--A history of depression is associated with an increased risk for Alzheimer’s disease, a new study has found, especially when the depression develops before age 60.
Researchers began the study with 486 men and women who did not have dementia, following them for an average of six years. A total of 134 reported a history of depression. During the study period 44 developed dementia; of those, 33 developed Alzheimer’s.
People who had reported incidents of depression before age 60 were almost four times as likely to develop Alzheimer’s as those who reported no depressive symptoms. Those who reported depression after 60 were more than twice as likely to develop Alzheimer’s as those who did not.
“The better we understand the link between depression and Alzheimer’s, the more insight we will have into the cause of Alzheimer’s,” said Dr. Monique M. B. Breteler, the senior author. “This can allow us to develop more rational therapies.”
Dr. Breteler is a professor of neuroepidemiology at Erasmus Medical Center in Rotterdam, the Netherlands.
The authors acknowledge that they depended on self-reports of depression, and that some people who had suffered mild depression may have been misclassified as having no history of it. Still, the large sample size, prospective design and complete follow-up give considerable strength to the study, published April 8 in Neurology.
Investigational Drug Slows Functional Decline in Early Alzheimer's

By John Gever
OXFORD, England, 30 april 2008-- The investigational anti-amyloid drug tarenflurbil (Flurizan) significantly slowed declines in the overall ability to function among mild Alzheimer's disease patients, researchers here said.
"This phase II study provides preliminary evidence of a possible therapeutic effect of tarenflurbil, the first selective [amyloid] lowering agent to complete a phase II evaluation," wrote Gordon K. Wilcock, D.M., of the University of Oxford, and colleagues online in Lancet Neurology.
Highlights of the data were presented two weeks ago at the American Academy of Neurology meeting in Chicago (See: AAN: Investigational Amyloid Inhibitor Slows Early Alzheimer's Progression).
Tarenflurbil inhibits the gamma-secretase enzyme that cleaves beta-amyloid protein from a larger precursor molecule. In particular, it blocks production of the Ab42 species of beta-amyloid that forms fibrillary plaques in the brains of Alzheimer's patients.
Expectations are that the drug will prevent additional deposits of amyloid plaques in the brain, but it is unlikely to eliminate existing plaques.
The agent is a chemical sibling (specifically, the R-enantiomer) of the nonsteroidal anti-inflammatory drug flurbiprofen (Ansaid).
Dr. Wilcock and colleagues tested two doses of tarenflurbil (800 and 400 mg twice daily) against placebo in 210 patients with mild to moderate Alzheimer's disease, as defined by scores of 15 to 26 on the Mini-Mental State Exam.
The placebo-controlled study, conducted in Britain and Canada, lasted one year. Canadian patients could then participate in a one-year extension trial in which those previously assigned to tarenflurbil continued at the same doses, and those taking placebo were re-randomized to one of the two doses of active drug. The double-blind was maintained.
Primary outcomes were rates of decline in three standardized measures used to assess Alzheimer's disease:
Alzheimer's Disease Assessment Scale, cognitive subscale
Alzheimer's Disease Cooperative Study Group Activities of Daily Living
Clinical Dementia Rating-Sum of Boxes (assesses global function)
Dr. Wilcock and colleagues found that neither dose of tarenflurbil had a significant effect in patients with moderate Alzheimer's disease, defined by scores of 15 to 19 on the Mini-Mental State Exam.
However, during the first year of treatment, global function and daily activities scores showed lower decline in patients receiving 800 mg of tarenflurbil twice daily versus those taking placebo.
When Activities of Daily Living scores were graphed, Dr. Wilcock and colleagues found a difference in slope of 3.98 (95% CI 0.33 to 7.72) points per year between high-dose tarenflurbil and placebo. This difference translated into a reduction of 46.4% from the decline rate with placebo (Cohen's d 0.45, P=0.033).
Similarly, the difference in slope for global function scores was -0.80 points per year (95% CI -1.57 to -0.03), translating into an effect size of 35.7% (d 0.42, P=0.042).
Cognitive subscale also suggested a benefit with high-dose tarenflurbil, with an effect size of 33.7%, but it was not significant (d 0.20, P=0.327).
But cognitive decline was significantly slowed according to results in the extension trial, comparing 22 patients receiving 24 months of high-dose tarenflurbil with 11 patients initially on placebo and then switched to high-dose tarenflurbil in the extension.
Mean change in cognition scores was 2.9 points (SD 1.7) among patients continuously taking high-dose tarenflurbil for two years, versus 11.5 points (SD 2.4) among those initially in the placebo group (P=0.005).
Patients also showed significantly better scores on the other two primary outcome measures at the end of the extension.
The lower dose showed no significant benefit on any outcome measure.
Few significant differences in adverse effects were seen among groups receiving either of the tarenflurbil doses or placebo. At the higher drug dose, significantly more patients had eosinophilia compared with the placebo group.
On the other hand, patients in the placebo group had higher rates of urinary incontinence.
About 85% to 90% of patients in all groups had some type of adverse event. Among patients in the high-dose tarenflurbil group, the most common were diarrhea and nausea, each seen in 10% of patients. These were not significantly less common in the placebo group (seen in 8% and 6% of patients, respectively).
In an accompanying commentary, Paul S. Aisen, M.D., of the University of California San Diego, noted that the drug failed to meet the original primary endpoint in the study, significant slowing in cognitive and functional decline in patients with moderate as well as mild Alzheimer's disease.
He chalked up the failure to the difficulties of proving benefit in a phase II trial with this type of drug.
"Disease-modifying interventions are expected to slow the progressive decline of cognitive and clinical measures without any short-term effect," he pointed out. "Proof of efficacy, or even proof of mechanism, might be impossible in a phase II study."
Indeed, the phase II results with tarenflurbil are "hardly conclusive," Dr. Aisen wrote.
Nevertheless, he said it was good that the drug's sponsor, Myriad Pharmaceuticals, has gone ahead with phase III testing.
Two phase III trials are now underway. Data from a U.S.-based trial of 1,684 patients are now being analyzed and are expected to be reported later this year. An international study involving 840 patients is scheduled to end in October.
Wrote Dr. Aisen, "With the need so enormous, and the potential benefit suggested (although not proven) by these phase II results, the effort is indeed justified despite the substantial uncertainty. In a few months, we will learn whether tarenflurbil will be the first anti-amyloid intervention to be efficacious in a pivotal trial."
The phase II study was funded by Myriad Pharmaceuticals.
Study co-authors reported relationships with Myriad.
Dr. Aisen reported that he was a site investigator on a phase III trial of tarenflurbil but has not had a consultant relationship with Myriad.
Primary source: Lancet NeurologySource reference:Wilcock G, et al "Efficacy and safety of tarenflurbil in mild to moderate Alzheimer's disease: A randomised phase II trial" Lancet Neurology 2008; DOI: 10.1016/S1474-4422(08)70090-5 Additional source: Lancet NeurologySource reference: Aisen P, "Tarenflurbil: A shot on goal," Lancet Neurology 2008; DOI: 10.1016/S1474-4422(08)70091-7
Researchers create health, happiness index

30 april 2008--Staying healthy and happy is a struggle for about half of Americans, according to a massive survey that attempts to measure the nation's general welfare, much like the Dow Jones Industrial Average portrays the health of the stock market.
The Gallup-Healthways Well-Being Index, based on interviews of more than 100,000 people so far, shows that 47 percent of Americans are struggling and 4 percent are suffering. Forty-nine percent of respondents are reported to be thriving based on a personal assessment of how they feel about their lives at the time of the survey, and where they think they'll be in five years.
Pollsters asked people to imagine where they would put themselves on a ladder with 10 steps. Those said they were on step seven or above are listed as thriving. Those at four or below are suffering. In between are the strugglers.
Those who are thriving tend to have higher incomes, more education and less illness. Those who are suffering have trouble meeting their basic needs, including food, shelter and medical care, said James Harter, Gallup's chief scientist for workplace management and well-being.
Just as the U.S is not No. 1 when it comes to health measures, it also is not No. 1 in well-being, he said. For example, 83 percent of the residents of Denmark are classified as thriving versus 1 percent who are suffering.
Researchers hope the findings, which can be broken down by occupation, commute time and exercise habits, will help employers better understand what they can do to create happier and healthier workers.
Eventually, they said, the data could even be used to compare health and happiness by ZIP code, creating quite a measuring stick for future generations of politicians.
"There's never been anything quite like it," said Daniel Kahneman, a Nobel Prize winner in economic sciences.
"You're getting details about what it's like to live in this country," said Kahneman, a Princeton University professor brought in by Gallup to discuss the potential uses for the data. "What is the experience of the weekend? What is the experience of the weekday for someone who is sick and has to go to work in the morning? We are going to learn a great deal about what are the determinants of actual happiness."
Dr. Julie Gerberding, director of the federal Centers for Disease Control and Prevention, noted that the United States invests more on health care than any country, but that its health care system ranks 37th.
"That doesn't sound like we're getting the best value from the investment we're making," Gerberding said. "That fundamentally is something we as a nation are waking up to."
The research has implications for employers who want to stay on top of problems confronting a particular work force.
The survey shows that manufacturing or transportation workers are most likely to report a negative work environment — 29 percent. Those who report a negative work environment tend to miss more days of work. A worker with up to three chronic conditions and a negative work environment will miss an average of 6.6 more days of work a year than a similar worker who likes his or her work environment, the survey found.
The survey said a negative work environment includes job dissatisfaction, an authoritative boss, lack of trust and lack of focus on individual strengths.
Among all workers, two-thirds reported one or more chronic diseases or recurring conditions. More than a quarter reported back or neck problems; 23 percent cited high cholesterol and 22 percent had high blood pressure. More than one in 10 said they suffered from depression.
Nearly two-thirds of workers reported body mass indexes indicating they could be obese or overweight.
Healthways, which works with companies to improve the health of workers, partnered with Gallup to pay for the survey. The cost of maintaining the index is projected at more than $20 million annually. More than 1,000 are being interviewed daily.
Cancer Diagnosis May Not Generate Healthy Living

