Friday, October 31, 2008

Clock-shifts affect risk of heart attack

31 oct 2008--Adjusting the clocks to summer time on the last Sunday in March increases the risk of myocardial infarction in the following week. In return, putting the clocks back in the autumn reduces the risk, albeit to a lesser extent. This according to a new Swedish study published in the prestigious New England Journal of Medicine.
Scientists at Karolinska Institutet have examined how the incidence of myocardial infarction in Sweden has changed with the summer and winter clock-shifts since 1987. Their results show that the number of heart attacks, on average, increases by about five per cent during the first week of summer time.
"There's a small increase in risk for the individual, especially during the first three days of the new week," says Dr Imre Janszky, one of the researchers behind the study. "The disruption in the chronobiological rhythms, the loss of one hour's sleep and the resulting sleep disturbance are the probable causes."
The team also observed that the readjustment back to winter time on the last Sunday in October, which gives us an extra hour's sleep, is followed by a reduction in the risk of heart attack on the Monday. The reduction for the whole week is, however, less than the increase related to the summer adjustment.
According to the scientists, the study provides a conceivable explanation for why myocardial infarction is most common on Mondays, as demonstrated by previous research.
"It's always been thought that it's mainly due to an increase in stress ahead of the new working week," says Dr Janszky. "But perhaps it's also got something to do with the sleep disruption caused by the change in diurnal rhythm at the weekend."
Even though the increase and decrease in risk are relatively small for the individual, the team believes that the study can improve our understanding of how disruptions to diurnal rhythms impact on our health.
"Roughly 1.5 billion people are subjected to these clock-shifts every year, but it's hard to make any generalised statement about how many heart attacks they can cause," adds Dr Rickard Ljung, another member of the research team.
Janszky I, Ljung R. "Shifts to and from Daylight Saving Time and Incidence of Myocardial Infarction", New England Journal of Medicine, 30 October 2008, 359;18:1966-68.
Consumer group asks government to ban Avandia

WASHINGTON, 31 oct 2008 – The government should ban the diabetes drug Avandia because of a wide variety of life-threatening risks, including heart and liver damage, a consumer group said Thursday.
The consumer group, Public Citizen, filed a petition with the Food and Drug Administration to have Avandia taken off the market.
It was the second setback in as many weeks for the GlaxoSmithKline medication, which at one time had shown great promise in reducing the blood sugar levels of people with Type 2 diabetes. Last week, the American Diabetes Association and a European counterpart jointly released updated treatment guidelines for doctors that pointedly recommended against using Avandia.
"The FDA is in possession of clear, unequivocal evidence that (Avandia) causes a wide variety of toxicities," Public Citizen said in its petition. "Many of these are life-threatening, such as heart attacks, heart failure (and) liver failure."
The FDA said it will "carefully review" the petition, and it continues to monitor Avandia's safety record.
Avandia's heart risks were brought to light two years ago in a medical journal article that reported a 43 percent higher risk of heart attacks among Avandia patients when compared with those taking other diabetes drugs. Although scientists are still debating a link between the drug and heart attacks, concerns about the medical evidence led to stronger warnings.
As a result, Avandia use dropped sharply but about a million U.S. patients still take it.
Public Citizen said its own research found 14 cases of liver failure associated with Avandia, 12 of which led to death. The petition also said Avandia predisposes some patients to eye problems, anemia and bone fractures.
Glaxo, in a statement, said it does not believe Avandia causes liver failure. The company said its own data shows the drug has a good safety record when it comes to liver problems. The company said the data on heart attacks is inconclusive and that Avandia is safe and effective, when used according to directions. Glaxo shares initially fell on the news, but later rose to close at $37.90, up 1.6 percent.
On the Net:
Public Citizen Web site:
Optimal dose of vitamin E maximizes benefits, minimizes risk

Corvallis, Oregon – 31 oct 2008 -- Vitamin E has been heralded for its ability to reduce the risk of blood clots, heart attack, and sudden death. Yet in some people, vitamin E causes bleeding. Scientists have known for more than 50 years that excess vitamin E promotes bleeding by interfering with vitamin K, which is essential in blood clotting. However, they haven't been able to pinpoint how the two vitamins interact. Nutrition researcher Maret Traber of Oregon State University reviews studies of possible explanations of the interaction in an article published recently in Nutrition Reviews.
One of the most compelling studies of the benefits of vitamin E is the Women's Health Study, in which 40,000 healthy women, 45 and older, took 600 IU vitamin E supplements or a placebo every other day for 10 years. Women taking the supplements had 24 percent fewer deaths from heart disease. Vitamin E's protective effect appeared even stronger in women 65 and older. Those taking the vitamin experienced a 26 percent reduction in cardiovascular events and a 49 percent reduction in cardiovascular deaths.
"That's a significant benefit," Traber said. Yet, she added, "In some people high doses of vitamin E increase the tendency to bleed. Women enrolled in the study had an increase in nose bleeds."
To lessen the bleeding risk, the U.S.-based Food and Nutrition Board in 2000 set the upper tolerable limit for daily vitamin E intake at 1500 I.U.
Research Traber reviewed suggests that a shared metabolic pathway in the liver causes vitamins E and K to interact. Vitamin K in the liver appears to diminish as vitamin E increases.
"Several different explanations could account for the interaction between the two vitamins," Traber said. "We need more research to understand the delicate balance between vitamins E and K."
This study is published in the November 2008 issue of Nutrition Reviews. Media wishing to receive a PDF of this article may contact
To view the abstract for this article, please click here.
A guide to the Hippocratic Oath

By Dr Daniel Sokol Medical ethicist
31 oct 2008--When I asked my medical students to name famous doctors in the history of medicine, their first answer was Harold Shipman, the GP who murdered hundreds of patients.
I nearly swallowed my tongue.
Their second answer was House, the fictional doctor from the American TV series.
Tears of frustration welled up in my eyes.
Their third answer was Hippocrates, presumed author of the Hippocratic Oath - I breathed a sigh of relief.
Written nearly 2,500 years ago, the Oath is the most famous text in Western medicine, yet most people (including doctors) know precious little about it.
One GP recounted the story of an elderly patient who believed the Oath instructed doctors never to tell patients the truth. It contains no such advice.
Here is a brief guide to the Oath.
The Oath starts: "I swear by Apollo the physician and by Asclepius and Hygieia and Panacea... to bring the following oath to fulfilment."
Apollo, the god of healing, fell in love with a human, Coronis.
I will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice I will keep them Hippocratic Oath
In his absence, Apollo sent a white crow to look after her.
When the crow informed Apollo that Coronis loved another man, Apollo's rage turned the crow black.
To avenge her brother, Apollo's sister shot Coronis with an arrow and, as she lay dying, Coronis told Apollo that she was bearing his child.
Although Apollo could not save Coronis, he rescued the unborn child, Asclepius.
Hygieia, the goddess of health, and Panacea, the goddess of cures, are the daughters of Asclepius.
According to legend, Hippocrates was a descendant of one of Asclepius' sons.
Doctors taking the Oath would doubtless have been inspired by this illustrious lineage of healers.
The next section instructs the doctor to treat his teachers as his parents, and to pass on the art of medicine to the next generation of healers.
In a pure and holy way, I will guard my life and my art and science Hippocratic Oath
The Oath continues: "And I will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice I will keep them."
In other words, doctors should act in the best interests of their patients, and when unjust circumstances arise - for instance, a certain life-prolonging drug may not be available on the NHS - they should strive to correct the injustice harming their patients.
The next part seemingly concerns euthanasia or physician-assisted suicide, saying: "And I will not give a drug that is deadly to anyone if asked, nor will I suggest the way to such a counsel."
Two leading scholars of the Oath, Littre and Miles, have however suggested that this passage alludes to the then common practice of using doctors as skilled political assassins.
Steven Miles notes: "Fear of the physician-poisoner may be traced very close to the time of the Oath."
The word "euthanasia" (meaning "easeful death") was only coined a century after the writing of the Oath.
The text continues: "And likewise I will not give a woman a destructive pessary."
This passage is often interpreted as a rejection of abortion.
However, abortion was legal at the time and the text only mentions pessaries (a soaked piece of wool inserted in the vagina to induce abortion), not the oral methods of abortion also used in ancient Greece.
As pessaries could cause lethal infections, the author of the Oath may have had a clinical objection to the method, rather than a moral objection to abortion itself.
The next sentence - "In a pure and holy way, I will guard my life and my art and science" - is a call for professional integrity.
Doctors should refrain from immoral behaviour and resist the temptations that accompany their privileged position (today, from drug companies offering generous gifts, for example).
The Oath continues: "I will not cut, and certainly not those suffering from stone, but I will cede this to men who are practitioners of this activity."
Another common misconception is that the Oath forbids surgery.
About whatever I may see or hear in treatment, or even without treatment, in the life of human beings, I will remain silent, holding such things to be unutterable Hippocratic Oath
In fact, it instructs doctors to acknowledge the limits of their competence and to refer cases to more specialised practitioners.
Next, the doctor enters the patient's house: "Into as many houses as I may enter, I will go for the benefit of the ill, while being far from all voluntary and destructive injustice, especially from sexual acts both upon women's bodies and upon men's."
The need for such a statement reflects the wide distrust in healers at the time.
In a competitive marketplace where quacks abounded, it was necessary to reassure the public that doctors would not exploit patients.
The penultimate section deals with confidentiality and reads: "And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings, I will remain silent, holding such things to be unutterable."
As today, patients in ancient times shared deeply personal information with doctors on the assumption that their details would not be revealed to others.
Without this trust, patients may withhold facts that would help the doctor make an accurate diagnosis.
The text ends with the rewards that await those who respect the Oath ("the benefits both of life and of art and science, being held in good repute among all human beings for time eternal") and the punishment of those who do not ("if, however, I transgress and swear falsely, the opposite of these").
This whistle-stop tour of the Oath gives some idea of the content and spirit of this ancient text.
In an age of technological developments, cosmetic surgery, complementary medicine, drug companies, and many other temptations for patients and doctors alike, the spirit of the Oath is as relevant as ever.