By Todd Neale
HALIFAX, Nova Scotia 30 april 2008-- Many cancer survivors don't follow healthy lifestyles, according to epidemiologists here.They are more likely to be non-smokers (82.6% to 91.6%) than adults in the general population (79.5%) but not more prone to exercise to recommended levels or to consume healthy diets, defined as having at least five servings of fruits and vegetables a day.In a study of more than 9,000 patients with a history of prostate, breast, colorectal, bladder, uterine cancer, or melanoma, 80.9% to 85.2% were not following the dietary recommendation of eating at least five servings of fruits and vegetables a day, Chris Blanchard, Ph.D., of Dalhousie University here, and colleagues reported in the May issue of the Journal of Clinical Oncology
And only 29.6% to 47.3% were getting the recommended 150 minutes of moderate-to-strenuous exercise or 60 minutes of strenuous physical activity a week, they said.
Only about one in 20 patients (3.6% to 5.8%) was following all three recommendations (smoking, diet, and exercise), and 7.3% to 12.5% were not following any.
This is concerning, the researchers said, because health-related quality of life increased significantly (P<0.001) across all cancer groups for each additional healthy behavior the patients had adopted.
The fact that most cancer survivors are not making the lifestyle changes necessary to improve their long-term outcomes illustrates the need to find ways to promote adherence to recommendations like those from the American Cancer Society, the researchers said.
Also, past studies have shown that physical activity is linked to health-related quality of life in cancer survivors, but more information is needed on the relationship between quality of life, smoking, and the consumption of recommended amounts of fruits and vegetables, they said.
Dr. Blanchard and colleagues analyzed self-reported and registry-based data on 9,105 patients with a history of cancer from the society's Study of Cancer Survivors-II. Breast, prostate, colorectal, bladder, uterine, and skin cancers were chosen because of their relatively lengthy long-term survival rates.
Health-related quality of life was assessed on the basis of eight physical and mental domains. Scores could range from 0 (worst) to 100.
Across all six cancer groups, those who were getting the recommended amount of exercise had higher health-related quality-of-life scores than those who were not, after controlling for age, race, education, marital status, disease stage, and comorbidities (P<0.05).
Patients with a history of breast, prostate, or colorectal cancer who ate the recommended amounts of fruits and vegetables and who did not smoke had significantly higher health-related quality-of-life scores than those who did not meet those criteria (P<0.05).
Melanoma survivors had higher health-related quality-of-life scores if they followed the fruits and vegetables recommendation (P<0.05), but no significant difference was found in regards to smoking.
No significant differences were found in the health-related quality-of-life scores in patients with a history of bladder or uterine cancer for either of the recommendations on fruits and vegetables or smoking.
There was an increasing trend for higher health-related quality-of-life scores among patients in all six cancer groups for each additional recommendation that was met (P<0.001 for all).
There was a difference of about eight points (on the scale of 100) between those who followed all three recommendations and those who did not follow any, a clinically significant change, according to study co-author Kevin Stein, Ph.D., of the American Cancer Society in Atlanta.
It would be challenging to implement an interventional program that considers multiple behaviors, the researchers said, but "doing so may provide an important opportunity to maximize the potency of the intervention from an outcomes perspective."
"Importantly," they said, "such an intervention should rely on a sound theoretical framework that takes multiple levels (i.e., intrapersonal, interpersonal, institutional, community, and policy) into account."
The authors acknowledged that the study was limited by the use of self-reported assessments of lifestyle behaviors, the lack of information on behaviors before the cancer diagnosis and the low overall response rate.
Also, the cross-sectional study design could not determine a causal relationship between these behaviors and an improved quality of life.
Finally, adding together the effects of various comorbidities may not account for the varying strengths of their effects on health-related quality of life.
The study was supported by intramural funding from the ACS.
One of Dr. Blanchard's co-authors, Kevin Stein, Ph.D., is an employee of the cancer society.
Primary source: Journal of Clinical OncologySource reference:Blanchard C, et al "Cancer survivors' adherence to lifestyle behavior recommendations and associations with health-related quality of life: Results from the American Cancer Society's Studies of Cancer Survivors (SCS-II)" J Clin Oncol 2008.

Tuesday, April 29, 2008

Honda develops walking assist device for the elderly

29 april 2008--Honda is known for it’s cars and motorcycles, but the company’s sights reach into other areas as well. Now that they have their robot, Asimo walking on his own, Honda is using robotics technology for some other things. Like an experimental walking assist device for disabled or elderly individuals.
Honda will be showcasing the device at the International Trade Fair on Barrier Free Equipments & Rehabilitation for the Elderly & the Disabled. The device is available in three sizes and uses brushless DC motors powered by lithium ion batteries that will provide up to two hours of walking assistance per charge. The assimilation of our elderly will soon be underway. Soon after they will be flying around in giant Borg cubes and harassing the Enterprise.
Hormone Therapy Linked to Stroke Regardless of Timing

By Peggy Peck

BOSTON, 29 April 2008 -- Women on hormone therapy are at increased risk of stroke, whether they start shortly before or a decade after menopause, researchers here said.
Women who used estrogen alone had an increased stroke risk of almost 40% compared with the risk faced by women who didn't use hormones, and when estrogen was combined with progestin, the risk increased by 27%, Francine Grodstein, Sc.D., of the Harvard School of Public Health, and colleagues reported in the April 28 issue of Archives of Internal Medicine.
Their analysis of data from the 121,700-woman Nurses' Health Study showed that, for women ages 50 through 54, the attributable risk was about two additional cases of stroke per 10,000 women per year taking hormones.
Moreover, they found a strong dose-dependent response. Relative risk was 0.93 for 0.3 mg of oral conjugated estrogen and escalated to 1.54 when the dose was 0.625 -- the dose used in the Women's Health Initiative study -- and 1.62 at a dose of 1.25 mg (P for trend <0.001).
The authors said there was no higher risk of stroke for hormone therapy initiated at a younger age with a duration of less than five years, but they cautioned that "this apparently null result was based on a small number of cases."
The results, the authors said, were virtually identical to those seen in the Women's Health Initiative study, and Wyeth, the maker of Premarin (conjugated estrogen) and Prempro (estrogen/progestin) concurred with that statement.
The Women's Health Initiative tested both Prempro and Premarin in healthy women for primary prevention of cardiovascular events but the trial was halted when its data safety monitoring board found that hormone use increased, rather than decreased, cardiovascular and cerebrovascular events and was associated with an increased risk of breast cancer.
Wyeth said the study reported today did not break new ground, noting that the increased stroke risk was already included in current labeling for all hormone therapy products.
The company also said that hormone therapy was "the most effective FDA-approved treatment for menopausal symptoms and the benefits of hormone therapy may outweigh the risks for many symptomatic menopausal women."
The Nurses' Health Study began in 1976 with an enrollment of 121,700 women ages 30 to 55 who returned mailed questionnaires that included detailed information on hormone use, menopause status, and cardiovascular risk factors.
Data on health and lifestyle are updated with biennial follow-up questionnaires. On each of the follow-ups, women are asked about postmenopausal hormone therapy, including use within the previous month, duration of use, and type of hormones taken. Data on dose of conjugated estrogen were first collected in 1980.
The current analysis included information on strokes that were identified between study enrollment and June 1, 2004. Nonfatal strokes were confirmed by a review of medical records.
When the data were adjusted for stroke risk factors as well as for dietary factors, physical activity, aspirin use, and vitamin supplementation the relative risk for total stroke was 1.43 (95% CI 1.19 to 1.71 for estrogen alone) and 1.45 (95% CI 1.18 to 1.80 for estrogen/progestin).
For women who began hormone therapy near menopause the relative risk for estrogen alone was 1.20 (95% CI 1.106 to 1.58) and for those who started 10 years or more after menopause the relative risk was 1.31 (95% CI 1.06 to 1.63).
For women taking estrogen/progestin just before menopause the relative risk was 1.22 (95% CI 0.95 to 1.55) and for those who waited 10 years or longer after menopause it was 1.18 (95% CI 0.87 to 1.60).
For men and women the risk of stroke increases with age, so it was not surprising that the lowest stroke risk in the Nurses' Health Study was observed in women younger than 50, who had an attributable risk of 0.93 per 10,000 person years of hormone therapy, the researchers said.
But from there the risk steadily increased so that women 65 or older had an attributable risk of 7.2 cases per 10,000 person years of hormone therapy.
Primary source: Archives of Internal MedicineSource reference:Grodstein F, et al "Postmenopausal hormone therapy and stroke role of time since menopause and age at initiation of hormone therapy" Arch Intern Med 2008; 168: 861-866.
Group Urges Ban on Medical Giveaways