• Dr Daniel Sokol is a medical ethicist at St George's, University of London

Thursday, October 30, 2008

Seniors Tend to Stick With End-of-Life Care Preferences

By Alan Mozes
30 oct 2008- Regardless of declines in either mental or physical health, most senior citizens do not change their outlook on how they want their end-of-life care to be when the time comes, new research suggests.
The study notes, however, that despite observing an overall stability in patient perspective, certain patients do seem to change their mind over time.
"We found that the people who wanted the least [aggressive treatment] were the most likely to continue wanting the least, whereas the people wanting the most were the most likely to change over to wanting less over time," noted study author Dr. Marsha N. Wittink from the department of family medicine and community health at the University of Pennsylvania School of Medicine in Philadelphia.
Wittink and her team published the observations in the Oct. 27 issue of the Archives of Internal Medicine.
Their findings are based on a comparative analysis of two end-of-life treatment preference questionnaires completed by 818 physicians, all of whom graduated from Johns Hopkins University between 1948 and 1964.
At an average age of 69 when the study was launched, all the participants completed an initial survey in 1999, followed by a second survey in 2002.
At both times, the patients were asked to indicate which types of interventions they would want should they experience brain death that rendered them unable to either speak or recognize those around them. Possible interventions included surgery, insertion of a feeding tube, dialysis, and/or cardiopulmonary resuscitation.
Serious changes in the participants' physical and/or mental health over the course of the intervening three years were also monitored.
The research team found that the overall percentage of study participants who fell into each level of treatment preference --"aggressive," "intermediate" or "least aggressive"-- remained pretty constant over the three years, as patients who turned down particular treatments in 1999 continued to be likely to do so in 2002.
Specifically, while 12 percent, 26 percent and 62 percent respectively preferred aggressive, intermediate or least aggressive treatment in 1999, overall preferences had shifted only slightly by 2002: to 14 percent, 26 percent and 60 percent, respectively.
Getting older or experiencing a decline in either mental or physical health did not appear to impact patient preferences, the researchers noted.
However, although the absolute numbers of those choosing one type of treatment approach or another remained more or less constant, individuals didn't necessarily stay in their original category, with some gravitating towards more or less aggressive intervention over time.
For example, among those who had indicated that they wanted "aggressive" treatment in 1999, just 41 percent maintained that preference in 2002.
On the other hand, those who lacked either a living will or a durable power of attorney when they first outlined their preferences in 1999 were twice as likely to want "aggressive" life-sustaining care (as opposed to "least aggressive" care) when they were re-interviewed in 2002.
"This dynamic is important to understand, because even though most people are stable in their preferences -- which is not surprising -- some people are not," said Wittink. "So that means that both doctors and patients need to be thinking and communicating about patient feelings as preferences change."
Dr. Steven Pantilat, director of the palliative program at the University of California, San Francisco, suggested that the findings make intuitive sense.
"Previous research has actually suggested that people do change their minds, and that it's hard to predict whether an individual will end up wanting more or less aggressive treatment down the road," he said. "But even though this finding is a little different than what the prior literature has indicated, I have to say that it's more in line with what I've personally observed. Which reflects the fact that generally people's values and goals don't change that much over time."
"I also think that moving from wanting more treatment to wanting less is typical of many patients," he said. "Because as seriously ill people experience the increasing burden of treatment coupled with what they realistically can expect to get from it, there is often a shift in focus towards gaining comfort and a better quality of life, and away from aggressive life-prolonging intervention."
"Whatever the case, what's important is that patients are upfront at an early stage about their preferences, so they get the care they want," he stressed. "Because preferences about end-of-life are not whims. And if you don't express yourself you may very well get the kind of care you don't want."
More information
For more on end-of-life directives, visit the American Academy of Family Physicians.
Depression often untreated in black heart patients

NEW YORK , 30 oct 2008– African Americans with heart disease are as likely to suffer from depression as their white counterparts, but they are less likely to be on medication for it, a new study suggests.
The study of 864 adults with coronary heart disease found that 35 percent of African Americans and 27 percent of whites had symptoms of depression. Yet black patients were less than half as likely to be on an antidepressant medication.
The findings are important, the researchers say, because depression in people with heart disease has been linked to a two- to four-fold higher risk of complications.
Studies have found that depressed heart disease patients have higher risks of a heart attack or stroke, and may die earlier than those without depression.
"Undertreatment of depression is a serious clinical issue," Dr. James Blumenthal, one of researchers on the current study, said in a statement.
These latest findings suggest that black heart patients, in particular, need better diagnosis and treatment of depression, according to Blumenthal and his colleagues at Duke University Medical Center in Durham, North Carolina.
The study included 727 white patients and 137 black patients seen at Duke for coronary heart disease. All completed a standard questionnaire used to screen for depression.
Blumenthal's team found that depression was similarly common among black and white patients, and the severity of their symptoms was comparable as well.
However, while 21 of depressed white patients were on an antidepressant, only 12 percent of black patients were.
The difference was greatest among men; 43 percent of moderately to severely depressed white men were taking an antidepressant, versus 22 percent of their black counterparts.
The researchers are not sure why the racial disparity exists. They lacked information on the study patients' health insurance, so it's not possible to tell whether differences in coverage are a factor. Nor do they know whether doctors were less likely to prescribe to black patients, or whether African Americans were less likely to want an antidepressant.
Blumenthal pointed out that therapies other than antidepressants may be helpful for heart disease patients' depression. He is currently conducting a study comparing aerobic exercise with drugs in treating depression.
"We clearly need to do a better job of recognizing and treating depression, especially in heart patients," Blumenthal said. "We need treatments that work, treatments that are acceptable to patients, and treatments that are actually incorporated into medical practice."
SOURCE: American Heart Journal, October 2008.
Tests Could Predict Benefit From Cancer Drugs

By Amanda Gardner
30 oct 2008-- What if a blood test or biopsy could predict if a cancer therapy will help cure you, or only make you feel worse?
Tests like these, based on genes, proteins or other "molecular markers" may someday do just that for people battling colon, lung and pancreatic tumors, scientists reported at a news conference Tuesday.
"The ultimate goal is to bring personalized medicine to reality, to identify characteristics of tumors or patients where we can make a relatively dramatic impact using targeted agents," said Dr. Bruce Johnson of the Dana-Farber Cancer Institute and Harvard Medical School, in Boston.
Johnson moderated the teleconference, sponsored by the American Society of Clinical Oncology (ASCO). The briefing focused on research being presented at the second annual meeting on Molecular Markers in Cancer, which will take place Oct. 30 through Nov. 1 in Hollywood, Fla. The meeting is co-sponsored by ASCO, the U.S. National Cancer Institute and the European Organization for Research and Treatment of Cancer.
First up, colon cancer. Researchers pooled data from four clinical trials involving 715 patients. They confirmed that the cancer drug Vectibix (panitumumab) was only successful in treating advanced colorectal cancer in patients with the normal ("wild type") form of the KRAS gene -- not a mutated version.
Vectibix blocks the epidermal growth factor receptor (EGFR) on cancer cells.
The patient response rate to Vectibix was 14 percent if they carried the normal KRAS gene, but that rate sank to zero if the patient had a mutated form of the gene, said study lead author Daniel Freeman, a principal scientist in oncology research at Amgen Inc., which makes the drug.
Progression-free survival (3.3 months versus 1.7 months) and overall survival (8.3 months versus 5.7 months) were also better in patients with the normal KRAS gene.
This isn't the first time the KRAS gene has dictated just how well a cancer therapy might work. Just last week, researchers reported in the New England Journal of Medicine that colon cancer patients with a KRAS mutation would not respond to the drug Erbitux (cetuximab).
"The data is quite consistent that KRAS is an important negative predictor of patients unlikely to get a benefit from EGFR antibodies," Johnson said.
A second study discussed Tuesday focused on the predictive value of a marker for lung cancer, the No. 1 cancer killer in the United States.
Spanish researchers found that when both blood and tumor samples from patients with metastatic non-small cell lung cancer had a mutated form of the EGFR gene, the patients had a more aggressive cancer, with less time to live -- even after taking Tarceva (erlotinib), another targeted therapy that blocks EGFR.
It could be that more aggressive tumors lead to more mutant DNA in the blood, according to the researchers, from the Catalan Institute of Oncology in Barcelona.
The finding has practical implications for lung cancer patients, they noted. That's because blood samples could yield the same critical information as hard-to-obtain tissue samples, circumventing the need for biopsy. In fact, about a third of patients with this type of lung cancer don't yield enough tumor tissue to analyze for the mutation, the study authors said.
Finally, a third study looked at a particularly deadly malignancy, pancreatic cancer. Researchers found that patients whose pancreatic cancer tumors do not contain the S100A2 protein have double the life expectancy of patients whose tumors show high levels of the protein.
Testing for the presence of the protein beforehand could help select which patients would benefit from surgery. Such surgeries are difficult to perform and available to only a minority of patients with this type of cancer.
The protein may also provide a target for new treatments for this cancer killer, the team said.
The goal of all three studies are tests that could pinpoint which patients will reap the biggest benefit from a particular cancer therapy, Johnson said.
"Most of the pharmaceutical industry has been focused on making 100 percent of patients 20 percent better," he reasoned. "Today, we're talking about markers that can help 20 percent of patients get 100 percent better."
More proof needed on costly diabetes drugs