29 april 2008--Drug and medical device companies should be banned from offering free food, gifts, travel and ghost-writing services to doctors, staff members and students in all 129 of the nation’s medical colleges, an influential college association has concluded.
The proposed ban is the result of a two-year effort by the group, the Association of American Medical Colleges, to create a model policy governing interactions between the schools and industry. While schools can ignore the association’s advice, most follow its recommendations.
Rob Restuccia, executive director of the Prescription Project, a nonprofit group dedicated to eliminating conflicts of interest in medicine, said the report would transform medical education.
“Most medical schools do not have strong conflict-of-interest policies, and this report will change that,” Mr. Restuccia said.
The rules would apply only to medical schools, but they could have enormous influence across medicine, said Dr. David Rothman, president of the Institute on Medicine as a Profession at Columbia University.
“We’re hoping the example set by academic medical colleges will be contagious,” Dr. Rothman said.
Drug companies spend billions wooing doctors — more than they spend on research or consumer advertising. Medical schools, packed with prominent professors and impressionable trainees, are particularly attractive marketing targets.
So companies have for decades provided faculty and students free food and gifts, offered lucrative consulting arrangements to top-notch teachers and even ghost-wrote research papers for busy professors.
“Such forms of industry involvement tend to establish reciprocal relationships that can inject bias, distort decision-making and create the perception among colleagues, students, trainees and the public that practitioners are being ‘bought’ or ‘bribed’ by industry,” the report said.
A group of influential doctors decried these practices in a 2006 article in The Journal of the American Medical Association, and said that medical schools should ban them. In the article’s wake, the medical college association created a task force.
With Dr. Roy Vagelos, a former Merck chief executive, serving as the task force’s chairman and the chief executives of Pfizer, Eli Lilly, Amgen and Medtronic on the roster, some who advocate for greater restrictions on industry influence in medicine predicted that the report would be weak.
They were wrong.
In addition to the gift, food and travel bans, the report recommended that medical schools should “strongly discourage participation by their faculty in industry-sponsored speakers’ bureaus,” in which doctors are paid to promote drug and device benefits.
It recommended that schools set up centralized systems for accepting free drug samples or “alternative ways to manage pharmaceutical sample distribution that do not carry the risks to professionalism with which current practices are associated.” It suggested that schools audit independently accredited medical education seminars given by faculty “for the presence of inappropriate influence.” And it said the rules should apply to faculty even when off-duty or away from school.
Speakers’ bureaus and drug samples are pillars of the industry’s marketing operations, and many medical school professors have resisted efforts to restrict them. Only a handful of medical schools presently bar faculty members from serving on speakers’ bureaus, so if this recommendation is widely adopted, it could transform the relationship between medical school faculty and industry, and it could change substantially the way medical education is routinely delivered.
Indeed, the chief executives of Pfizer and Eli Lilly dissented from the report’s recommendation regarding speakers’ bureaus.
“We continue to believe that these types of programs, which are subject to clear regulations regarding their content, can be worthwhile educational activities,” wrote Jeffrey B. Kindler of Pfizer and Sidney Taurel of Lilly.
David Beier, an Amgen senior vice president, wrote a letter that endorsed the report’s recommendations but disagreed with some of its text “because we have a different view about the accuracy concerning representations about the motives of the participants in industry-academic interactions.”
Ken Johnson of the Pharmaceutical Research and Manufacturers of America, said his group would review the report.
“Providing physicians — and medical students — with timely, accurate information about the medicines they prescribe clearly benefits patients and advances healthcare throughout the United States,” Mr. Johnson said.
Dr. Robert J. Alpern, dean of the Yale School of Medicine, said that the university presently had no limits on participation in company speakers’ bureaus, but that because of the medical college association’s report he was thinking of taking them on.
“I don’t have a problem with doctors making $3,000 or $5,000 a year on the side,” he said, “but it’s a totally different thing when it’s $80,000.” Even more distasteful, Dr. Alpern said, is that the slides used in many of these presentations are created by drug makers, not the speakers.
“That’s like ghost-talking,” Dr. Alpern said.
Dr. Arthur S. Levine, dean of the University of Pittsburgh School of Medicine, said that when he graduated from medical school in 1964, Eli Lilly gave him his first doctor’s bag, and Roche gave him an Omega watch for being valedictorian. He still has the watch.
But this year’s graduating class of doctors at Pittsburgh will not be allowed to accept any of these gifts, and the daily pizza lunches brought by drug companies are gone, he said.
Julie Gottlieb, assistant dean of policy coordination for Johns Hopkins University School of Medicine, said Hopkins had adopted some of the association’s recommendations and was considering others.
“This report is bound to influence our deliberations,” she said.
Dr. Vagelos, formerly of Merck, said that the report’s recommendations were certain to face resistance among faculty who liked the present system.
“The outcome of this for the industry is that those companies that are strong in science will always be welcome at medical colleges and others won’t,” Dr. Vagelos said.
Overweight warning: More than exercise needed

29april 2008--Exercise will not cut the risk of heart disease in those who are overweight unless they also slim down, according to a study of thousands of U.S. women published on Monday.
"Even high quantities of physical activity are unlikely to fully reverse the risk of coronary heart disease in overweight and obese women without concurrent weight loss," Dr. Amy Weinstein and colleagues at Boston's Beth Israel Deaconess Medical Center reported.
"Regardless of body weight, (the findings) highlight the importance of counseling all women to participate in increasing amounts of regular physical activity and maintaining a healthy weight to reduce the risk of coronary heart disease," they concluded.
The study, appearing in the Archives of Internal Medicine, was based on information from a study of nearly 39,000 women that began in 1992 and traced a number of health issues.
The researchers said 34 percent of the women in the study were physically active based on government guidelines, 31 percent were overweight and 18 percent were obese.
In the end, 948 women were diagnosed with heart disease. Active women with normal weight had the lowest risk of developing heart problems while there was a slightly higher risk for those with normal weight who were not active.
The risk was next highest for active women who were either overweight or obese, and highest for similar women who were inactive.
Fat cells produce chemicals that can speed up hardening of the arteries and increase inflammation, the researchers said, harming blood vessels, while physical activity makes for healthier blood vessels and reduces the risk of blood clots.
Gene Therapy Shows Promise for Blindness Reversal