By Julie Steenhuysen
CHICAGO , 30 oct 2008– U.S. doctors are using a wider array of newer, more costly drugs to treat diabetes with little long-term proof that they work better than older, cheaper medications, U.S. researchers said on Monday.
They said newer treatments boosted the average cost of a diabetes prescription by nearly 40 percent in six years.
A separate team that combed through clinical trial data found only the drug metformin cut the risk of heart problems in people with type 2 diabetes, the most common form in which the body gradually loses its ability to respond to insulin.
Taken together, the studies make the case for more long-term data on diabetes drugs as Americans' poor diet and rising rates of obesity are expected to swell the number of diabetics to 29 million by 2050, up from 21 million.
"Diabetes is common and costly. More than one in every 10 healthcare dollars goes to treating diabetes or its complications," said Dr. Caleb Alexander of the University of Chicago, whose study appears in Archives of Internal Medicine.
Alexander and colleagues analyzed prescription data from U.S. patients 35 and older with type 2 diabetes who visited a physician's office between 1994 and 2007. Information about medication costs was available from 2001 to 2007.
They found the annual cost of diabetes drugs rose to $12.5 billion in 2007 from $6.7 billion in 2001.
Alexander said more diabetics using more and newer drugs fueled the rise. Yearly patient visits for diabetes rose to 36 million in 2007 from 25 million in 1994, and the average number of drugs per patient rose to 1.63 from 1.14. The average cost per prescription rose to $76 in 2007 from $56 in 2001.
During this time, prescriptions for older and cheaper sulfonylurea drugs fell to 34 percent from 67 percent of treatment visits, while those for drugs such as metformin and glitazones, such as Takeda Pharmaceutical Co Ltd Actos or pioglitazone and GlaxoSmithKline's Avandia or rosiglitazone, increased.
Newer forms of insulin helped drive costs, as did new drugs such as Merck & Co Inc's Januvia or sitagliptin, which made up eight percent of prescriptions in 2007, and Eli Lilly and Co and Amylin Pharmaceuticals Inc's Byetta or exenatide, prescribed four percent of the time in 2007.
"Some of these drugs may represent valuable pharmaceutical innovation, but I think the need for greater evidence regarding their safety and effectiveness is important since they cost eight to 10 times more than some of the older, more time-tested alternatives," Alexander said in a telephone interview.
Elizabeth Selvin of Johns Hopkins in Baltimore and colleagues analyzed data on heart problems in 40 clinical trials of diabetes drugs published on or before January 2006. Twenty seven of the studies lasted less than one year.
Only metformin cut the risk of death or other heart problems. And only Avandia appeared to raise the risk of death or problems such as a heart attack or stroke, but that did not reach statistical significance, the researchers said.
They said poor quality and inconsistent reporting of heart data, along with the lack of long-term studies, make it hard to draw firm conclusions about diabetes medications.
In a Eulogy, Finding a Person, Not a Patient

30 oct 2008--Sometimes you learn about a patient only after he dies.
Not long ago, I took care of a young man named Michael with severe congestive heart failure. Michael received the diagnosis when he was 18, but as is so often the case with this disease, we never figured out how he got it. He was a student at a community college in Brooklyn when I met him, though he dropped out when his condition worsened. Despite the setbacks, he was a model patient, coming in diligently with his mother for weekly appointments, eliminating salt from his diet, taking his medications regularly.
Eventually I referred him to a heart-transplant center in Manhattan, where he went for evaluation and frequent follow-up visits. He had to lose weight to qualify for a transplant, and by the time he did, his lungs had become so waterlogged from heart failure that he was suffering from severe fatigue and worsening shortness of breath.
Two weeks before his 20th birthday, Michael went on a weeklong religious retreat with friends in Kentucky. His doctors had strongly discouraged him from going, but he had insisted. He left by car on a Sunday. The following Friday, he died in a Lexington hotel room.
His mother called to tell me the news. Voice breaking, she thanked me and John, the nurse practitioner I work with, for treating him over so many months. She invited us to the funeral; amazed and touched at her grace in the depths of her loss, we accepted.
The church, in Queens, resounded with lilting hymns as we arrived. Inside, men were dressed in cream-colored suits and women in Sunday finery. An organ was playing eerie music in the high-ceilinged chamber. Two men stood in front of the coffin, which carried a portrait of Michael wearing a pinstriped suit, looking debonair, unlike the way I remembered him. As we took our seats, a man got up and started tap dancing, exhorting the crowd to come up and dance with him.
Soon, people were clapping on tambourines and playing harmonicas in fast, crazy rhythms. A few were dancing wildly as Gospels were shouted. Men came up to praise Michael: “He walked with God. ... He is in a better place. ... He never did anything the wrong way.”
His uncle, a bishop, stood up and delivered the main eulogy. In soaring oratory, he declared that Michael had an unshakeable conviction that God would save him. “Even in his worst sickness, when he had to tell his brothers to give him a few minutes because he could not get up from a chair, even then, he had faith.”
“Tick tock!” he screamed into a microphone, which reverberated in dissonant feedback. “Your time is coming, too. Keep on with the insults, the small-minded bruises and disputes. Tick tock! Your time is coming, too.” Murmurings swelled to shouts of support.
The sermon then took on a more subdued tone. The uncle recalled how Michael had been adopted as an infant. (I did not know.) He said Michael had taught himself Hebrew and liked being called “T.R.,” for Temple Rabbi. (Another thing I didn’t know.)
Then he said, “Forgive me, but I want to focus on the lighter side of my nephew.” He told how Michael wore fancy clothes. He recalled Michael’s youthful indiscretions. “Michael loved White Castle cheeseburgers and Chinese food.” Chinese food? I thought. “And chicken rolls with soy sauce.” Michael had always denied such improprieties to us. “Whenever he was with me, we would always stop for takeout.”
I looked at John. He had the same disbelieving look I must have had.
“Michael did not like taking his medications,” his uncle went on. “I’d remind him to do it, force him to, but he would avoid it because they didn’t make him feel good.” I shifted uncomfortably in my seat. “And you all know he never wanted a heart transplant. He never would have accepted one.” (That was news to me, too.)
Afterward, John and I were asked to say a few words. John recalled how much Michael loved pens, how John would always give him a fancy pen when he came to see us. (I had no idea.)
As I walked up, I wasn’t sure what to say. I thought about how easy it is, with the time pressures of medical practice, to ignore social history, habits, the sorts of things that make a patient into a real person — and vice versa. Undoubtedly, such information would have helped me treat Michael.
I told the crowd that Michael was brave and vibrant. I called his death a tragedy. Then I thanked his adoptive mother for inviting me. I had learned so much about her son that day.
Sandeep Jauhar is a cardiologist on Long Island and the author of the new memoir “Intern: A Doctor’s Initiation.”

Wednesday, October 29, 2008

Octogenarians can be good candidates for heart surgery
Open-heart surgery should remain a viable treatment option for people in their 80s, according to experts at the MUHC

Montreal, 29 oct 2008 - Patients 80 years and older who are in overall good health are perfectly able to withstand open-heart surgery, according to the latest study of Dr. Kevin Lachapelle of the McGill University Health Centre (MUHC). His findings were presented this morning in Toronto during the 2008 Canadian Cardiovascular Congress.
"Age should not be a reason for doctors to rule out the possibility of heart surgery for their octogenarian patients," explained Dr. Lachapelle. "If patients with heart problems are otherwise in good health, this surgery can significantly improve their quality of life."
This study conclusion is based on the follow-up of 185 patients who underwent open-heart surgery at the MUHC for a cardiac valve replacement. Five years after the operation, 60% of these patients were still alive and 90% of the survivors were leading active and independent lives. "This outcome is extremely positive," said Dr. Lachapelle. "It proves that age alone should not be a factor in ruling out this type of surgery: feasibility must be assessed by a surgeon based on the patient's overall state of health."
Quality of life is a major concern for octogenarians, a growing segment of the Quebec population. It is therefore important to evaluate all possible treatments according to each patient's specific needs and limitations in order to provide everyone with the best possible care. "Pediatricians account for children's specific needs, as they differ from those of adults. The elderly also have specific issues that must be objectively assessed and not considered based on pre-conceived notions," explained Dr. Lachapelle.
Dr. Kevin Lachapelle is a cardiac surgeon at the MUHC as well as a researcher in the Cardiovascular Diseases and Critical Care Axis of the Research Institute of the MUHC. He is also an Associate Professor in Surgery at the Faculty of Medicine of McGill University.
The McGill University Health Centre
The McGill University Health Centre (MUHC) is a comprehensive academic health institution with an international reputation for excellence in clinical programs, research and teaching. Its partner hospitals are the Montreal Children's Hospital, the Montreal General Hospital, the Royal Victoria Hospital, the Montreal Neurological Hospital, the Montreal Chest Institute and the Lachine Hospital. The goal of the MUHC is to provide patient care based on the most advanced knowledge in the health care field and to contribute to the development of new knowledge.
A high-fat diet could promote the development of Alzheimer's

Quebec City, 29 oct 2008—A team of Université Laval researchers has shown that the main neurological markers for Alzheimer's disease are exacerbated in the brains of mice fed a diet rich in animal fat and poor in omega-3s. Details of the study—which suggests that diets typical of most industrialized countries promote the development of Alzheimer's—are outlined in the latest online edition of Neurobiology of Aging.
To demonstrate this, the team led by Frédéric Calon used a type of transgenic mice that produce two proteins found in the brains of Alzheimer patients—tau proteins, which prevent proper neuron functioning, and amyloid-beta, associated with the formation of senile plaques within the brains of afflicted patients.
The researchers fed transgenic and regular mice different diets for nine months, after which they compared the effects on the animals' brains.
The mice whose diet was poor in omega-3s and rich in fat (60% of consumed calories) showed amyloid-beta and tau protein concentrations respectively 8.7 and 1.5 times higher than the control group mice, whose food contained 7 times less fat. The high-fat diet also reduced drebrin protein levels in the brain, another characteristic of Alzheimer's disease.
"Metabolic changes induced by such a diet could affect the inflammatory response in the brain," suggests study co-author Carl Julien to explain the link between fat consumption and Alzheimer's.
In most Western countries, diets rich in saturated fats and poor in omega-3s are the norm. "Our findings lead us to believe that a diet containing more omega-3s and less saturated fat could prevent the development of Alzheimer's, at the very least among people genetically predisposed to the disease," comments Dr. Calon. "We cannot state with any certainty that what we have observed among transgenic mice also occurs in humans, but there is no harm in eating less fat and more omega-3s," concludes the researcher.
In addition to Calon and Julien, this study was co-authored by Cyntia Tremblay, Alix Phivilay, Line Berthiaume, Vincent Émond, and Pierre Julien.
Highly specialized, minimally invasive surgery for lung cancer allows patient to go home sooner

Video-assisted thoracic surgery offers comprehensive cancer removal compared to open surgery

Philadelphia, 29 oct 2008 -- Minimally-invasive surgery for lung cancer called video-assisted thoracic surgery or VATS is a relatively new procedure performed almost exclusively at academic centers. Now, a preliminary study to be presented this month at the annual CHEST meeting in Philadelphia is giving surgeons an early look at its benefits.
Conventional or open surgery for lung cancer requires a six to 10-inch incision, cutting the major muscles overlying the chest. The surgeon spreads the ribs apart with a retractor in order to view and gain access to the lung, sometimes even removing a portion of one rib. With open surgery or VATS, the surgeon removes either a section of the lung or the affected lobe.
VATS is performed with two to four small incisions (the main incision is only 2 inches long). Instead of spreading the ribs, the surgeon gains access to the lungs through a space between the ribs. By inserting a small camera, the surgeon has a magnified view of the organs on a monitor in the operating room.
"Anecdotally, we've observed similar outcomes with open surgery and VATS, but we've seen a significant advantage with VATS concerning quality of life matters," says Walter Scott, M.D., a thoracic surgeon at Fox Chase Cancer Center, one of few surgeons in the country who performs this highly-specialized surgery. "Now, we have well-analyzed comparison data that supports what we've observed in our patients."
For the study, Scott and his colleagues analyzed the records of 140 lobectomy patients who underwent VATS (74 patients) and open surgery (66 patients) for stage I non-small cell lung cancer. Five of the 74 VATS lobectomies were converted to open procedures. Operative mortality was 1/66 (1.5 percent) for open surgery and 1/74 (1.5 percent) for VATS.
"The most exciting finding is that our patients go home much sooner when they have VATS compared to open surgery," Scott says. The post-operative hospital stay was four days for VATS patients and seven days for open surgery patients (P<0.0001).
"VATS patients also had the post-operative chest tube removed sooner than patients with open surgery," he says. Adjusted median chest tube duration was 5 days for open surgery versus 4 days for VATS (P<0.0001) The percentage of patients with any complication was 42 percent for open surgery versus 35 percent for VATS (P=0.516).
Scott says the new study shows VATS allows the same comprehensive approach to removing the cancer as open surgery. "Removing all of the cancer is always our main goal which includes the removal of lymph nodes." Adjusted mean lymph nodes stations (#/patient) was 4.6 (open) versus 4.2 (VATS), p=0.249. Adjusted mean number of lymph nodes per patient was 18.1 (open) versus 14.7 (VATS), p=0.145. (Walter, the last couple of sentences here are clunky and contain too much jargon. Can you help me out by translating this?)
"Minimally invasive surgical techniques have been used for many decades, but only recently have we applied the technology to patients with lung cancer," Scott says. "This study is important in demonstrating the effectiveness and the reduced impact it can have for our patients."
Scott's co-authors include T. Salewa Oseni, M.D., Philip Prest D.O., Brian L Egleston Ph.D., James Flaherty M.D. and Abraham Lebenthal, M.D. The authors report no disclosures.
Osteoporosis drugs increase risk for heart problems

Irregular heartbeat is side effect of common osteoporosis medications

29 oct 2008--People who take bisphosphonates for osteoporosis may be at risk for serious atrial fibrillation (AF), or irregular heartbeats, according to a new study. The research, presented at CHEST 2008, the 74th annual international scientific assembly of the American College of Chest Physicians (ACCP), shows that people taking alendronate or zoledronic acid, two common medications to prevent or slow the occurrence of osteoporosis, were significantly more likely to experience serious AF, including hospitalization or death, compared with placebo.
"Atrial fibrillation can be serious if it is persistent or occurs in people with preexisting heart disease or hypertension," said Jennifer Miranda, MD, Jackson Memorial Hospital, Miami, FL. "If left untreated, it can lead to pulmonary edema, congestive heart failure, or the formation of a blood clot that can cause a brain embolism and stroke."
In a metaanalysis, Dr. Miranda and colleagues from the University of Miami evaluated the relationship between the use of bisphosphonates and AF, a condition that can produce a wide range of symptoms, including light-headedness, palpitations, chest pain, and shortness of breath, or no symptoms at all. Three studies met eligibility criteria and included a total of 16,322 patients, of whom 76 to 100 percent were women using bisphosphonates for osteoporosis with a mean age range 69 to 75 years. Patients in the study were taking alendronate or zoledronic acid. The analysis showed that 2.5 to 3 percent of patients taking bisphosphonates experienced atrial fibrillation and 1 to 2 percent experienced serious AF, including hospitalization or death. Patients taking bisphosphonates were more likely to experience AF than patients receiving placebo and up to two times more likely to experience serious AF than patients receiving placebo.
"In patients with increased risk factors for atrial fibrillation, clinicians should be more cautious when choosing treatment for osteoporosis and weigh the risks against the benefit of decreased fracture risk," said Dr. Miranda.
"Bisphosphonates are widely used to treat millions of women and men who suffer from osteoporosis or low bone density," said James A. L. Mathers, Jr., MD, FCCP, President of the American College of Chest Physicians. "A potential link between bisphosphonates and atrial fibrillation warrants additional research in this area."
CHEST 2008 is the 74th annual international scientific assembly of the American College of Chest Physicians, held October 25-30 in Philadelphia, PA. ACCP represents 17,000 members who provide patient care in the areas of pulmonary, critical care, and sleep medicine in the United States and throughout the world. The ACCP's mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication. For more information about the ACCP, please visit the ACCP Web site at
Physicians lack smoking cessation training