By Charles Bankhead
PHILADELPHIA, 29 April 2008 -- Gene therapy for blindness caused by Leber's congenital amaurosis led to improved vision for four of the first six patients treated, including all three at a hospital here.
None of the patients had restoration of normal vision, but the results provide impetus for continued evaluation of gene therapy for the inherited blinding disease, Joan E. Bennett, M.D., Ph.D., of the University of Pennsylvania, and colleagues reported online in the New England Journal of Medicine.
Noting that the three patients were young adults, the authors speculated that earlier treatment might lead to greater vision improvement.
"It is possible that efficacy will be improved if treatment is applied before amblyopia and retinal degeneration are established . . . ," the authors concluded. "Our study provides the foundation for gene-therapy approaches to the treatment of [Leber's congenital amaurosis] and possibly other forms of retinal degeneration."
In the same issue of the NEJM, British investigators reported significant vision improvement in one of three patients with Leber's treated with gene therapy.
The published reports coincided with a presentation at the Association for Research in Vision and Ophthalmology meeting in Fort Lauderdale, Fla.
Leber's congenital amaurosis comprises a group of recessively inherited severe rod-cone dystrophies that have an onset in infancy. Mutation of the RPE65 gene causes a form of the disease that involves impaired vision at birth, progressing to blindness by the third decade of life in most cases, Dr. Bennett and coauthors noted.
RPE65 is expressed in the retinal pigment epithelium and encodes a protein that is integral to the visual cycle, a biochemical pathway that regenerates visual pigment after exposure to light. The encoded enzyme catalyzes the conversion of all-trans-retinyl esters to 11-cis-retinal. The latter is the precursor of rhodopsin, which is required for phototransduction and vision. Lack of a functional RPE65 renders rod photoreceptor cells unable to respond to light. Mutations in RPE65 account for approximately of cases.
The presence of visual function in childhood and evidence that photoreceptor-cell death occurs late in the disease process suggest that Leber's might be amenable to gene therapy. Dr. Bennett and colleagues previously reported use of gene-replacement therapy to restore vision in an animal model of Leber's.
In the current study, investigators administered subretinal injections of a recombinant adeno-associated viral vector carrying RPE65 complementary DNA to three patients ages 19 to 26. All three patients had modest improvement in measures of retinal function and on subjective tests of visual acuity.
"Patients' vision improved from detecting hand movements to reading lines on an eye chart," said co-author Albert M. Maguire, M.D., also of the University of Pennsylvania.
However, the patients have been followed for only five months, the authors noted.
In one patient, an asymptomatic macular hole developed, which was considered an adverse event. However, the patient subsequently regained some retinal function.
The British study involved three patients ages 17 to 23 with early-onset, severe retinal dystrophy caused by mutations in RPE65. All had visual acuity worse than 20/120 on the Snellen visual acuity scale, reported Robin R. Ali, Ph.D., of University College London, and colleagues.
None of the patients had clinically significant improvement in visual acuity or in peripheral visual fields or change in retinal responses. During follow-up for as long as 12 months, one patient had significant improvement in visual function on microperimetry and on dark-adapted perimetry, as well as improvement in a subjective test of visual mobility.
"Our findings provide support for the development of further clinical studies in children with RPE65 deficiency," Dr. Ali and colleagues concluded. "These children are more likely to benefit than adults."
In an accompanying editorial, Joan W. Miller, M.D., of Harvard, offered a cautious assessment of the two studies. Noting the brief follow-up in both studies, she said the data "suggest that in the short term, the procedure is safe. Moreover, the data are suggestive of efficacy."
The reproducibility and persistence of improved retinal function remain to be demonstrated, as does the therapy's ability to delay or prevent retinal degeneration. Additionally, systemic or ocular complications could arise with treatment of more patients, use of higher doses, or longer follow-up.
Given those limitations, Dr. Miller agreed with the authors of the two studies that "treatment of younger patients with less advanced retinal degeneration might allow greater improvement of visual function."
Drs. Bennett and Maguire identified themselves as co-inventors of a technique for preventing blindness which has one or more patents pending (but with no financial interest). Several co-authors acknowledged commercial relationships relevant to the study. Dr. Ali and several co-authors reported interests in patent and intellectual property rights related to the study, and one co-author is an employee of Targeted Genetics and has received consulting fees from Sangamo Biosciences. Dr. Miller acknowledged consulting fees and grant support from Genzyme, which has a gene-therapy program.

Primary source: The New England Journal of MedicineSource reference:Maguire AM, et al "Safety and efficacy of gene transfer for Leber's congenital amaurosis" N Engl J Med 2008; 358: DOI: 10.1056/NEJMoa0802315. Additional source: The New England Journal of MedicineSource reference: Bainbridge JWB, et al "Effect of gene therapy on visual function in Leber's congenital amaurosis" N Engl J Med 2008; 358: DOI: 10.1056/NEJMoa0802268. Additional source: The New England Journal of MedicineSource reference: Miller JW "Preliminary results of gene therapy for retinal degeneration"N Engl J Med 2008; 358: DOI: 10.1056/NEJMe0803081.
Tight Blood Pressure Control Fails to Stall Kidney Disease in Blacks

By Charles Bankhead ,
BALTIMORE, 29 April 2008 -- Many African Americans getting tight blood pressure control had worsening chronic kidney disease nonetheless, a large multicenter trial found.
During a 10-year follow-up, more than half the patients had deterioration of renal function, progression to end-stage renal disease, or they died, Lawrence J. Appel, M.D., of Johns Hopkins, and colleagues reported in the April 28 issue of Archives of Internal Medicine.
Neither the choice of antihypertensive medication nor a lower blood pressure target affected a patient's likelihood of disease progression.
"These results highlight the importance of preventing initial kidney damage, the critical need to identify modifiable risk factors, and the requirement to test promising therapies at the earliest stages of [chronic kidney disease]," the authors concluded.
The findings came from an extension phase of the African American Study of Kidney Disease and Hypertension (AASK) study. The primary findings of the study were that treatment with an ACE inhibitor reduced the risk of death or progression of kidney disease by 48% compared with a calcium-channel blocker and by 22% compared with a beta-blocker.
Upon completion of the AASK trial, participants were invited to enroll in a cohort study to evaluate the use of therapy targeting the renin-angiotensin system (ACE inhibitors or angiotensin receptor blockers) to treat blood pressure to a target of 130/80 mm Hg. The study involved 1,094 original participants in the AASK trial, all with hypertensive chronic kidney disease. They were followed from 2002 to 2007, and the primary endpoint was the same composite used in the primary trial.
Use of an ACE inhibitor or ARB ranged from 83.7% to 89% during each year of the cohort study, and mean blood pressure during the follow-up study was 133/78 mm Hg.
More than half the patients (567 of 1,094) reached the endpoint during follow-up, resulting in a 10-year cumulative incidence of 53.9%. Among 567 participants with at least seven years of follow-up, 33.5% had a slow decline in kidney function, defined by a mean annual decline in estimated glomerular filtration rate of less than 1 mL/min/1.73 m2.
Acknowledging that the data paint a "sobering picture," the authors emphasized that the findings "do not alter current recommendations for use of [ACE inhibitors or ARBs] and a low blood pressure goal in persons with hypertensive chronic kidney disease. The rate of chronic kidney disease progression would likely have been even greater without renin-angiotensin sysem-blocking therapy."
The authors suggested several strategies to manage modifiable risk factors early in the course of hypertensive kidney disease: nocturnal blood pressure control, aldosterone blockade, combined ACE inhibitor-ARB therapy, fish oil supplementation, bicarbonate therapy, and sodium restriction.
"There are a lot of ideas but none of them has been adequately tested," Dr. Appel said in an interview. "It's hard to say whether there is any blockbuster treatment that is about ready to take off. I don't see one at this point."
In the meantime, clinicians should continue treating patients with hypertensive kidney disease to a low blood pressure target, he added. The means using three or four drugs, if necessary, and frequent blood pressure monitoring in the office or clinic.

Primary source: Archives of Internal MedicineSource reference:Appel LJ, et al "Long-term effects of renin-angiotensin system-blocking therapy and a low blood pressure goal on progression of hypertensive chronic kidney disease in African Americans" Arch Intern Med 2008; 168: 832-839.