Poor quit rates may reflect lack of provider knowledge

29 oct 2008--Physicians and other health-care providers may advise their patients to quit smoking, but few providers have the adequate training to follow their patients through the cessation process. New research presented at CHEST 2008, the 74th annual international scientific assembly of the American College of Chest Physicians (ACCP), shows that 87 percent of physicians and other medical professionals receive less than 5 hours of training on tobacco dependence and less than 6 percent knew Agency for Healthcare Research and Quality (AHRQ) treatment guidelines for tobacco dependence, including the signs of nicotine withdrawal. Researchers speculate that this lack of knowledge related to tobacco dependence treatment may, in turn, affect quit rates among smokers.
"If health-care providers are unaware of the AHRQ guidelines for tobacco dependence, and consequently unsure of how to treat their patients who are tobacco-dependent, they are less likely to do more than ask and advise their patients to quit," said the study's lead researcher, Virginia Reichert, NP, who conducted her research while at the North Shore-LIJ Health System Center for Tobacco Control, Great Neck, NY.
Researchers from the North Shore-LIJ Center for Tobacco Control surveyed 600 health-care providers, of which 322 were considered prescribers (physicians, nurse practitioners, or physician assistants), and the remaining 278 participants were considered nonprescribers (pharmacists, registered nurses, social workers, counselors, respiratory therapists, and students). Survey questions regarding tobacco control issues were related to prevalence of smoking, tobacco treatment guidelines, cessation pharmacotherapy, interaction of nicotine with other drugs, and symptoms and implications of nicotine withdrawal.
Results showed that a significant number of health-care providers lack general knowledge related to tobacco dependence treatment. Of those surveyed, 87 percent of prescribers and 93 percent of nonprescribers received less than 5 hours of tobacco-dependence training. In addition, only 6 percent of prescribers and 5 percent of nonprescribers knew the AHRQ treatment guidelines for tobacco dependence.
"Without appropriate training in tobacco dependence treatment, health-care providers may lack the knowledge and confidence to help their patients quit smoking," said Ms. Reichert. "Furthermore, providers may not recognize that tobacco dependence is a chronic relapsing condition and become frustrated when patients do not quit when advised to do so." Research indicates that approximately 70 percent of smokers report a desire to quit but believe it will be too difficult without assistance. Research also indicates that smokers are 30 percent more likely to quit with assistance from their health-care provider.
In relation to cessation pharmacotherapy, 16 percent of prescribers and 8 percent of nonprescribers knew which FDA-approved medications were over-the-counter and which required a prescription. The majority of prescribers and nonprescribers also failed to recognize select contraindications and changes to medication dosages in patients undergoing smoking cessation. In addition, only 1 percent of prescribers and 3 percent of nonprescribers correctly identified the signs of nicotine withdrawal.
"If clinicians are unaware of the contraindications related to cessation medications, this could lead to adverse reactions for the patient and, consequently, a failure to quit," said study author Patricia Folan, RN, acting director of the North Shore-LIJ's Center for Tobacco Control. "In addition, if clinicians are unaware of withdrawal symptoms, they may not encourage their patients to use the cessation medications. Without the cessation medications, patients experience the discomfort of withdrawal symptoms and are less likely to sustain their quit attempt."
"Patients who are advised to quit smoking, but who are not given the tools and resources to help them, will be less likely to quit," said James A. L. Mathers, Jr., MD, FCCP, President of the American College of Chest Physicians. "Health-care providers must be educated about the smoking cessation process and available resources in order to provide comprehensive guidance to patients who wish to stop smoking."
CHEST 2008 is the 74th annual international scientific assembly of the American College of Chest Physicians, held October 25-30 in Philadelphia, PA. ACCP represents 17,000 members who provide patient care in the areas of pulmonary, critical care, and sleep medicine in the United States and throughout the world. The ACCP's mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication. For more information about the ACCP, please visit the ACCP Web site at
New hormone data can predict menopause within a year

ANN ARBOR, Mich., 29 oct 2008---For many women, including the growing number who choose later-in-life pregnancy, predicting their biological clock's relation to the timing of their menopause and infertility is critically important.
Now, investigators from the University of Michigan have provided new information about hormonal biomarkers that can address the beginning of the menopause transition.
"In the end, this information can change the way we do business," said MaryFran Sowers, professor in the U-M School of Public Health Department of Epidemiology. "The information provides a roadmap as to how fast women are progressing through the different elements of their reproductive life."
A research team headed by Sowers examined the naturally occurring changes in three different biomarkers over the reproductive life of more than 600 women: follicle-stimulating hormone (FSH), anti-Mullerian hormone (AMH) and inhibin B.
Researchers found that the biomarker AMH declined to a very low or non-measurable level five years prior to the final menstrual period. This decline pinpoints a critical juncture in which a woman probably has so few follicles (eggs) that her fertility becomes increasingly questionable, Sowers said. They found that the changes in AMH and inhibin B concentrations were predictive of the time to menopause.
The research team also measured and reported the rates of change in FSH and used the information to identify different reproductive stages. Based on a woman's age and the level of FSH in the blood, researchers were able to describe four different stages that occur for women from their late reproductive period to the time of their final menstrual period.
While clinicians have the ability to measure these hormones now, they haven't had the kind of information about AMH, inhibin B or FSH collected on a large group of women over time to know how to relate levels or changes in the levels to fertility or to a menopause endpoint.
"People really want information about how long do I have and when will I have my final menstrual period," Sowers said. "Now we are beginning to say, 'If you have a specific FSH level combined with your age, this is the likelihood that you are in this reproductive stage.'
"We finally have numbers from enough women evaluated over a long time period to describe the reproductive aging process. It begins to give women and clinicians an expanded way to look at menses and endocrine events in terms of reproductive progression."
Sowers said additional study results have been submitted to describe the amount of bone loss that occurs at the different FSH stages.Thus, if women and clinicians know where women are in the various reproductive stages, it will further their understanding of the likely health implications associated with each stage.
The two papers defining these reproductive states are, "Follicle-Stimulating Hormone and its Rate of Change in Defining Menopause Transition Stages," and "Anti-Mullerian Hormone and Inhibin B in the Definition of Ovarian Aging and the Menopause Transition." They are available online at the Journal of Clinical Endocrinology and Metabolism.
The research team also includes: Huiyong Zheng, Daniel McConnell, Bin Nan, Sioban Harlow, all of the U-M School of Public Health, and John F. Randolph Jr. of the U-M Department of Obstetrics and Gynecology.
For more on Sowers: For more on the Department of Epidemiology:

Tuesday, October 28, 2008

Study reveals factors of exceptional health in old age

Positive outlook, low stress and no smoking contributes to healthy old age

PORTLAND, Ore, 28 oct 2008— Elderly people who have a positive outlook, lower stress levels, moderate alcohol consumption, abstention from tobacco, moderate to higher income and no chronic health conditions are more likely to thrive in their old age, according to a study in the October issue of The Journal of Gerontology: Medical Sciences.
The first study of its kind, researchers from Portland State University, the Kaiser Permanente Center for Health Research, Oregon Health & Science University, and Statistics Canada surveyed 2,432 older Canadians about their quality of life. The few who maintained excellent health over an entire decade were considered "thrivers." Most previous studies have been based on one-time surveys and have focused on factors that contribute to poor health.
"Important predictors of 'thriving' were the absence of chronic illness, income over $30,000, having never smoked, and drinking alcohol in moderation," said Mark Kaplan, DrPH, lead author and professor of community health at Portland State University. "We also found that people who had a positive outlook and lower stress levels were more likely to thrive in old age."
"Many of these factors can be modified when you are young or middle-aged," said David Feeny, PhD, co-author and senior investigator at the Kaiser Permanente Center for Health Research. "While these findings may seem like common sense, now we have evidence about which factors contribute to exceptional health during retirement years."
Study participants filled out an extensive health survey every other year, starting in 1994 and continuing through 2004. One measure, called the Health Utilities Index, asked people to rate their abilities in eight categories, including vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain. "Thrivers" were those who rated themselves as having no or only mild disability in all eight categories on at least five of the six surveys.
If respondents reported moderate or severe disability on any of the six surveys, they were classified as "non-thrivers." Just over half (or 50.8 percent) of the respondents started out as "thrivers", but by the end of the 10 years, only 8 percent of the respondents were considered thrivers. At the end of the study period, 47 percent of the respondents were classified as non-thrivers. Thirty-six percent had died and 9 percent were institutionalized.
"Even though the study was conducted in Canada, the findings are certainly applicable to the United States and other industrialized nations," says Bentson McFarland, MD, PhD, co-author and professor of psychiatry, public health and preventive medicine at at Oregon Health & Science University. "Our population here in the United States is similar demographically to Canada's, and both health care systems rely on the same underlying technologies."
The study was funded by a grant from the National Institute on Aging. Authors include Mark S. Kaplan, PhD, and Nathalie Huguet, PhD, from Portland State University; Heather Orpana, PhD, from Statistics Canada and the University of Ottawa; David Feeny, PhD, from the Kaiser Permanente Center for Health Research and Health Utilities Incorporated; Bentson H. McFarland, MD, PhD, from Oregon Health & Science University, and Nancy Ross, PhD, at McGill University in Canada.
Author David Feeny has a proprietary interest in Health Utilities Incorporated (HUInc.), Dundas, Ontario, Canada. The HUI survey instrument used in this study was developed in cooperation with the Canadian government. Neither Feeny nor HUInc. received any monetary reimbursement for use of the survey.
The Journal of Gerontology: Social Sciences is a refereed publication of The Gerontological Society of America, the nation's oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,000+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA's structure also includes a policy institute, the National Academy on an Aging Society, and an educational branch, the Association of Gerontology in Higher Education.
Kaiser Permanente's Center for Health Research, founded in 1964, is a not-for-profit research institution dedicated to advancing knowledge to improve health. It has research sites in Portland, OR, Honolulu, HI, and Atlanta, GA.
NCI: No prostate benefit from vitamin E, selenium