Monday, April 28, 2008

How to find a doctor online

By Elizabeth Cohen
28 april 2008--
These days, many people are using electronic word of mouth. Put "doctor ratings" into a search engine and you'll come up with a list of sites where people rate physicians and make comments.
Last month, Angie's List -- the place you go to find a good plumber -- joined the club by starting a doctor section, and even Zagat's, the folks who rate restaurants, is launching a doctor rating service.
A lot of doctors aren't crazy about these sites and point out that random, anonymous opinions don't truly measure a physician's quality. But many consumer health experts say these sites are here to stay, and can be helpful if used properly. Here are five tips for smart surfing on physician rating Web sites.
1. Decide what you care about
Are you looking for a long-term medical partner like a pediatrician or internist, or are you looking for a specialist for a short-term relationship?
This is important because many of the comments on these sites have to do with logistics ("a very dictatorial front office" writes one reviewer on about a gastroenterologist) or character ("Dr. X is quite pretentious," writes another reviewer on the same site). Nasty secretaries and a haughty doctor can be bad news if this is someone you'll be seeing often. But if the doctor's going to yank out your tonsils and you're never going to see her again, do you really care that she's full of herself and her office staff is mean?
"The 'what' is as important as the 'who,' " says David Lansky, president of the Pacific Business Group on Health. "If I want a heart surgeon, I'm going to look for different things than if I'm looking for a primary care doctor."
2. Look for volume
It's a matter of statistics: The more reviews you read, the more likely you are to get an accurate assessment. "I would check a lot of different Web sites," says Carol Cronin, executive director of the Informed Patient Institute. "Look across them, not just within one."
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In Depth: Empowered Patient
Speaking of volume, a common concern about doctor rating sites is that one angry patient can make multiple nasty comments, using a different name each time (or, conversely, that the physician herself could go on and make multiple glowing comments).
But Martin Schneider, chairman of the Informed Patient Institute, says these sites have ways of detecting when one person is making several comments under different names. Back in the 1990s, Schneider was president of a now-defunct doctor rating site called "Even back then, we had to the technology to stop that from happening," he says.
3. Look for specifics, not adjectives
"A general statement like, 'Dr. Smith is really a jerk,' doesn't tell you much," says Steven Findlay, a health care analyst for Consumers Union. "It doesn't get to the quality of care they deliver."
Findlay says to look for reviews with specific examples of what the doctor did right or wrong. "Let's say someone's writing about how a doctor handled a kidney stone," he says. "You want to know how quickly that doctor got you to an X-ray. How quickly did they assess the X-ray? Did you get the medicine you needed? Did the doctor monitor the case and follow-up?"
4. Look for patterns
Once you've found specifics, look for patterns. Five complaints that say the same thing are statistically more meaningful than five complaints about different issues, says Dr. Robert Wachter, associate chairman of the department of medicine at the University of California, San Francisco.
"If I look someone up and they have five dings all on a similar theme and I have a choice, I'm going to go elsewhere," says Wachter, who blogs on health care quality issues.
5. Use reviews along with objective information
While patient reviews might be useful, they have several clear drawbacks, our experts say. First, many doctors have just a few reviews or none at all. Second, even if a doctor has 20, 30, 50 or 100 reviews, that's still only a small fraction of his entire patient population -- and a warped fraction at that.
"The person most likely to write is the one who's most enthralled with the doctor, or the one who's most pissed," Wachter says. "You're getting a skewed view."
Health Library Health Library
Wachter and others urge patients to check out objective information about a physician. Some sites with doctor ratings also include objective information, and there are other places to look, too.
You can find out if your doctor is board certified by going to the American Board of Medical Specialties Web site. For information about legal judgments, go to the Federation of State Medical Board's site and click on your state. The National Committee for Quality Assurance can tell you whether a physician has met certain quality standards for treating some medical problems.
One more place to check: your health insurance company, which has access to information about your doctor that no one else has. Several insurers have set up systems to measure physician quality.
But would an insurance company, out of self-interest, recommend the cheapest doctor rather than the best one? Both Findlay and Wachter say while this was a concern in the past, they both say insurance company data on doctors are now trustworthy.
Herceptin® Combined With Chemotherapy Improves Disease–Free Survival for Patients With Early–Stage Breast Cancer

Results from two large randomized clinical trials for patients with HER-2 positive invasive breast cancer show that those patients with early-stage breast cancer who received Herceptin (trastuzumab) in combination with chemotherapy had a significant decrease in risk for breast cancer recurrence compared with patients who received the same chemotherapy without trastuzumab. Patients are considered “HER-2 positive” if their cancer cells "overexpress," or make too much of, a protein called HER–2, which is found on the surface of cancer cells. Trastuzumab slows or stops the growth of these cells, and it is only used to treat cancers that overexpress the HER–2 protein. Approximately 20 percent to 30 percent of breast cancers overexpress HER-2. These tumors tend to grow faster and are generally more likely to recur than tumors that do not overproduce HER-2.
The clinical trials were sponsored by the National Cancer Institute (NCI), part of the National Institutes of Health, and conducted by a network of researchers led by the National Surgical Adjuvant Breast and Bowel Project (NSABP) and the North Central Cancer Treatment Group (NCCTG), in collaboration with the Cancer and Leukemia Group B, the Eastern Cooperative Oncology Group, and the Southwest Oncology Group. Genentech, Inc., South San Francisco, Calif., which manufactures trastuzumab, provided the drug for the trials under the Cooperative Research and Development Agreement (CRADA) with NCI for the clinical development of trastuzumab.
The Data Monitoring Committees overseeing the combined analysis of these trials (known as NSABP-B-31 and NCCTG-N9831)* recommended that the results of a recent combined interim analysis be made public because the studies had met their primary endpoints of increasing disease-free survival (the amount of time patients live without return of the cancer) in patients receiving trastuzumab in combination with chemotherapy. The improvement in overall survival also was statistically significant for women receiving a combination of chemotherapy and trastuzumab.
Patients in the clinical trials who received trastuzumab in combination with standard combination chemotherapy had a 52 percent decrease in disease recurrence compared to patients treated with chemotherapy alone. This difference is highly statistically significant. “This is a major advance for many thousands of women with breast cancer,” said NCI Director Andrew C. von Eschenbach, M.D. “These results are one more example that we are at a major turning point in the use of targeted therapies to eliminate suffering and death from cancer,” he added.
The leaders of the studies underscored the significance of these results and cited the collaborative efforts involved. “These findings confirm that we now have a very potent weapon against the recurrence of cancer cells that overexpress HER-2,” said Edith A. Perez, M.D., who chaired the NCCTG trial and is a medical oncologist at the Mayo Clinic in Jacksonville, Fla. “We gratefully acknowledge the contribution of our co-investigators and, most importantly, our courageous patients in helping to achieve these unprecedented results.”
Edward Romond, M.D., study chair for the NSABP and professor of oncology at the University of Kentucky, in Lexington, Ky., noted, “For women with this type of aggressive breast cancer, the addition of trastuzumab to chemotherapy appears to virtually reverse prognosis from unfavorable to good.”
“These are truly life-saving results in a major disease,” said JoAnne Zujewski, M.D., who oversees breast cancer trials for NCI’s Cancer Therapy Evaluation Program. More detailed results from these studies will be presented at the American Society of Clinical Oncology (ASCO) annual meeting on May 16, 2005, in Orlando, Fla.
Information from over 3,300 patients enrolled in these studies was used for analysis. Patients with operable breast cancer whose tumors over-expressed HER-2 were enrolled in these studies between February 2000 and April 2005. Patients were randomized to receive chemotherapy with doxorubicin and cyclophosphamide followed by paclitaxel, or doxorubicin and cyclophosphamide followed by paclitaxel and trastuzumab. Most patients had lymph node-positive breast cancer, or breast cancer that had spread to the lymph nodes, with only a minority having lymph node-negative disease. The limited information in the node-negative group did not allow for a separate analysis of this group.
Chemotherapy of the type given in these studies has a risk of congestive heart failure (weakening of the heart muscle) of less than 1 percent. In these studies, the likelihood of congestive heart failure in women receiving the combination of chemotherapy and trastuzumab was increased by 3 percent to 4 percent. Patients in these studies will continue to be followed for any additional side effects. Additional safety data will be presented at ASCO.
Trastuzumab is an example of a “targeted” therapy — an agent that is directed against a specific change in the cancer cell. Trastuzumab was approved for the treatment of advanced breast cancer in 1998.
An estimated 211,240 women will be diagnosed with breast cancer in the United States in 2005. Of these, about 30 percent have lymph node-positive breast cancer, and about 20 percent to 30 percent of these tumors overexpress the HER-2 protein, the target for trastuzumab. Breast cancer is the most commonly diagnosed cancer in women and the second leading cause of cancer-related death in women in this country. An estimated 40,110 deaths from female breast cancer will occur in 2005 in the United States, accounting for about 15 percent of all cancer-related deaths in women in the nation.
Scanner to Find Fatty Deposits in Vessels Is Approved

28 april 2008--Federal regulators have approved the sale of a new laser scanning system intended to locate fatty deposits in blood vessel walls that are thought to cause heart attacks.
The maker, InfraRdDx, a privately held company based in Burlington, Mass., said Friday that it expected the system to help doctors avoid placing coronary stents in vessels in ways that might raise the risk of a heart attack.
Stents are metal mesh scaffolds that prop open arteries after angioplasty, the procedure in which tiny balloons are inflated inside blood vessels to clear blockages.
Angioplasty with stenting relieves the chest pain known as angina but it does not normally — contrary to popular belief — do anything to prevent heart attack. Research suggests that heart attacks are not caused by the kind of blockages typically cleared with angioplasty but from the rupturing of thin vessel walls containing fatty deposits known as lipid pools.
Lipid pools may be anywhere in an artery wall, not just where a blockage has formed from the buildup of plaque. Researchers are unsure whether stenting the pools might reduce heart attack risk, but many believe that inadvertently covering only part of a pool probably increases the risk of rupture. And some think it is better to cover the pools with older bare metal stents than the newer drug-coated stents.
Thus, better tools to find the lipid pools could be an important aid to doctors performing angioplasty and crucial for long-term research into whether stenting the pools could save lives by preventing ruptures.
But some researchers say the whole concept of trying to find and treat lipid pools with devices is a waste of time and money. The pools, they say, are a symptom of arterial disease that affects all of the heart’s arteries and indeed the whole circulatory system. They favor efforts to use drugs and lifestyle changes to reduce concentrations of the potentially dangerous lipids throughout the body.
Doctors have tried other ways to locate lipid pools. Approaches include external CT scanners and tiny ultrasound devices inserted on the ends of catheters similar to those used to deploy angioplasty balloons and stents. InfraRdDx said its catheter, which emits near-infrared laser light inside the artery and forms an image from how much is absorbed, could produce a fuller picture of the contents and dimensions of lipids in the vessel walls.
The company’s product, the LipiScan Coronary Imaging System, consists of a $150,000 computer console that analyzes and displays the data gathered by the LipiScan laser catheter, which costs $2,400 and can be used only once.
The Short End of the Longer Life