WASHINGTON, 28 oct 2008 – The government is stopping a major study of whether vitamin E and selenium prevent prostate cancer — because the supplements aren't working and there's a hint of risk.
More than 35,000 men age 50 and older have been taking one or both supplements or dummy pills for several years as part of a study called the SELECT trial.
But the National Cancer Institute announced Monday that they will be getting letters in the next few days telling them to stop: An early review of the data shows neither supplement, taken alone or together, is preventing prostate cancer.
Of more concern, slightly more users of vitamin E alone were getting prostate cancer — and slightly more selenium-only users were getting diabetes, the NCI said.
That doesn't prove there is a risk from the supplements, the NCI stressed: Neither blip was statistically significant, meaning it could be a coincidence.
Earlier smaller studies had suggested the nutrients might help, but instead they've become latest failures in a quest to find cancer-preventing dietary supplements.
Researchers will continue to track the men's health for three years. As with most well-designed studies, the participants didn't know which nutrients they'd been assigned to take, or if they were in the placebo group. If they ask now, doctors will tell them. But researchers say the study's results will be more accurate if most of the men wait to find that out until the follow-up health tracking is complete.
The study had been scheduled to run through 2011, enough time for latest-enrolling participants to have taken the supplements for seven years.
Prostate cancer is the most common cancer in American men. More than 186,000 cases will be diagnosed this year, and prostate cancer will claim 28,660 lives.
Some research shows that a drug already used for an enlarged prostate, finasteride, can help prevent prostate cancer as well, but side effects limit its use.
Masks, hand washing, prevent spread of flu-like symptoms by up to 50 percent

ANN ARBOR, Mich., 28 oct 2008---Wearing masks and using alcohol-based hand sanitizers may prevent the spread of flu symptoms by as much as 50 percent, a landmark new study suggests.
In a first-of-its-kind look at the efficacy of non-pharmaceutical interventions in controlling the spread of the flu virus in a community setting, researchers at the University of Michigan School of Public Health studied more than 1,000 student subjects from seven U-M residence halls during last year's flu season.
"The first-year results (2006-2007) indicate that mask use and alcohol-based hand sanitizer help reduce influenza- like illness rates, ranging from 10 to 50 percent over the study period," said Allison Aiello, co-principal investigator and assistant professor of epidemiology at the U-M SPH. Dr. Arnold Monto, professor of epidemiology, is also a principal investigator of the study.
Aiello stressed the first year of the two-year project, called M-Flu, was a very mild flu season and only a few cases were positive for flu, so results should be interpreted cautiously. Ongoing studies will test for other viruses that may be responsible for the influenza-like illness symptoms observed, she said.
"Nevertheless, these initial results are encouraging since masks and hand hygiene may be effective for preventing a range of respiratory illnesses," Aiello said.
The findings, "Mask Use Reduces Seasonal Influenza-like Illness In The Community Setting," was presented Sunday at The Interscience Conference on Antimicrobial Agents and Chemotherapy and the Infectious Diseases Society of America annual meeting in Washington, D.C.
At the start of flu season in the last two years, participants were randomly assigned to six weeks of wearing a standard medical procedure mask alone, mask use and hand sanitizer use, or a control group with no intervention. Researchers followed students for incidence of influenza like illness symptoms, defined as cough with at least one other characteristic symptom such as fever, chills or body aches, Monto said.
From the third week on, both the mask only and mask/hand sanitizer interventions showed a significant or nearly significant reduction in the rate of influenza-like illness symptoms in comparison to the control group. The observed reduction in rate of flu-like symptoms remained even after adjusting for gender, race/ethnicity, hand washing practices, sleep quality, and flu vaccination.
Non-pharmaceutical interventions such as hand washing and masks---especially in a pandemic flu outbreak---are critical to study because pharmaceutical interventions such as vaccinations and antivirals may not be available in sufficient quantity for preventing and controlling pandemic influenza outbreaks.
In February 2007, the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services in collaboration with other federal agencies, education, businesses, healthcare and private sectors developed an interim planning guide on the use of Non-Pharmaceutical Interventions (NPIs) to mitigate an influenza pandemic.
The measures include voluntary home quarantine, isolation and treatment of cases, social distancing, personal protection such as face masks and hand hygiene, and school dismissal.
"Although a few of these measures can be evaluated during seasonal influenza outbreaks, many are difficult or impossible to evaluate in advance of a pandemic," Monto said. "However, use of face masks and hand hygiene interventions can be evaluated now, during seasonal influenza outbreaks, which can provide concrete evidence for decision makers."
Further studies are needed to confirm whether mask use may be an effective means of reducing influenza in shared living settings. Since it was not possible to blind subjects, knowledge of the intervention may have influenced influenza-like symptom reporting and therefore the results of this study should be interpreted with caution, Aiello said.
"During year two of the study (2007-2008) a major outbreak of influenza took place," Aiello said. "Forthcoming studies will examine whether results observed during this more severe outbreak mirror those observed during the milder year one influenza season. Influenza virus identification will also be examined as an additional outcome."
EDITORS: Listen and link to a podcast related to this story at
The M-Flu study is a collaboration between SPH, U-M Housing, and University of Michigan Heath Services. The study was funded by Centers for Disease Control and Prevention.
Co-authors include: Genevra Murray, PhD; Rebecca Coulborn, BS; Anne-Michelle Noone, all of the U-M SPH Department of Epidemiology.
For information about M-Flu, including video, news clips, FAQs, visit:

Monday, October 27, 2008

Are you phonagnosic?

28 oct 2008--The first known case of someone born without the ability to recognise voices has been reported in a paper by UCL (University College London) researchers, in a study of a rare condition known as phonagnosia. The UCL team are calling for other people to come forward if they think they have also grown up with the condition.
The case study, reported in the online issue of the journal Neuropsychologia, is of a woman who is unable to recognise people by their voice, including her own daughter whom she has great difficulty identifying over the phone. The woman, known as KH, avoids answering the phone where possible, and for many years has only answered 'booked calls'. KH books calls with friends or co-workers, so she knows who to expect when the telephone rings at a certain time. In the 1980s, KH had a job in which she introduced herself with a different form of her first name so she would know that it was someone related to her job when they called and asked for her using that name.
KH, a 60-year old successful professional woman, was aware from an early age that there was something she couldn't do that others clearly could. But it was only when reading an article in a popular science magazine years later that KH finally understood her lifelong problem. The article discussed prosopagnosia, a condition where people have severe difficulty recognising faces. KH realized she might have the vocal analogue of prosopagnosia, and contacted the magazine, who put her in touch with UCL's Dr Brad Duchaine.
Dr Brad Duchaine, co-author of the paper, says: "Occasionally, people have experienced problems recognising voices following a stroke or brain damage, but this is the first documented case of someone growing up with this condition. We suspect that there are other people out there with similar problems, and we'd like to get in touch with them. If you think you might be phonagnosic, please contact us."
"Voice recognition may not seem as important as face recognition, given that failing to recognise someone in front of you can cause much more social anxiety than not recognising them over the phone. Yet we rely on voice recognition in our day-to-day lives, to identify people on the phone or those speaking on the radio."
In the study, Dr Duchaine and Lucia Garrido of the UCL Institute of Cognitive Neuroscience presented KH with a series of tasks involving the recognition of faces, voices, vocal emotions, speech perception and music. KH struggled to recognise the voices of famous actors and politicians, and also had difficulty learning and recognising new voices. Compared to a control group of volunteers, nearly all of whom identified the voices of Margaret Thatcher, David Beckham, Dawn French, Chris Tarrant, Joanna Lumley, Sean Connery and Ann Widdecombe, KH was only able to identify the voice of Sean Connery.
However, KH performed well on nearly all other tasks. For example, in a test involving emotional sounds - achievement/triumph, amusement, anger, disgust, fear, pleasure, relief, sadness and surprise - KH could identify the emotional state of the person speaking roughly 80 per cent of the time, similar to the control group. KH also did well on all music tasks, identifying famous tunes and discriminating between instruments. KH says that she is able to enjoy and appreciate music, though she usually doesn't recognize singers.
Phonagnosia has only been documented so far in people with brain lesions in the right hemisphere following a stroke or brain damage, and the mechanisms behind it are not well understood. In KH's case, a MRI brain scan showed no evidence of brain damage in regions associated with voice or auditory perception, and her hearing abilities were found to be normal.

Massive flu vaccine dose protects elderly better

WASHINGTON , 27 oct 2008– Giving four times the usual dose of flu vaccine helps protect elderly people better than the usual dose, researchers reported on Sunday, offering a potential solution to the problem of vaccinating seniors.
Recent research has shown the standard flu vaccine does not reduce deaths noticeably among the elderly, who make up most of the 36,000 people a year in the United States who die of influenza each year.
This is likely because their immune systems are not as active as those of younger people.
Dr. Ann Falsey of the University of Rochester School of Medicine and Dentistry and colleagues tried giving a much bigger dose of flu vaccine to see if that might help.
They tested the idea on 3,800 volunteers aged 65 and older and found their bodies produced up to twice as many antibodies -- the immune system proteins that help attack invaders such as viruses -- compared to seniors given the usual vaccine dose.
The patients had many different chronic conditions and many were considered at high risk of complications from flu but the high-dose vaccine appeared to work well in them all, the researchers told a joint meeting of the American Society for Microbiology and Infectious Diseases Society of America.
The study was paid for by flu vaccine maker Sanofi Pasteur, which makes one of the flu vaccines licensed for use in the United States. It hopes to license the higher-dose vaccine for older patients
"The goal is to increase immune response in older adults, since this is one of the populations most at risk for becoming seriously ill or dying from influenza," Falsey said in a statement.
Annual flu vaccines are recommended for most of the U.S. population, including people over the age of 50, people with chronic conditions such as diabetes, children and pregnant women. Globally, seasonal influenza kills between 250,000 and 500,000 people every year.
AIDS treatment should start sooner, study finds

WASHINGTON, 27 oct 2008 – People who have the AIDS virus should start drug treatments sooner than current guidelines recommend, suggests a large new study that could change the care of hundreds of thousands of Americans.
The study found that delaying treatment until a patient's immune system is badly damaged nearly doubles the risk of dying in the next few years compared to patients whose treatment started earlier.
Doctors have thought it would be better to spare patients the side effects of AIDS drugs as long as possible.
"The data are rather compelling that the risk of death appears to be higher if you wait than if you treat," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, which helped pay for the study.
If the results prompt doctors to change practice — as Fauci and other AIDS specialists predict — several hundred thousand Americans who are not taking AIDS drugs now would be advised to start.
The study was reported Sunday at an infectious diseases conference in Washington.
About 56,300 Americans are newly infected with HIV each year. The virus ravages T-cells — "helper cells" of the immune system that fight off germs. Once that happens, people can fall prey to a host of diseases that prove fatal.
Powerful drug combinations available since the mid-1990s have transformed HIV infection into a manageable chronic condition rather than the death sentence it once was. But they can cause heart and cholesterol problems, diarrhea, nausea and other side effects. They also must be taken faithfully or resistance develops and the drugs stop working.
That is why guidelines by the government and the International AIDS Society recommend that patients who are not yet having AIDS symptoms delay starting on the drugs until their T-cell counts fall below 350 per cubic millimeter of blood (healthy people have more than 800).
"There was this thinking, maybe the drugs were worse than the disease. If you could wait as long as you possibly could wait, you would have fewer side effects," said Dr. Robert Schooley, infectious diseases chief at the University of California, San Diego.
The new study is the largest to look at whether that advice is sound. Researchers led by Dr. Mari Kitahata of the University of Washington in Seattle pooled information on 8,374 people in the United States and Canada with T-cell counts of 351 to 500 from 1996 to 2006.
About 30 percent started taking AIDS drugs right away; the rest waited until their T-cell counts fell below 350, as guidelines recommend.
"We found a 70 percent improvement in survival for patients who initiated therapy between 350 and 500" compared to those who waited, Kitahata said.
Two other recent studies found that people who start taking AIDS drugs while their T-cell count is above 350 have a better chance of getting their count back to normal than those who start later. Another key study found that briefly interrupting treatment to give patients "drug holidays" puts them at grave risk.
"These studies have all shown the same thing — that we were starting too late" and need to keep treatment going once it starts, said Schooley. He helped write the AIDS society guidelines and consults for several companies that make AIDS drugs.
The bigger problem is that as many as a third of people diagnosed with HIV only discover they are infected after their T-cell counts already have fallen below 350 and they have serious complications.
"People are still being tested and identified way too late," and the new study shows how important it is to test and find people sooner, said Dr. Daniel Kuritzkes, an AIDS specialist at Brigham and Women's Hospital in Boston.
Newer drug combinations that have come out in recent years have fewer side effects. Also, some require only a pill or two a day, making adherence less of an issue.
These advances and the new study justify a fresh look at the guidelines, Fauci said. He predicted that doctors would not wait for them to change to start treating patients sooner.
The new study's findings do not apply to HIV patients who also have hepatitis, kidney damage or other medical problems, or who are pregnant — doctors have long advised that these people start treatment as soon as they are diagnosed.
On the Net:
AIDS information:
Oral hygiene curbs pneumonia risk in elderly

NEW YORK , 27 oct 2008– Among nursing home residents, having a nursing aide help them maintain good oral hygiene lowers the odds of them dying from pneumonia, a study suggests.
Pneumonia is the leading cause of death in elderly nursing home residents, Dr. Carol W. Bassim and colleagues point out in the Journal of the American Geriatrics Society. "Several studies have shown that poor oral hygiene or inadequate oral care are also associated with pneumonia," they add.
Bassim, now at the National Institute of Dental and Craniofacial Research in Bethesda, Maryland, and her associates studied the impact of enhanced oral hygiene care for residents in two wards at a Florida nursing home compared with residents in two other wards.
Initially, there was no difference in the mortality rate from pneumonia between the two groups. However, patients in the oral care group were older and more disabled than those who did not receive oral care, and once this was taken into account the risk of dying from pneumonia was more than three times higher in patients who did not receive oral care.
Pneumonia in the elderly is often triggered by aspirating saliva or food. It is likely that the risk of pneumonia "depends on the quality and the quantity of the oropharyngeal contents of a patient at the time of respiratory inoculation or introduction," Bassim and colleagues explain.
"The quantity of saliva inhaled and a predisposition to gross aspiration events may not be modified through oral care," they add, "but this study indicates that oral care may be involved in significantly reducing the harmful quality of the intra-oral environment, reducing the risk of a patient dying from pneumonia."
SOURCE: Journal of the American Geriatrics Society, September 2008.
FDA: Incontinence surgery linked to complications

WASHINGTON, 27 oct 2008 – A type of mesh used in surgeries to treat severe incontinence, cases of prolapsed uterus and other women's health problems has been linked to serious but infrequent complications, federal health officials say.
The Food and Drug Administration said this week it has received more than 1,000 reports in the last three years of problems with surgical mesh used to repair pelvic organ prolapse and stress urinary incontinence. The mesh is inserted through the vagina, using minimally invasive surgical techniques.
The complications include erosion of the mesh through vaginal tissue, infection, pain and urinary problems. Some patients have experienced a recurrence of the original condition that the surgery was supposed to resolve. Others have had to undergo repeat surgeries to remove the mesh. Some suffered significant loss of quality of life, including pain during sexual intercourse.
The FDA said it has received reports of complications from nine different manufacturers. It is investigating the cause of the problems, which could include the patient's age and overall health, the mesh material and its size and shape, as well as specific techniques used by surgeons.
In the meantime, federal health officials are advising doctors to:
_Get special training for each mesh placement technique, and be aware of risks.
_Follow patients closely for infection and erosion of tissue.
_Watch for complications that could result from instruments used in surgery.
_Fully inform patients about the possible complications.
On the Net:
FDA information on surgical mesh:
Job, Education May Buffer Against Dementia

27 oct 2008-- Having a higher level of education and a mentally demanding job may help protect against the memory loss that precedes Alzheimer's disease, according to an Italian study.
It included 242 people with Alzheimer's, 72 with mild cognitive impairment, and 144 with no memory problems. People with mild cognitive impairment have memory problems beyond what's normal for their age but not the serious memory problems associated with Alzheimer's disease.
The participants' memory and cognitive skills were tested, and their brains were scanned to look for changes and damage. They were then followed for an average of 14 months, during which time 21 of those with mild cognitive impairment developed Alzheimer's disease.
Among people with the same level of memory impairment, those with more education and more mentally demanding jobs had significantly fewer brain changes and damage than those with less education and less mentally demanding occupations.
This was true in both those with Alzheimer's and those with mild cognitive impairment who developed Alzheimer's, which suggests the cognitive reserve is already in effect during the mild cognitive impairment that precedes Alzheimer's.
"The theory is that education and demanding jobs create a buffer against the effects of dementia in the brain, or a cognitive reserve," study author Dr. Valentina Garibotto, of the San Raffaele University and Scientific Institute and the National Institute of Neuroscience in Milan, said in an American Academy of Neurology news release.
"Their brains are able to compensate for the damage and allow them to maintain functioning in spite of damage. There are two possible explanations. The brain could be made stronger through education and occupational challenges. Or, genetic factors that enabled people to achieve higher education and occupational achievement might determine the amount of brain reserve. It isn't possible to determine which accounts for our findings," Garibotto said.
The study was published in the Oct. 21 issue of Neurology.