28 april 2008--THROUGHOUT the 20th century, it was an American birthright that each generation would live longer than the last. Year after year, almost without exception, the anticipated life span of the average American rose inexorably, to 78 years in 2005 from 61 years in 1933, when comprehensive data first became available.
But new research shows that those reassuring nationwide gains mask a darker and more complex reality. A pair of reports out this month affirm that the rising tide of American health is not lifting all boats, and that there are widening gaps in life expectancy based on the interwoven variables of income, race, sex, education and geography.
The new research adds weight to the political construct popularized by former Senator John Edwards of North Carolina, that there are two Americas (if not more), measured not only by wealth but also by health, and that the poles are growing farther apart.
The most startling evidence came last week in a government-sponsored study by Harvard researchers who found that life expectancy actually declined in a substantial number of counties from 1983 to 1999, particularly for women. Most of the counties with declines are in the Deep South, along the Mississippi River, and in Appalachia, as well as in the southern Plains and Texas.
The study, published in the journal PLoS Medicine, concluded that the progress made in reducing deaths from cardiovascular disease, thanks to new drugs, procedures and prevention, began to level off in those years. Those gains, as they shrank, were outpaced by rising mortality from lung cancer, chronic obstructive pulmonary disease and diabetes. Smoking, which peaked for women later than for men, is thought to be a major contributor, along with obesity and hypertension.
“Some people are actually sinking,” said Majid Ezzati, one of the report’s authors. “The line of excuse that we can live with inequality as long as no one is getting worse is just no longer there.”
The researchers found statistically significant declines for women in 180 of the 3,141 counties in the United States and in 11 counties for men. In an additional 783 counties for women and 48 for men, there were declines that did not reach the threshold of statistical significance.
Of particular concern is that the gap in life expectancy between top and bottom counties expanded by two years for men and by about 10 months for women. In the worst-performing counties, all in southwestern Virginia, the drop in life expectancy over the 16-year period was nearly six years for women and two and a half years for men. In the counties showing the greatest improvement, many in the desert West, life expectancy rose nearly five years for women, and nearly seven years for men.
The first of the two reports, released two weeks ago by the Congressional Budget Office, declared that the life expectancy gap is growing between rich and poor and between those with the highest and lowest educational attainment, even as it is narrowing between men and women and between blacks and whites.
Pointing to the effects of smoking, obesity and chronic disease, the budget analysts wrote that “in recent decades, socioeconomic status has become an even more important indicator of life expectancy, whether measured at birth or at age 65.” Among the implications, they wrote, is that Social Security payroll taxes will become less progressive as the wealthy increase their longevity advantage over the poor.
Peter R. Orszag, the budget office’s director, said that the decline in life expectancy among some Americans was “remarkable in an advanced industrial nation” and that he believed the growing gap related to income inequality. “We’ve had sluggish income growth at the bottom and rapid income growth at the top for the last three decades,” he said.
Mr. Edwards said in an interview that the new findings on disparities demonstrate both the reach and consequences of income inequality. “The wealth and income disparity effectively infiltrates all parts of people’s lives,” he said.
What remains to be determined by the increasingly dynamic field of research into health disparities is precisely how income interacts with factors like race, gender and education to give some people better odds of living longer.
Taken to their extreme, the numbers can be striking: a 2006 study found that Native American men in southwestern South Dakota could expect to live to 58, while Asian women in Bergen County in New Jersey had a life expectancy of 91.
For some groups at some times, disparities can widen and shrink because of societal changes (like fluctuating homicide rates) and medical developments (like the emergence of H.I.V., or the discovery of drugs to treat it). But the causes of more lasting trends may not always be obvious, and some research suggests that income alone cannot explain away many differences.
For example, a 2006 study found that low-income whites in the northern Plains could expect to live four years longer than low-income whites in Appalachia and the Mississippi Valley. Other research indicates that health insurance status, which can relate directly to income, may not be a significant determinant of longevity.
And yet, this month’s Harvard study showed that counties with declining or stagnant life expectancy were poorer than those with improving numbers. Recent cancer studies have found that the uninsured are more likely to fail to get a diagnosis until late stages of the disease. Research also shows that many of the behaviors that drive mortality — unhealthy diet, smoking, poor management of chronic disease — are more common among low-income Americans.
“We know from hundreds of studies that income does have an impact on health, but it’s not a simple relationship,” said Sam B. Harper, an epidemiologist at McGill University who has studied the issue.
Dr. Ezzati, of the Harvard School of Public Health, asked: “How much of this is pure material well being, the ability to purchase high-quality food, the ability to have a particular lifestyle? And how much of it is the impact of income on risk behaviors like alcohol and tobacco and stress mechanisms that are more psychosocial? There’s a series of debates around that that are unresolved.”
As for a prescription, Dr. Ezzati and his colleagues are realists. In a 2006 study, they concluded that “because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the U.S.,” life expectancy disparities would have to be addressed through public health strategies directed at reducing the risk factors that cause chronic disease and injuries.
Dr. Ezzati noted that few industrialized countries have had declines of comparable duration. “This is a very unusual pattern,” he said, “and the question we’re starting to ask is, ‘Is the fact that the bottom 20 percent is not getting better, and may be worse off, going to drive the health of the whole country?’ ”
Elderly More Likely to Battle Sleep Disorders

28 april 2008-- Many older adults don't get enough sleep, which can increase the risk of serious health problems such as obesity, cardiovascular disease and diabetes, says the American Academy of Sleep Medicine.
While sleep patterns do change as people age, disturbed sleep and waking up tired every day aren't a normal part of aging.
"As we get older, the amount of nightly sleep that we need remains the same as that of what we needed when we were younger. However the ability to get the sleep that we need does change. Older people have a hard time getting the sleep they need because of the interference of medical illness, the medications they take for those illnesses, and changes in their biological clock," Sonia Ancoli-Israel, a professor of psychiatry at the University of California, San Diego, School of Medicine and director of the sleep disorders clinic at the Veterans Affairs San Diego Healthcare System, said in a prepared statement.
Ancoli-Israel, who is also co-director of the Laboratory for Sleep and Chronobiology at the UCSD General Clinic Research Center, cited a number of common sleep disorders in the elderly:Insomnia affects almost half of adults aged 60 and older. Obstructive sleep apnea (OSA) affects almost 40 percent of adults, and is more common among older adults. OSA can increase the risk of high blood pressure, heart disease, stroke and cognitive problems. Restless legs syndrome, which affects more than 20 percent of people aged 80 and older, includes uncomfortable feelings in the legs, such as tingling, or pins and needles. Periodic limb movements cause people to jerk and kick their legs every 20 to 40 seconds during sleep. One study found that about 40 percent of older adults have a least a mild form of this condition.
Older adults who don't get enough sleep are more likely to feel depressed, have attention and memory problems, excessive daytime sleepiness, more nighttime falls, and to use more over-the-counter or prescription sleep medications.
In order to get a better night's sleep, older adults should:Establish a routine sleep schedule. Avoid using the bed for activities other than sleep or intimacy. Avoid substances that disturb sleep, such as caffeine and alcohol. Avoid napping during the day. If you have to nap, limit it to less than one hour and do it no later than 3 p.m. Develop pre-sleep rituals that help you relax, such as a warm bath, a light snack or a few minutes of reading. Leave worries behind. Bedtime is a time to relax, not replay the stresses of the day. Keep your bedroom dark, quiet and a little cool. If you can't fall asleep, leave the bedroom and do a quiet activity. Go back to bed only when you're tired.

Sunday, April 27, 2008

How not to give a presentation

Richard Smith
23 december 2000--The invitation arrives. You are invited to speak on the same programme as the Pope, Bill Clinton, and Madonna. Beside yourself with excitement, you forget that you've had these sort of invitations beforeand that, for some strange reason, none of the famous people ever turn up. They are all replaced by people you've never heard of and who turn out to be even more boring than you. Having accepted the invitation, you get your own back by forgetting it completely. Two years later, 15 minutes before you are due to start speaking in Florence, you receive a telephone call in your office in London asking where you are.
"I'm sorry," you answer lamely, "I forgot."
"Don't worry," answers the cheery voice at the end, "We'll just ask Madonna to speak for 20 minutes longer. The audience of world leaders will be disappointed you're not here, but extra Madonna will be some compensation."
Far from ruining this presentation, you may have improved the world leaders' conference. But forgetting altogether that you agreed to speak is a good way to make a mess of your presentation. A variant is to arrive late. Don't arrive too late because they will simply have cancelled your session, probably sending a thrill of pleasure through an audience facing the prospect of five consecutive speakers.

Preparing for a bad presentation
One way to prepare for a bad presentation is not to prepare at all. Step up to the platform, open your mouth, and see what comes out. With luck, your talk will be an incoherent ramble. This is, however, a high risk strategy because spontaneity may catch you out. Most medical presentations are so premeditated that spontaneity may inspire both your audience and you. Inspiration must be avoided at all costs. Similarly you might be caught out by truth: "I've been asked to promote this new drug, but actually I'd be fearful of throwing it into the Thames because it might poison the few shrivelled fish that survive there." Truth is compelling to an audience, even if mumbled.
A really bad presentation needs careful preparation. A useful standby is to prepare for the wrong audience. If asked to speak to Italians speak in German. If the audience is composed of 15 year olds then prepare a complex talk that would baffle a collection of Nobel prize winners. It's much the best strategy to give an overcomplicated presentation. "Nobody ever lost money underestimating the public's intelligence," said Barnum, Richard Nixon, or somebody, and so you may be surprised by how well your grossly oversimplified presentation is received by your audience of professors.
Be sure to prepare a presentation that is the wrong length. Too long is much the best. Most of the audience will be delighted if your talk is too short, not least because it may provide more opportunity for them to hear their own voices. But something that is too long always depresses an audience, even if what you are saying is full of wit and wisdom.
Another trick is to ignore the topic you are given. Simply give the bad presentation that you have honed to the point of perfection by deleting anything that raises a flicker of interest. With luck, most of the audience will have heard it several times before.
You may be able to enhance your bad presentation by sending the organisers in advance a long and dull curriculum vitae. Your presentation may then be prefaced by the chairman reading out your whole boring life story in a monotone. If you are lucky you might find yourself beginning your presentation after you were supposed to finish.

Aids to a bad presentation
When it comes to aids, standards are rising for those who want to give bad presentations. Technology has produced breakthroughs. First rate bad presentations are usually multimedia: poorly filmed videos that are long and incomprehensible; tapes that are inaudible; music that is out of tune; props that initially can't be found and then break; and Powerpoint presentations that use every feature the software offers.
Bad slides are the traditional standby of a bad presentation. There must be far too many. They must contain too much information and be too small for even those in the front row to read. Flash them up as fast as you can, ensuring that they are in the wrong order with some upside down. Be sure to say at some point, "I know that this slide breaks all the rules but . . ." Ideally there should be little connection between what you are saying and what is on the slide. A good trick, especially with a politically correct audience, is to insert a slide of a naked woman and say something like, "My beautiful assistant is, I'm sure you will all agree, a little top heavy."

Delivering your bad presentation
The essence of a bad presentation is to be boring. Anything that isn't boring will detract from your bad presentation. Don't wear interesting or unusual clothes. Never look at the audience. Mumble your presentation, and preferably read it. A presentation that is read will usually be satisfyingly bad, but for the full effect you should have long complicated sentences with dozens of subclauses. Try for something as complex as Proust, but get the grammar wrong. Then put all the emphases in the wrong place to ensure that your audience can't understand what you're saying.
Try to torture your audience. Speak for about 10 minutes and then say, "This is what I'm going to talk about." Then after another 20 minutes say, "I'm now coming to my central point." Ten minutes later, start saying, "Finally." Say it at least five times in the next 15 minutes.

Winding down
A truly bad presentation rarely produces any questions. Most people just want to get away. If you do get questions, you may have failed. But all is not lost. By sticking to the basic rules of being boring and overcomplicated and speaking too long, you may be able to rescue your bad presentation. The extra rule on answering questions is that under no circumstances should you answer them. Once you have finished say, "Does that answer your question?" If the questioner has the effrontery to say no, then don't answer his question againonly at greater length. This formula can be repeated if necessary, but a third non-answer is hardly ever needed.
This guide is written, you will have judged, from long experience. I've made all these mistakes, and more. Kurt Vonnegut boasts that he gave such bad lectures when a lecturer at New York University that he fell asleep during them. I remember giving a lecture in Manchester on creativity in science where the entire audience was almost unconscious and I suddenly thought, "This is rubbish, utter rubbish." I was tempted to stop and say, "You're not enjoying this, and neither am I. Let's stop and go down the pub." I didn't, and thank goodness that I didn'totherwise it wouldn't have been an outstandingly bad presentation.
Unhappy LASIK patients urge FDA to take action

By Susan Heavey
GAITHERSBURG, 28 april 2008- Patients unhappy with their laser eye surgery urged U.S. health regulators to do more to limit poor results, saying complications from the LASIK procedure have taken a toll on their sight and emotions.
Blurred vision, dry eyes, glare and double-vision have led to depression and in some cases suicide, several patients told a U.S. Food and Drug Administration advisory panel.
"Since LASIK, I am visually handicapped," said patient David Shell, adding that he has near constant eye pain and depression. "My eyes never feel comfortable... 10 years have passed and I still suffer from this problem."
Millions of Americans have had successfully undergone LASIK, or laser-assisted in-situ keratomileusis, which uses a laser to reshape the eye's cornea, making them less dependent on glasses or contact lenses.
Surgeons and other industry representatives told the FDA's outside advisers most LASIK patients are satisfied with their vision. They noted depression is a complex condition and that no studies show a direct link to laser eye surgery.
Still, the FDA is taking another look at the surgery after receiving 140 reports of side effects and device malfunctions between 1998 and 2006.
The FDA wants its panelists' advice on what information it would add to its website or product labeling to help those considering undergoing LASIK.
"Most of the patients who are having these procedures are fairly satisfied and are doing well. Clearly there is a group who are not satisfied and do not get the kind of results they expect," Daniel Schultz, head of the FDA's device center, told reporters on Thursday ahead of the meeting.
Several unhappy patients at the advisory meeting faulted their surgeon for not ruling them out as a poor candidates for LASIK, or for failing to stress the severity of possible side effects.
The FDA, which has said the surgery is safe and effective regulates LASIK devices but not the surgeons or clinics that offer the procedure.
Stock analysts have said the FDA focus on the procedure could further hurt LASIK companies, which have already seen the softening U.S. economy dampen demand for the elective surgery that is usually not covered by health insurance.
LASIK device makers include Advanced Medical Optics Inc, Alcon Inc and Bausch & Lomb, among others. TLC Vision Corp and LCA-Vision Inc run LASIK clinics.
Eric Donnenfeld, an ophthalmologist at New York University Medical Center, said the surgery aims to improve patients' lives.
"The reality is that, following LASIK, the great majority of our patients see as well or better than they ever saw with their glasses or contact lenses with which they were unhappy," he told the advisory panel.
Still, some patients said that while their vision had improved, dry-eye and other side effects were overwhelming.
The FDA is also planning to begin a study on LASIK patient satisfaction in 2009 along with the National Eye Institute and two industry groups: the American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology.
Patient and consumer advocates at Friday's meeting objected to the groups' involvement with the study, citing conflicts of interest. Industry representatives said it would help them understand why some patients are unhappy with their LASIK results.
FDA Approves Relistor for Opioid-Induced Constipation Drug will help reduce effects of drugs like morphine on bowel function

28 april 2008--The U.S. Food and Drug Administration today approved Relistor (methylnaltrexone bromide) to help restore bowel function in patients with late-stage, advanced illness who are receiving opioids on a continuous basis to help alleviate their pain.
Opioids are often prescribed on a continuous basis for patients with late-stage, advanced illness to help alleviate pain. This includes patients with a diagnosis of incurable cancer, end-stage Chronic Obstructive Pulmonary Disease (COPD) from emphysema, heart failure, Alzheimer’s disease with dementia, HIV/AIDS or other advanced illnesses.
Opioids can interfere with normal bowel elimination function by relaxing the intestinal smooth muscles and preventing them from contracting and pushing out waste products. Relistor acts by blocking opioid entrance into the cells thus allowing the bowels to continue to function normally.
“This new drug will be helpful to patients who experience severe constipation associated with the continuous use of morphine or other opioids, which are an important part of care for patients with late-stage, advanced illness.” said Joyce Korvick, M.D., deputy director of the Division of Gastroenterology Products, FDA.
Relistor is an injectable medication. It can be administered as needed, but not to exceed one dose in a 24 hour period. The recommended starting schedule is one dose every other day as needed for patients with late-stage advanced illness. Relistor is not recommended for patients with known or suspected intestinal obstructions.
Common side effects include abdominal pain, gas, nausea, dizziness and diarrhea. If severe diarrhea, vomiting, nausea or abdominal pain occurs while taking Relistor, patients should discontinue use of the medication in consultation with their health care professional.
The safety and effectiveness of the drug was demonstrated in clinical studies conducted by the sponsors. The two randomized, double-blind placebo-controlled studies involving a total of 287 participants were conducted over a four month period. The median age of the study participants was 68 years, and 51 percent of the participants were women. In both studies, all patients had advanced late-stage illnesses with a life expectancy of less than 6 months. Prior to treatment with Relistor, participants had either less than three bowel movements in the week prior to treatment or no bowel movement for more than 2 days. Patients who were treated with Relistor had a significantly higher rate of elimination than those receiving placebo. The safety and effectiveness of Relistor have not been studied in pediatric populations.
Relistor is manufactured by Wyeth Pharmaceuticals Inc., Philadelphia, PA., and Progenics Pharmaceuticals, Tarrytown, NY.
Life spans decline in some U.S. areas

By Janet Kornblum
28 april 2008--While most Americans enjoyed a clear jump in life expectancy from 1960 to 2000, a startling number — especially women — living primarily in the Deep South and in Appalachia actually saw a drop in life spans beginning in 1983, says a study that came out Monday.
In sum, where you live makes a difference in how long you can expect to live.
Researchers at the Harvard School of Public Health and the University of Washington found that 4% of the male population and 19% of the female population experienced either declines or stagnation in their life expectancy in the '80s and '90s. The paper appears in the online non-profit journal The Public Library of Science.
Most counties with the worst downward swings were in the Deep South, along the Mississippi River, and in Appalachia, extending into the southern portion of the Midwest and into Texas.
While race and poverty explain some of the disparity, they don't account for all of it, says Majid Ezzati, an associate professor at the Harvard School of Public Health and lead author.
Researchers found contributing causes: an increase in diabetes, cancers and chronic obstructive pulmonary disease, illnesses often caused and exacerbated by smoking and obesity.
While more research needs to be done on causes of the disparity, Ezzati hopes it will prompt some "pretty serious discussion at the national, state and arguably county level" about how to reach people in affected communities.
Researchers have long known that generally wealthier and better-educated communities have longer life spans than those that are worse off. But many also thought that all communities were steadily improving. That wasn't the case.
From 1983 to 1999, the gap between men living in the best- and worst-off counties widened from nine to 11 years. The gap for women widened from 6.7 to 7.5 years.
"The worse off are getting worse," Ezzati says. "There's just more inequality."
It's not the type of inequality that one would expect in the United States, says Richard Suzman of the National Institute on Aging.
"One generally associates declines in life expectancy with Russia and the USSR after the fall … and countries in Africa in the midst of wars, etc." Suzman says. "The fact that life expectancy has actually declined in quite a few counties is quite surprising."
The declines should not just worry those living in the places affected, says James Marks of the Robert Wood Johnson Foundation. They "should worry us all. These counties may be the canary in the coal mine (indicating) the deterioration in the U.S. health standing relative to the rest of the world."
Risk of depression dims hopes for anti-addiction pills

CHICAGO,27 april 2008 — Two years ago, scientists had high hopes for new pills that would help people quit smoking, lose weight and maybe kick other tough addictions like alcohol and cocaine.
The pills worked in a novel way, by blocking pleasure centers in the brain that provide the feel-good response from smoking or eating. Now it seems the drugs may block pleasure too well, possibly raising the risk of depression and suicide.
Margaret Bastian of suburban Rochester, N.Y., was among patients who reported problems with Chantix, a highly touted quit-smoking pill from Pfizer Inc. that has been linked to dozens of reports of suicides and hundreds of suicidal behaviors.
"I started to get severely depressed and just going down into that hole ... the one you can't crawl out of," said Bastian, whose doctor took her off Chantix after she swallowed too many sleeping pills and other medicines one night.
Side effects also plague two other drugs:
_ Rimonabant, an obesity pill sold as Acomplia in Europe, was tied to higher rates of depression and a suicide in a study last month. The maker, Sanofi-Aventis SA, still hopes to win its approval in the United States.
_ Taranabant, a similar pill in late-stage testing, led to higher rates of depression and other side effects in a study last month. Its maker, Merck & Co., stopped testing it at middle and high doses.
The makers of the new drugs insist they are safe, although perhaps not for everyone, such as people with a history of depression. Having to restrict the drugs' use would be a big setback because it would deprive the very people who need help the most, since addictions and depression often go hand-in-hand, doctors say.
A bigger fear is that the whole approach may be in trouble. Researchers say blocking pleasure, especially the way the obesity drugs do, might take the fun out of many things, not just the harmful substances and behaviors these drugs target.
It may be possible to improve the drugs so they act more precisely. Chantix targets a different pathway — nicotine pleasure switches — and in a different way than the obesity drugs, which aim at the same pathway that gives pot smokers the munchies. That is one reason many doctors are optimistic that any risks about Chantix will prove manageable.
But doctors are no longer talking about so-called "super pills" for a host of addictions.
"It certainly diminishes my enthusiasm" to see these side effects, said Mark Egli, co-leader of medicine development at the National Institute on Alcohol Abuse and Alcoholism.
The buzz started four years ago, when studies showed rimonabant helped people shed weight and keep it off longer than previous pills had. It also was being tested for smoking cessation. The Associated Press and other media reported extensively on prospects for a pill that might tackle two big problems at once.
Rimonabant won approval in Europe. But advisers to the U.S. Food and Drug Administration opposed it because of depression risks that became clearer with further study. Sanofi withdrew its U.S. application and said it hoped to resubmit after more research.
But in a new study last month, 43 percent of people taking rimonabant developed psychiatric issues versus 28 percent of those on dummy pills. One rimonabant patient committed suicide and one in the placebo group tried to. Unlike previous studies, this one did not exclude people who had depression in the past.
"I felt it was important to do an 'all-comers' study" to see how real-world patients might fare, said Cleveland Clinic's Dr. Steven Nissen, who led the work.
Sanofi now tells doctors to avoid giving the drug to people with a history of depression, said a company vice president, Dr. Douglas Greene.
"We are at the cutting edge of being able to manage this risk," he said.
Meanwhile, Merck had bad news from a study of its obesity drug, taranabant, which showed an increased risk of depression and other side effects among people taking medium and high doses.
"We're doing a lot to define this risk-benefit," including adding another year to all studies under way and going forward only with the lowest dose, said a Merck vice president, Dr. John Amatruda.
Others were less optimistic.
"The door is closing" on this approach, said Dr. James Stein, a University of Wisconsin-Madison cardiologist. If another study he is helping lead does not show benefit for rimonabant, "this drug's already slim chances of approval will be even more jeopardized," he said.
The situation is murkier with Chantix, which went on sale in the U.S. in 2006 and is sold as Champix in other countries.
The drug binds to the same spots in the brain that nicotine does when people smoke, causing release of a "feel-good" chemical, dopamine. Taking it is supposed to keep any inhaled nicotine from giving the same buzz.
In February, the FDA said a link between Chantix and psychiatric problems appears "increasingly likely." Pfizer added warnings to the drug's label and said that although a link had not been proved, it could not be ruled out.
But a Pfizer vice president, Dr. Ponni Subbiah, said nicotine withdrawal and even quitting smoking can cause mood swings and depression.
It is hard to know "what is causing what," she said. "We know that smokers are at higher risk of suicide than non-smokers, and heavy smokers are at higher risk than lighter smokers."
Some doctors agreed.
"Psychologically, just giving up this 'friend' that they've had many years in their life can be depressing," said Dr. Geoffrey Williams, co-director of the Greater Rochester Area Tobacco Cessation Center and a paid speaker for Pfizer.
Jeanne Morrison, 63, of suburban of Louisville, Ky., looked forward to giving up cigarettes when she and a friend went on Chantix. The friend did well, but Morrison lasted only 10 days on it.
"I got so depressed, I didn't want to go anywhere. I didn't want to do anything, and I'm a very high-energy person. It was a depression like I've never experienced in my life," she said. She also had "major, major nightmares. These would wake me up, and I would be absolutely shaking and sweating."
Several doctors said such reactions are rare, and that most patients do well on Chantix.
Morrison's doctor, psychiatrist Dr. Jesse Wright at the University of Louisville, said Chantix helped one of his schizophrenic patients, "who smoked like a smokestack," without worsening his psychological symptoms.
"The risk-benefit ratio is still very much on the side of use of the medication," Williams said. "The alternative, smoking, is extremely highly risky."