Sunday, October 26, 2008

The silver market phenomenon

26 oct 2008--Springer book discusses business challenges and opportunities in times of demographic change
The current shift in demographics – aging and shrinking populations – in many countries around the world presents a major challenge to companies as well as societies. Although this sensitive issue has recently started to draw the attention of scholars, business leaders and politicians, research on the implications of the demographic change on businesses is still in its infancy. One particular result of the demographic shift is the emergence and constant growth of the "silver market" – the market seg-ment more or less broadly defined as the people aged 50 or 55 and older. However, the reactions of countries and industries to this market segment are very different – from still neglecting to proactively developing solutions and offering products for it.
In their book The Silver Market Phenomenon: Business Opportunities in an Era of Demographic Change, the editors Florian Kohlbacher and Cornelius Herstatt offer a thorough and up-to-date analy-sis of the challenges and opportunities in advancing technology, product development, marketing and innovation for elder consumers and employees. Using the Japanese lead market as well as other se-lected countries as role models, experts and researchers point out different answers and reactions to the attractive and promising, but - regarding to product and service offerings - still underdeveloped "silver market". Various illustrations and graphic charts highlight the discussed requirements and needs in the business sector caused by the demographic shift in societies all over the world.
The Silver Market Phenomenon is written for professionals who have an interest in business oppor-tunities in the "silver market" as well as scientists in the field of management science and sociology. But it is also addressing the broad public by making sense of the silver market phenomenon and en-couraging both an active and creative debate and real action in coping with the challenges and op-portunities of the demographic change.
Florian Kohlbacher is a research fellow at the German Institute for Japanese Studies in Tokyo, Japan. He teaches business and management classes at several universities in Tokyo. His research in-terests include knowledge management, product development and innovation management and cross-cultural management. Cornelius Herstatt is Managing Director and full professor of the Institute of Technology and Innovation Management (TIM) at the Hamburg University of Technology in Germany. He teaches classes in product planning as well as management and leadership.
Florian Kohlbacher, Cornelius Herstatt (Eds.): The Silver Market Phenomenon Business Opportunities in an Era of Demographic Change
Study finds genomic changes in the brains of people who commit suicide

Philadelphia, PA, 26 oct 2008– Are genes destiny? Alternatively, are we simply the products of our environment? There is a growing sense that neither of these two possibilities fully captures the essence of the risk for psychiatric disorders. New light is being shed on the complex interaction of genetic and environmental factors as the result of growth in the field of epigenetics. While genetics is the study of how variation in gene sequence or "genotype" influences traits or "phenotypes," epigenetics (epi- from the Greek meaning outside or above) is the study of heritable changes in gene function that may occur without modifying the gene sequence, often as a consequence of environmental exposures.
There are an increasing variety of epigenetic mechanisms that have been described, including the regulation of gene function via the methylation or demethylation of DNA. The study by Drs. Michael Poulter and Hymie Anisman and colleagues in the October 15th issue of Biological Psychiatry illustrates one exciting new example in this area of research, an epigenetic study of depression/suicide. The researchers compared the brain tissues of those who had major depressive disorder and committed suicide to those from a control group who died suddenly, from heart attacks and other causes.
They found the genome in people who have committed suicide as a result of major depression was being chemically modified by a process that is normally involved in regulating cell development. As Poulter explains, "We have about 40,000 genes in every cell and the only reason a skin cell becomes a skin cell as opposed to a heart cell is because only a fraction of the genes are being expressed, and the other genes not being expressed are shut down by this genetic process of DNA methylation." The rate of methylation in the suicide brains was found to be nearly ten times that of the control group, and the gene being shut down was a neurotransmitter receptor that plays a major role in regulating behavior. John H. Krystal, M.D., Editor of Biological Psychiatry and affiliated with both Yale University School of Medicine and the VA Connecticut Healthcare System, comments, "This is exciting new evidence that genetic and environmental factors may interact to produce specific and long-lasting modifications in brain circuits. Further, these modifications may shape the course of one's life in extremely important ways, including increasing the risk for major depressive disorder and perhaps suicide."
"The whole idea that the genome is so malleable in the brain is surprising, because brain cells don't divide. You get dealt your neurons at the start of life, so the idea that there are still epigenetic mechanisms going on is pretty unusual," adds Poulter. The authors note that these observations open an entirely new avenue of research and potential therapeutic interventions.
Notes to Editors:
The article is "GABAA Receptor Promoter Hypermethylation in Suicide Brain: Implications for the Involvement of Epigenetic Processes" by Michael O. Poulter, Lisheng Du, Ian C.G. Weaver, Miklós Palkovits, Gábor Faludi, Zul Merali, Moshe Szyf, and Hymie Anisman. Dr. Poulter is affiliated with the Molecular Brain Research Group, Robarts Research Institute, Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada. Dr. Poulter is also affiliated with, along with Drs. Merali and Anisman, the Institute of Neuroscience, Department of Psychology, Carleton University, Ottawa, Ontario, Canada. Dr. Merali, along with Dr. Du, is also from the Departments of Psychology and Psychiatry, University of Ottawa Institute of Mental Health Research, Ottawa, Ontario, Canada. Drs. Weaver and Szyf are with the Department of Pharmacology and Therapeutics (ICGW, MS), McGill University, Montreal, Quebec, Canada. Dr. Palkovits is affiliated with the Neuromorphological and Neuroendocrine Research Laboratory (MP), Hungarian Academy of Sciences and Semmelweis University, and Dr. Faludi is with the Department of Clinical and Theoretical Mental Health, Semmelweis University, Budapest, Hungary. The article appears in Biological Psychiatry, Volume 64, Issue 8 (October 15, 2008), published by Elsevier.

Study: Elderly women can increase strength but still risk falls

Research subject Ellen Prouty, 80, participates in a strength-building study conducted by Dain LaRoche, assistant professor of exercise science at UNH.

DURHAM, N.H., 26 oct 2008 – Elderly women can increase muscle strength as much as young women can, a new study from the University of New Hampshire finds, indicating that decline in muscle function is less a natural part of the aging process than due to a decline in physical activity.
The research, published in the journal Medicine & Science in Sports & Exercise, compared strength gains of inactive elderly women and inactive young women after both groups participated in an eight-week training regime. Yet while the two groups increased similar percentages of strength, the older group was far less effective in increasing power, which is more closely related to preventing falls.
"Power is more important than strength for recovery from loss of balance or walking ability," says Dain LaRoche, assistant professor of exercise science at UNH and the lead author of the study. Preventing falls, which occur in 40 percent of people over 65 and are the top reason for injury-related emergency room visits, is the driving force behind LaRoche's research agenda.

Researcher Dain LaRoche, assistant professor of exercise science at UNH, works with Jean Haigh.
Click here for more information.
LaRoche compared the initial strength of 25 young (18 – 33) and 24 old (65 – 84) inactive women then had both groups participate in resistance training on a machine that targeted knee extensor muscles, which are critical for walking, stair-climbing, or rising from a chair. "They're what let you live on your own," he says.
After eight weeks of training, the older group not only increased their strength by the same percentage as the younger group, they achieved gained strength similar to a control group of young inactive women. But the older group's ability to increase power – force over time – was significantly less than the younger group's; the elderly women saw only a ten percent increase in power versus the younger women's 50 percent increase.
"It's somewhat troublesome that these older individuals had a reduced capacity to increase performance that's so closely associated with falls," says LaRoche. It seems that the key to muscle power in the elderly is to maintain it over the lifespan rather than try to develop it later in life, he says.
Acknowledging that the type or frequency (six sets, three times per week) of his training protocol may have affected the older group's ability to make gains in power, LaRoche is continuing to research older women's capacity to develop muscle power. As baby boomers age, doubling the over-65 population by 2030, research that supports fall prevention and independent living is a growth area. "I tell my students, 'there's room for you in this field,'" says LaRoche.
Of those 40 percent of elderly people who will fall, research has shown that 20 to 30 percent suffer injuries that reduce mobility, independence and longevity. Health care cost of a fall injury totals nearly $20,000, and following a hip fracture, life expectancy is just two years.
LaRoche's own interest in fall prevention in the elderly arose after helping his parents and sister care for his completely sedentary grandmother, helping her stay in her own home until she died at age 93. She broke both hips, lost six inches of height, and had osteoporosis so severe that a caregiver accidently crushed several of her ribs just helping her out of a chair.
"There's a gap between life expectancy and quality of life in older age," LaRoche says. "We can improve that a lot with physical activity."
An abstract of the research, "Elderly Women Have Blunted Response to Resistance Training Despite Reduced Antagonist Coactivation," is available to download here: