Sunday, November 30, 2014

Why do so many seniors with memory loss and dementia never get tested?

memory decline
Credit: Public Domain
30 nov 2014--Despite clear signs that their memory and thinking abilities have gone downhill, more than half of seniors with these symptoms haven't seen a doctor about them, a new study finds.
University of Michigan researchers and their colleagues say their findings suggest that as many as 1.8 million Americans over the age of 70 with dementia are not evaluated for cognitive symptoms by a medical provider, which in some patients can lead to a failure to uncover modifiable causes of thinking or memory impairment.
The study, published online in Neurology, the medical journal of the American Academy of Neurology, documents a clear lack of clinical testing for seniors with signs of cognitive problems.
Those who were married, and those with the worst levels of dementia symptoms, were more likely to have had their memory and thinking ability evaluated by a primary care doctor, neurologist or psychiatrist. The study included people withmild cognitive impairment through severe dementia, from all causes.
"Early evaluation and identification of people with dementia may help them receive care earlier," says study author Vikas Kotagal, M.D., M.S., who sees patients at the University of Michigan Health System and is an assistant professor in the U-M Medical School's Department of Neurology. "It can help families make plans for care, help with day-to-day tasks including observed medication administration, and watch for future problems that can occur. In some instances, these interventions could substantially improve the person's quality of life."
Free dementia clinical testing now available to all seniors in Medicare
The data in the study come from before the start of Medicare's free annual wellness exams for seniors, which began in 2011 under the Affordable Care Act and are required to include a cognitive evaluation.
Even so, says Kotagal, "The results of this study have implications in both primary care and specialty care settings. Recognizing cognitive impairment in older individuals is important, and physicians should explore reasons why dementia has occurred and communicate these findings clearly with patients and family members so that they can take this information with them when they leave the office."
More about the study population
The study was part of a larger, nationally representative, community-based study called the Health and Retirement Study, based at the U-M Institute for Social Research. From that study, 856 people age 70 and older were evaluated for dementia, including a video interview and standard testing. For each participant, a spouse, child or other person who knew the person well was asked whether the participant had ever seen a doctor for any concerns about memory or thinking.
A total of 297 of the participants met the criteria for dementia. Of those, 45 percent had seen a doctor about their memory problems - and the more severe their issues, the more likely they had had that evaluation. By comparison, 5 percent of those with memory and thinking problems that did not meet the criteria for dementia had been tested by a doctor for those issues, and 1 percent of those with normal memory and thinking skills had undergone testing.
People who were married were more than twice as likely to undergo cognitive evaluations as people who were not married. Why? "It's possible that spouses feel more comfortable than children raising concerns with their spouse or a health care provider," said Kotagal. "Another possibility could be that unmarried elderly people may be more reluctant to share their concerns with their doctor if they are worried about the impact it could have on their independence."
Other demographic factors did not have an effect on whether or not people had cognitive evaluations, including race, socioeconomic status, the number of children and whether children lived close to the parents. "Our results show that the number and proximity of children is no substitute for having a spouse as a caregiver when it comes to seeking medical care for memory problems for a loved one," Kotagal said.
Next stop: Finding out why
While the study doesn't answer the question of why people with signs of dementia don't get tested, Kotagal suggests that many factors may be involved - - some driven by the patient, some by physicians, and others by the nature of our health system.
Many patients and physicians, he says, may perceive that clinical cognitive exams don't have enough value. But experts have shown that they can improve medical outcomes and help reduce societal costs.
For instance, knowing that a stroke or vascular issues in the brain caused dementia means patients can work to control risk factors like blood pressure that might otherwise cause it to keep worsening.
The next steps in research on this topic are to find out why patients don't get tested, and what parts of the diagnostic process are most valuable to patients and caregivers.
Provided by University of Michigan Health System

Saturday, November 29, 2014

Moderate coffee consumption may lower the risk of Alzheimer's disease by up to 20 percent, study suggests

Credit: George Hodan/public domain
29 nov 2014--Drinking 3-5 cups of coffee per day may help to protect against Alzheimer's Disease, according to research highlighted in an Alzheimer Europe session report published by the Institute for Scientific Information on Coffee (ISIC), a not-for-profit organisation devoted to the study and disclosure of science related to coffee and health.
The number of people in Europe aged over 65 is predicted to rise from 15.4% of the population to 22.4% by 20251 and, with an aging population, neurodegenerative diseases such as Alzheimer's Disease are of increasing concern. Alzheimer's Disease affects one person in twenty over the age of 65, amounting to 26 million people world-wide
Recent scientific evidence has consistently linked regular, moderate coffee consumption with a possible reduced risk of developing Alzheimer's Disease. An overview of this research and key findings were presented during a satellite symposium at the 2014 Alzhemier Europe Annual Congress.
The session report from this symposium highlights the role nutrition can play in preserving cognitive function, especially during the preclinical phase of Alzhemier's, before symptoms of dementia occur. The report notes that a Mediterranean diet, consisting of fish, fresh fruit and vegetables, olive oil and red wine, has been associated with a reduced risk for development of Alzheimer's Disease. Research suggests that compounds called polyphenols are responsible for this protective effect, these compounds are also found in high quantities in coffee.
Epidemiological studies have found that regular, life-long moderate coffee consumption is associated with a reduced risk of developing Alzheimer's Disease with the body of evidence suggesting that coffee drinkers can reduce their risk of developing the disease by up to 20%. A recent paper, suggested that moderate coffee consumption was associated with a lower risk of developing dementia over a four year follow-up period, however the effect diminished over longer follow up period.
Finally, the report explores the compounds within coffee, which may be responsible for this protective effect, identifying caffeine and polyphenols as key candidates. Caffeine helps prevent the formation of amyloid plaques and neurofibrulary tangles in the brain - two hallmarks of Alzheimer's Disease. In addition to this, both caffeine and polyphenols reduce inflammation and decrease the deterioration of brain cells - especially in the hippocampus and cortex, areas of the brain involved in memory.
Dr. Arfram Ikram, an assistant professor in neuroepidemiology at Erasmus Medical Centre Rotterdam, presented his findings at the symposium. He commented: "The majority of human epidemiological studies suggest that regular coffee consumption over a lifetime is associated with a reduced risk of developing Alzheimer's Disease, with an optimum protective effect occurring with three to five cups of coffee per day."
Dr. Iva Holmerova, vice chairperson of Alzheimer Europe, commented: "The findings presented in this report are very encouraging and help to develop our understanding of the role nutrition can play in protecting against Alzheimer's Disease. Coffee is a very popular beverage enjoyed by millions of people around the world and I'm pleased to know that moderate, lifelong consumption can have a beneficial effect on the development of Alzheimer's Disease."
The session report details the key scientific research presented by Dr. Neville Vassallo, Dr. Arfan Ikram and Dr. Astrid Nehlig during a session entitled: Nutrition and Cognitive Function, which took place on the 23rd October in Glasgow, UK.
Provided by Institute for Scientific Information on Coffee

Friday, November 28, 2014

Help beat Alzheimer's with the click of a mouse

Help beat Alzheimer's with the click of a mouse
UA researchers Lee Ryan (left) and Betty Glisky created an online memory test that they hope will provide data that helps them better understand Alzheimer's disease. Credit: Beatriz Verdugo/UANews

28 nov 2014--The ambitious MindCrowd project, which includes two UA researchers, aims to gather data from 1 million people across the globe.
If you've got 10 minutes and an Internet connection, you may be able to help researchers answer pressing questions about Alzheimer's disease.
As many as 5 million Americans are living with Alzheimer's, and while scientists are learning more about the disease every day, its exact cause remains unknown.
Researchers, including two neuropsychologists from the University of Arizona, are now leveraging the power of the Internet to collect information they hope will help them to better understand the human memory and possible risk factors for Alzheimer's.
The ambitious project, called MindCrowd, aims in its first phase to engage an unprecedented 1 million people across the globe in online memory testing. Anyone can take the test, which takes about 10 minutes to complete on the MindCrowd website.
Those who meet certain criteria in the first phase of testing may later be invited to participate in the project's second phase, which will include additional online memory tests, as well as genetic testing of participants' saliva.
Researchers ultimately hope to be able to identify genetic markers that are linked to learning and memory, which could be a major step toward understanding and treating Alzheimer's disease and other brain disorders.
A global reach
MindCrowd is a collaborative effort among the Translational Genomics Institute in Phoenix (also known as TGen), the UA and the Alzheimer's Prevention Initiative.
Professors Elizabeth Glisky, head of the UA psychology department, and Lee Ryan, associate head of the UA psychology department and associate director of the UA's Evelyn F. McKnight Brain Institute, developed the online test.
More than 50,000 people have taken the test as of this month, which is National Alzheimer's Disease Awareness Month.
"We're pretty excited about this. We don't know of anybody else who's done anything like this or been able to get this many people participating in a research study," said Glisky, also a member of the UA's Evelyn F. McKnight Brain Institute.
Help beat Alzheimer's with the click of a mouse
As many as 5 million Americans are living with Alzheimer's disaese. Researchers are using the Internet to conduct memory testing that may help them solve the puzzle of what causes the disease.
The MindCrowd website was created with the average Internet user in mind. Anyone can take the test from the comfort of home, and they will instantly see their results and how they stack up against others.
"We designed our study site from a marketing and user experience perspective, very much as if we were a business asking our customers to 'do something,' instead of designing it to look and feel like what it really is, a scientific study run by scientists who work in academia," said MindCrowd principal investigator Matt Huentelman, an associate professor in TGen's Neurogenomics Division. "That really is part of our success, I believe—the user experience was foremost in our mind because that would drive participation."
The MindCrowd test is now being translated into as many as 10 different languages to make it more accessible to people across the globe.
"Most studies are done in a confined area, but this is an opportunity to get data from all over the world," Glisky said. "Using the Internet, we have an opportunity to see across really large numbers of people with really different ages, different backgrounds, different histories, different everything. It really gives us an opportunity to look at a lot of variables that we can't look at as easily with a population that's confined to one region."
The study's cross-cultural findings could be a significant contribution to the Alzheimer's literature, Ryan said. "The majority of the studies out there focus on Caucasian individuals, so we don't really know as much about cognitive functioning in other groups."
Initial findings on gender, education, family history
The MindCrowd team already has some initial findings, which Huentelman presented last week during the Society for Neuroscience's annual meeting in Washington, D.C.
Among those findings: Women performed better on the memory test than men across all age groups, from 18 to 85. Individuals who reported having a higher level of education also tended to have higher scores. And people who reported having a family history of Alzheimer's disease scored consistently lower than those who did not report a family history of the disease.
"When you control for all other factors, you see that individuals with a family history of Alzheimer's disease do more poorly on the test, even in the youngest ages, and we're very interested in that," Ryan said.
Help beat Alzheimer's with the click of a mouse
Anyone can take the MindCrowd test, developed by UA researchers to collect information about the brain and memory.
The first-phase testing focuses only on verbal memory, asking participants to memorize word pairings. Phase-two tests, which also are being developed by Glisky and Ryan, will look at verbal, visual and spatial memory, for a broader scope.
Also during phase two, which is expected to launch sometime in the spring, TGen will conduct genetic testing of saliva samples mailed in by selected participants. Additional data will be collected through brain scans of certain participants, done at the UA.
"The ultimate goal is to figure out to what extent there is a genetic component here," Glisky said. "We know there are some genetic components but not one that's absolute."
The gene variant ApoE4 is a known genetic risk factor for Alzheimer's disease. However, not everyone with the gene variant will develop the disease, and not everyone who develops the disease has the gene variant.
"A significant number of people—about half—with a family history of Alzheimer's are not E4 positive, so it's a mystery," Ryan said. "Maybe there's another specific gene that nobody's found yet, or it's a cluster of genes or some combination or profile of genes. You would need really large numbers of people to find those kinds of patterns, so we're pretty excited about exploring that."
By evaluating the memory test results alongside genetic data, the researchers also will be able to look at possible relationships between genetics and demographic or environmental factors, Glisky said.
"The answers to the questions about Alzheimer's disease are going to be very complicated," she said. "So far, we haven't been wildly successful at coming up with treatments, and that is at least partly because we don't fully understand the disease and the factors that are involved."
Using the Internet to crowdsource such a large and diverse number of study participants hopefully will give researchers enough data to start answering some of the many questions that remain about Alzheimer's, Glisky said.
"I think this study could lead towards improved genetic treatments, drug treatments, environmental treatments, cognitive treatments, behavioral interventions down the road," she said. "It could be the first step to be able to think about prevention and treatment."
Provided by University of Arizona

Thursday, November 27, 2014

Benefits of regular vitamin D tests remain unproven, study says

Vitamin D
27 nov 2014--Experts said Monday regular tests for vitamin D levels are not proven to be beneficial or harmful, despite previous research warning of damaging effects of vitamin D deficiencies in adults.
Studies have found that low levels of the vitamin can increase the risk of bone fractures, heart disease, colorectal cancer, diabetes, depression, Alzheimer's disease and death.
But the US Preventative Services Task Force (USPSTF) said there was no evidence that getting regularly tested for sufficient vitamin D decreased health risks.
"Current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults," USPSTF said in a statement.
"We found no direct evidence on effects of screening for vitamin D deficiency versus no screening on clinical outcomes."
The experts from the federal panel said that tests should be ordered on a case-by-case basis and should not be conducted universally.
People get vitamin D from sunlight and from oily fish such as salmon, tuna or mackerel, as well as milk, eggs and cheese. It is also available in supplement form and is a key component for healthy bones and muscle strength.
A 2010 report by the US Institute of Medicine concluded that vitamin D was essential for bone health but did not find that a deficiency causes disease.
The Institute recommends 600 milligrams per day for adults under 70 years old and 800 milligrams for older people.
A recent study in the British Medical Journal based on medical records from 95,766 people in Denmark found that reduced vitamin D levels increased the risk of mortality by 30 percent and boosted the risk of cancer-related deaths by 40 percent.
However, the researchers found no link between vitamin D deficiency and cardiovascular deaths.
About one billion around the globe are thought to have low vitamin D levels.
The elderly can be particularly vulnerable to such a deficiency because their skin is less adept at converting sunlight into vitamin D.

Wednesday, November 26, 2014

More aging boomers, but fewer doctors to care for them

More aging boomers, but fewer doctors to care for them
We need to rethink care for the elderly. Credit: Lighthunter/Shutterstock

26 nov 2014--By 2030, the last of the Baby Boomer generation will have turned 65 years old, putting the population of "senior boomers" in the United States at approximately 71 million. Currently, only about 7,000 certified geriatricians – physicians specializing in the care of older adults – are practicing in the US. That's about one geriatrician for every 10,000 of these expected seniors, assuming that the number of geriatricians remains stable. However, the number of new trainees in the field of geriatrics is going down.
In 2010 there were 1,000 fewer geriatricians in practice than a decade earlier. To compound this problem, only about 220 physicians complete geriatrics fellowship training programs.
Geriatricians often act as primary care doctors, and at times as specialist consultants, for patients who are advancing in age and may require targeted, specialized care to maintain function and quality of life. Geriatricians are attuned to the specific needs of the patient at all stages of aging, regardless of what or how many chronic conditions that patient may have. As America's population ages, these doctors will play a critical role in caring for senior citizens.
Many factors contribute to the declining number of geriatric specialists. Geriatrics fellowships require extra years of training. Despite their additional training, geriatricians are among the lowest paid physicians across all medical specialties. This is largely due to the fact that reimbursements for geriatrics services are lower, which translates to lower pay for the geriatrician. Further, the specialty also suffers from a general lack of prestige. These are all reasons why medical students aren't as interested in pursuing geriatrics as a specialty.
Without a fundamental change in public policy, financial reimbursement, and training this is unlikely to change anytime soon. So, how can we care for an aging population while our pool of geriatricians is shrinking?
New models of care
The shortage of geriatricians does not necessarily condemn the elderly to poor medical care. New models of care are emerging that focus on better coordination of care for older adults that will help improve their likelihood of remaining healthy.
If we want care for older adults that is more than just "good enough," we need more boots on the ground to provide that care. We don't just need more geriatricians. We need more pharmacists, nurses, nurse practitioners and physician assistants trained in the special needs of the older patient. There are many examples of new care models that demonstrate the effectiveness of comprehensive, coordinated care for older adults.
In hospital settings for example, Acute Care for the Elderly (ACE) units use teams made up of nurses and nurse practitioners, physicians, social workers and other health-care professionals. These interdisciplinary teams use coordinated care principles to ensure better patient outcomes at a lower cost than traditional care, with a relatively small investment of geriatrician time.
Another program, Nurses Improving Care for Healthsystem Elders (NICHE) empowers nursing leaders to help health-care organizations improve the care of older adults by implementing principles designed to stimulate culture change within health-care systems that help make hospitals more senior-friendly. At present, over 575 hospitals have NICHE designation.
In outpatient settings, Program of All Inclusive Care for the Elderly (PACE) improves patient satisfaction while reducing use of institutional care and overall costs for poor, functionally impaired older adults by improving coordination between community and clinical services.
In each case, the geriatrician's expertise is amplified throughout health-care organizations through care systems, better use of resources, technology, financial incentives and teamwork.
Responding to reality
The recruitment and training of geriatricians is an important part of the vision for excellent health care for elderly adults in the future. However, that is only part of the issue. Our health-care system needs to respond the realities of caring for older patients.
It takes more time to care for medically complex, often functionally or cognitively impaired older patients. This is an under-appreciated fact about geriatric care. Clinicians must be able to operate in a system that is conducive to coordinated, patient centered care. Ideal systems allow practitioners to take the additional time needed to provide the best possible care.
The extra time it takes to provide proper care for seniors also has to be accounted for in reimbursement mechanisms. If not, there is a risk that the services older patients need will only be available to those who can afford to pay extra for them.
What older adults need in order to optimize function and quality of life transcends simply the medical issues and extends to policies and infrastructure of our health-care systems and communities. Whether our society prioritizes these needs sufficiently to meet them remains an open question.
Source: The Conversation

Monday, November 24, 2014

People experience recurring life crises at the start of each new decade in age, study says

Credit: George Hodan/public domain

24 nov 2014—New research from NYU Stern School of Business Professor Adam Alter and UCLA Anderson School of Management Professor Hal Hershfield shows that when adults approach a new decade in age (i.e., at ages 29, 39, 49 or 59), they search for existential meaning and behave in ways that can be constructive or destructive.
In six studies looking at exercise, extramarital affairs and suicide rates among adults between the ages of 25 and 64, the researchers determine that certain numerical ages inspire greater self-reflection than others. Further, the authors suggest that people across dozens of countries and cultures are prone to making significant life decisions as they approach each new decade.
Background on the studies and key results:
  • Studies 1 & 2: The authors examined data from 42,063 adults from more than 100 countries, who completed the World Values Survey and reported how often they questioned the meaning of life. They found that people who were entering a new decade in their lives are more likely to question whether their lives were meaningful.
  • Study 3: Professors Alter and Hershfield categorized more than 8 million male users registered on a dating website that caters to people who are seeking extramarital affairs. They found that men aged 29, 39, 49 and 59 were nearly 18% more likely than men at other ages to register on the site.
  • Study 4: The researchers examined the number of suicides per 100,000 individuals across the US from 2000 to 2011. Suicide rates were 2.4% higher among individuals whose age ended in a 9 than among people whose ages ended in any other digit.
  • Study 5: The professors collected data from Athlinks, a website that compiles running race times, and found that runners ran about 2% faster at ages 29 and 39 than during the two years before and after those ages.
  • Study 6: The authors examined the ages of 500 first-time marathon runners randomly drawn from the Athlinks website, and found 25% more "9-enders" than runners whose ages ended in any other digit.
"People are more apt to evaluate their lives as a chronological decade ends, and, as a result, more likely to make life-altering decisions," explain the authors. "As we age, it's good to understand this propensity so we're more likely to make constructive rather than destructive choices." Professors Alter and Hershfield also posit that the implications of their studies could be significant for consumers. "Our research suggests that people who are nearing the end of a decade may be more likely to make large purchases (e.g., buy life insurance, invest in retirement savings, pursue cosmetic surgery, etc.). Being aware of the tendency to do so can help consumers decide if they are making such decisions for the right reasons."
The article, "People Search for Meaning When They Approach a New Decade in Chronological Age," was published on November 17 in the Proceedings of the National Academy of Sciences.
More information: "People search for meaning when they approach a new decade in chronological age." PNAS 2014 ; published ahead of print November 17, 2014, DOI: 10.1073/pnas.1415086111
Provided by New York University

Sunday, November 23, 2014

Senior-to-senior aggression common in US nursing homes

Senior-to-senior aggression common in U.S. nursing homes
Up to one in five residents involved in unpleasant, sometimes inappropriate confrontations, N.Y. study suggests.
22 nov 2014—Elderly adults who live in nursing homes may commonly deal with aggressive or inappropriate behavior from fellow residents, a new study suggests.
The study of 10 centers in New York state found that, in the space of just one month, nearly 20 percent of residents were involved in some type of incident with a fellow resident.
Most often, it was a verbal clash, with someone yelling or cursing at another resident. In other cases, the incidents involved hitting or kicking—or, in a small percentage, inappropriate touching.
"We discovered that this is a much more prevalent problem than any of us realized," said researcher Karl Pillemer, a gerontology professor at Weill Cornell Medical College in New York City.
Results of the study were presented at a recent meeting of the Gerontological Society of America. Findings from studies presented at meetings are generally considered preliminary until they've been published in a peer-reviewed journal.
Pillemer's research also zeroed in on the residents who were most likely to be involved in incidents. "Typically," Pillemer said, "they were people who were in the moderate stages of dementia, but were still physically able to get around."
That makes sense, according to Dr. Laura Mosqueda, a geriatrics specialist who was not involved in the study. Mosqueda directs the National Center on Elder Abuse at the University of Southern California, in Los Angeles.
Nursing home residents with dementia commonly become confused, and may act out aggressively—but only if they have the physical capacity to do so, explained Mosqueda.
"I think the point this study raises is, who's responsible or accountable for this behavior?" Mosqueda said. "It's not the residents. In my view, it's the owners and people running the facilities. Do they have enough staff with the appropriate training?"
Still, Mosqueda also cautioned against an alarmist interpretation of the findings.
She noted that one of the more common forms of "aggression" in this study was "unwelcome entry" into another resident's room or going through another person's possessions.
"I'm not saying that behavior is OK," Mosqueda said. But, she added, it's common for dementia patients to become confused and unintentionally wander into a room that is not theirs.
For the study, Pillemer's team randomly selected 10 nursing homes in New York state that housed more than 2,000 residents altogether. Through staff interviews, surveys of residents and direct observation, the researchers estimated that over one month, nearly 20 percent of residents were involved in at least one incident of aggressive or inappropriate behavior.
Overall, 16 percent were involved in a verbal clash, while 10.5 percent had an invasion-of-privacy issue. Almost 6 percent were involved in a physical incident, like kicking, biting or hitting; and just over 1 percent experienced a sexual incident, like inappropriate touching, according to the researchers.
Pillemer said his team did not try to distinguish between "perpetrator" and "victim."
"It's often difficult to know," he noted. "And when you're talking about people with dementia, the traditional terms of 'perpetrator' and 'victim' don't hold up anyway."
One surprise, Pillemer said, was that men and women were equally likely to be involved in these incidents. "We'd suspected that it might be more common among men, but that wasn't the case," he said.
Pillemer added that the findings highlight an issue for nursing home administrators to address. Facilities need not only enough staff members, but also adequately trained ones, he said.
"We believe that the first line of defense is appropriate staff training," Pillemer said. He added that right now, staff often feel frustrated by incidents between residents, but "relatively helpless" in preventing them.
Beyond training, Pillemer said nursing homes could look at their design, and see whether "crowding" in hallways or shared areas could be minimized. "They could also pay attention to how they assign roommates," he said. "Are there some residents who are likely to do better without a roommate?"
As for families, Pillemer and Mosqueda said awareness of the issue is key. "I'd suggest visiting often and spending time not only in your family member's room, but also the public areas," Mosqueda said. If you notice a problem, tell the staff, she advised.
Pillemer agreed, adding, "If your family member complains of being bullied or being scared of another resident, take it seriously and tell the staff."
"Remember," Pillemer noted, "the staff is probably as concerned about these issues as you are."
More information: The U.S. National Institute on Aging has advice on choosing a nursing home.

Friday, November 21, 2014

Nearly 30% of world population is overweight: study

Credit: Peter Häger/Public Domain

21 nov 2014--More than 2.1 billion people globally—or nearly 30 percent of the world's population—are now overweight or obese, with the figure set to rise further by 2030, according to a study published Thursday.
Obesity is now blamed for around 5 percent of all deaths worldwide and has a similar negative effect on the global economy to smoking and armed conflict, according to the report by consultants McKinsey Global Institute.
The study predicted that almost half of the world's adult population will be overweight or obese by 2030.
It called for a "coordinated response" from governments, retailers and food and drink manufacturers, arguing that targeted action could bring 20 percent of obese people back to normal weight within a decade.
"Obesity is a major global economic problem caused by a multitude of factors," it said.
"Today obesity is jostling with armed conflict and smoking in terms of having the greatest human-generated global economic impact."
The report identified 74 interventions that it argued will help tighten waistlines around the world.
Recommendations include limiting the size of portions in packaged fast food, parental education and introducing healthy meals in schools and workplaces.
According to the report, obesity now costs the global economy $2 trillion in healthcare and lost productivity—or 2.8 percent of global GDP—$100 billion less than both smoking and armed conflict.
Britain provided the report's main case study, and was found to have three percent of its GDP wiped off each year due to obesity, the biggest drag on the country's economy after smoking.
The combined annual cost of obesity-linked healthcare and lost output reaches £47 billion ($73.8 billion, 58.7 billion euros).
A person is considered obese if they have a body mass index (BMI), which divides your weight in kilograms by your height in metres squared, above 25.
Alison Tedstone, chief nutritionist at Public Health England, called obesity a complex problem that required "action across individual and societal levels involving industry, national and local government and the voluntary sector.
"Today 25 percent of the nation is obese and 37 percent is overweight," she added.
"If we reduce obesity to 1993 levels, where 15 percent of the population were obese, we will avoid five million disease cases and save the NHS alone an additional £1.2 billion by 2034."
McKinsey plans to carry out emerging world case studies in China and Mexico, but believes its recommendations will be applicable worldwide.
The report concluded that drastic action was needed "as obesity is now reaching crisis proportions".

Thursday, November 20, 2014

Publication's debut addresses pain among older adults

The first issue of a new publication series from The Gerontological Society of America (GSA) called From Policy to Practice explores pain as a public health problem and takes a look at how various policies impact the care provided to patients in a range of practice settings. It also provides readers with an overview of provisions of the Affordable Care Act that address pain research, education, training, and clinical care—as well as steps taken to implement those provisions.
20 nov 2014--"An Interdisciplinary Look at the Potential of Policy to Improve the Health of an Aging America: Focus on Pain," as this inaugural installment is titled, aims to ensure that researchers, practitioners, educators, and policy makers are aware of major policy issues at federal, state, and local levels that impact the prevention, assessment, and treatment of pain, as well as the social and practical supports required by older adults with pain. Support for the publication was provided by Purdue Pharma.
The issue was assembled by an expert panel chaired by GSA member Mary Beth Morrissey, PhD, MPH, JD, of Fordham University.
"This publication will serve as a resource for policy makers, researchers and practitioners dealing with the complexities of older adults' pain experience in diverse social and cultural contexts," Morrissey said. "It may also help to inform the design of broad-based policy and practice responses that encompass both medical and social services and supports."
Joining Morrissey as faculty for the publication were GSA Fellows Ann L. Horga, PhD, or the University of Florida; Edward Alan Miller, PhD, MPA, of the University of Massachusetts, Boston; and Joshua M. Wiener, PhD, of RTI International.
"This publication addresses how public policy helps to shape responses by medical and long-term care providers to the needs of older people," Wiener said. "My hope is that this publication will draw attention to the regulatory and funding constraints and incentives that currently exist and motivate changes to reduce pain among older people in the community, hospitals and nursing homes, especially at the end of life."
Chronic pain affects about 100 million American adults—and costs the nation up to $635 billion each year in medical treatments and lost productivity, according to the 2011 Institute of Medicine (IOM) report "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research," which went on to identify older adults as a population at risk for inadequate assessment and treatment of pain.
Morrissey called the release of the new GSA publication very timely, as it follows on the heels of the recently released IOM report titled "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life," which recommends integrated financing of medical and social services for individuals with serious advanced illness.
"GSA's primary focus in this 2014 report is bringing attention to the urgent needs of older adults living with pain, especially chronic pain that is often accompanied by multiple chronic illnesses," Morrissey said. "These complex needs call for both person-centered and public health responses."
The new issue of From Policy to Practice goes on to examine current policies in the context of the Affordable Care Act implementation and structural incentives for integrated and coordinated care, and highlight the role of policy in helping to eliminate pain disparities and assure equitable access to appropriate pain care and management for older Americans.
Morrissey additionally emphasized the value of the interdisciplinary approach taken by this publication.
"There is robust evidence showing that pain is a multidimensional experience involving the complex interaction of sensory, cognitive, emotional, social, cultural and spiritual dimensions," she said. "In light of this, it is essential that knowledge and expertise from across the various disciplines—for example, medicine, nursing, social work, psychology, pharmacy, and rehabilitation therapy—be brought to bear on the challenges pain poses for older adults and their family caregivers through interprofessional and interdisciplinary collaboration."
Provided by The Gerontological Society of America

Wednesday, November 19, 2014

Low vitamin D levels increase mortality

New research from the University of Copenhagen and Copenhagen University Hospital shows that low blood vitamin D levels increase mortality. The study included 96,000 Danes and was recently published in the distinguished British Medical Journal.
19 nov 2014--Vitamin D deficiency is generally associated with an increased risk of poor bone health. However, recent studies have shown that low levels of this important vitamin also involve an increased risk of other diseases and higher mortality rates. For the very first time, a brand new scientific study has established a causal relationship between low vitamin D levels and increased mortality. The researchers have not only established a statistical relationship as in previous studies.
- We have conducted a major Danish study, in which we have examined the connection between genes associated with permanent low levels of vitamin D and mortality. We can see that genes associated with low vitamin D levels involve an increased mortality rate of 30 per cent and, more specifically, a 40 per cent higher risk of cancer-related deaths. An important factor in our study is that we have established a causal relationship, says Shoaib Afzal, Medical Doctor at Herlev Hospital, Copenhagen University Hospital.
96,000 Danes from large-scale population studies
In the scientific study, which is based on the Copenhagen City Heart Study and the Copenhagen General Population Study, vitamin D levels were measured using blood samples from both studies, and specific genetic defects were examined. All participants were followed in the 100% complete Danish registers for mortality from 1976 until today.
- In previous studies, a close statistical relationship has been established between low vitamin D levels and increased mortality rates. However, the fact that vitamin D deficiency can be a marker for unhealthy lifestyles and poor health in general may have distorted the results. This led to our current study, which was based on an examination of the participants' genes - genes which cannot be explained by unhealthy lifestyles, says Børge Nordestgaard, Clinical Professor at the Faculty of Health and Medical Sciences, University of Copenhagen, and Chief Physician at Copenhagen University Hospital research from the University of Copenhagen and Copenhagen University Hospital shows that low blood vitamin D levels increase mortality. The study included 96,000 Danes and was recently published in the distinguished British Medical Journal. Credit: The Faculty of Health and Medical Sciences, University of Copenhagen
Preventive treatment?
- Our study shows that low vitamin D levels do result in higher mortality rates, but the best way of increasing vitamin D levels in the population remains unclear. We still need to establish the amount of vitamin D to be added, as well as how and when it is most effective: Should we get vitamin D from the sun, through our diet or as vitamin supplements? And should it be added in the foetal stage via the mother, during childhood or when we have reached adulthood? Børge Nordestgaard continues.
When the sun shines on our skin, the skin produces vitamin D. Evidence suggests that sunshine has a positive effect on our health, but sunburns must be avoided as they increase the risk of skin cancer. A diet rich in vitamin D or the intake of vitamin D supplements can also cover our need to some extent.
The researchers define 'a low level' of vitamin D as 'a level that is 20 nmol/L lower than normal'. In Denmark, a minimum level of 50 nmol per litre plasma is currently recommended.
Provided by University of Copenhagen

Tuesday, November 18, 2014

Simple clinical tests help differentiate Parkinson's disease from atypical parkinsonism

Two simple tests conducted during the neurological exam can help clinicians differentiate between early-stage Parkinson's disease (PD) and atypical parkinsonism. By asking patients to perform a tandem gait test and inquiring whether they are still able to ride a bicycle, clinicians can ascertain whether medio-lateral balance is impaired, a defining characteristic of atypical parkinsonism. These findings are published in the Journal of Parkinson's Disease.
18 nov 2014--This issue of the Journal of Parkinson's Disease also marks the inauguration of a new feature, "How I examine my patient," which is designed to help improve the clinical skills of physicians, allied health professionals, and other professionals involved in the care of patients with PD and other movement disorders.
The occurrence of a sideways or medio-lateral balance impairment is a "red flag" of atypical parkinsonism conditions, such as multiple system atrophy (MSA), progressive supranuclear palsy, or vascular parkinsonism. As the condition progresses, patients with this deficit often compensate by adopting a wide-based walking pattern, probably reflecting widespread pathologic brain involvement of the cerebellum and brain stem, explains Jorik Nonnekes, MD, of the Radboud University Medical Center, Department of Rehabilitation, Nijmegen, the Netherlands.
In contrast, patients with PD develop a shuffling gait, maintaining a narrow distance between their feet. Because medio-lateral balance is preserved, a PD patient may still be able to ride a bicycle even when walking is difficult.
In the first test, 36 patients with PD and 49 patients with atypical parkinsonism were given a tandem gait test. Patients were instructed to take 10 consecutive steps along an imaginary straight, thin line, toe-to-heel. An abnormal tandem gait was scored if one or more side steps were needed to maintain balance. The researchers found that 18% of patients with atypical parkinsonism were able to perform the tandem gait test without a single side step, compared with 92% of patients with PD. The results were similar for patients with only early disease (< 3 years).
Another study included 45 patients with PD and 64 patients with atypical parkinsonism, all of whom said they previously rode bicycles before the onset of motor symptoms. When asked if they still were able to ride a bicycle, 52% of the atypical parkinsonism patients said they had stopped cycling compared to 2% of those with PD.
"Both tests are easy to perform in clinical practice and have a good diagnostic accuracy, even early in the course of the disease," says Dr. Nonnekes. He adds that the tests should always be judged in the clinical context and presence of other red flags or supportive features.
In the new "How I examine my patient," feature researchers and clinicians will contribute practical information about how to conduct good neurological examinations. In many cases, the literature and even neurological textbooks do not include practical descriptions of very common clinical tests.
In the first example, "How I examine my patient: The art of neurological examination for Parkinson's disease and atypical parkinsonism," authors Bastiaan R. Bloem, MD, PhD, Department of Neurology, Radboud University Nijmegen Medical Center, the Netherlands, and Patrik Brundin, MD, PhD, Laboratory of Translational Parkinson's Disease Research, Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, discuss how a well-done examination provides important diagnostic information. They write, "Details about how to perform certain clinical tests can be retrieved from standard neurological textbooks, but many useful clinical tips and tricks have been simply transmitted from teacher to student...such clinical pearls were never laid down in accessible form for a broad readership.
"We hope this new section offers readers a glimpse into the examination room of experienced clinicians who share their clinical pearls," say Dr. Bloem and Dr. Brundin.
Provided by IOS Press

Monday, November 17, 2014

Study: Baby boomers will drive explosion in Alzheimer's-related costs in coming decades

As baby boomers reach their sunset years, shifting nationwide demographics with them, the financial burden of Alzheimer's disease on the United States will skyrocket from $307 billion annually to $1.5 trillion, USC researchers announced today.
17 nov 2014--Health policy researchers at the USC Leonard D. Schaeffer Center for Health Policy and Economics used models that incorporate trends in , health care costs, education and demographics to explore the future impact of one of humanity's costliest diseases on the nation's population.
Other key findings include:
  • From 2010 to 2050, the number of individuals aged 70+ with Alzheimer's will increase by 153 percent, from 3.6 to 9.1 million.
  • Annual per-person costs of the disease were $71,000 in 2010, which is expected to double by 2050.
  • Medicare and Medicaid currently bear 75 percent of the costs of the disease.
"Alzheimer's disease is a progressive disease with symptoms that gradually worsen over time. People don't get better," said Julie Zissimopoulos, lead author of the study and an assistant professor at the USC Price School of Public Policy. "It is so expensive because individuals with Alzheimer's disease need extensive help with daily activities provided by paid caregivers or by family members who may be taking time off of work to care for them, which has a double impact on the economy," she said.
"In late stages of the disease," she added, "they need help with personal care and lose the ability to control movement which requires 24-hour care, most often in an institutional setting."
Zissimopoulos collaborated with Eileen Crimmins of the USC Davis School of Gerontology and Patricia St.Clair of the USC Schaeffer Center on the study, which was posted online ahead of publication by the Forum for Health Economics and Policy on Nov. 4.
The team found that delaying the onset of Alzheimer's even a little can yield major benefits—both in quality of life and in overall costs.
According to the U.S. Census Bureau, in 2012, 43.1 million Americans were 65 and older, constituting 14 percent of the population. By 2050, that number will more than double to 83.7 million, constituting 21 percent of the population.
Medical advances that delay the onset of Alzheimer's by five years add about 2.7 years of life for patients. By 2050, a five-year delay in onset results in a 41 percent lower prevalence of the disease in the population and lowers the overall costs to society by 40 percent, according to the team's research.

"Our colleagues in the medical field are working on ways to understand how the disease interferes with brain processes—and then stop it," said Zissimopoulos, who is also an associate director at the USC Schaeffer Center. "Investment in their work now could yield huge benefits down the line."

Provided by University of Southern California

Sunday, November 16, 2014

Sharpening state spending on seniors

Sharpening state spending on seniors

16 nov 2014--As our society ages, a University of Montreal study suggests the health system should be focussing on comorbidity and specific types of disabilities that are associated with higher health care costs for seniors, especially cognitive disabilities. Comorbidity is defined as the presence of multiple disabilities. Michaël Boissonneault and Jacques Légaré of the university's Department of Demography came to this conclusion after assessing how individual factors are associated with variation in the public costs of healthcare by studying disabled Quebecers over the age of 65 who live in private homes. "Healthcare spending accounts for a growing share of the budgets of economically developed countries. While technological innovations have been identified as the main driver of the increase in costs in recent decades, population aging could contribute more in the years to come. It is therefore important to understand the individual characteristics associated with the high costs of health care," Légaré said.
To explore the relationship between health status and level of , the research team worked from an original database that links data from Quebec's RAMQ public health insurance board (Régie de l'assurance maladie du Québec) with information from the Québec Survey on Activity Limitations, Chronic Diseases and Aging, the latest survey available on the topic. It was prepared by the Quebec government's statistical institute in 1998. The data enabled the researchers to examine whether older individuals with disabilities differed in terms of healthcare costs according to the number and nature of their disabilities. Healthcare costs in related to the costs of health professional consultations and pharmaceuticals.
The researchers found that healthcare costs increased with the number of disabilities. "The costs for consultations with health professionals and the use of pharmaceuticals were about two times higher for people with two disabilities compared to those with a single disability. The costs were again slightly higher for people with three or more disabilities," Boissonneault said.
They also noted that some types of disabilities were associated with higher costs than others were. This is the case for disabilities associated with agility, mobility, and cognition. "People with disabilities related to agility, mobility, and cognition are more likely to suffer from other disabilities simultaneously, which adds to the costs of healthcare," Boissonneault said. "This is especially true for disabilities related to cognition, which are responsible for higher costs due to the use of pharmaceuticals."
The study, one of the few of its kind to focus on the Quebec population, is important because it indicates that people with poor health are not uniform in terms of healthcare costs and that prevention may be beneficial even for people with deteriorated health. "We must pay particular attention to comorbidity and the prevalence of disabilities related to cognition in order to contain healthcare costs in the context of an aging population. This type of disability can indeed reveal the presence of pathologies such as Alzheimer's disease, which is expected to grow significantly in the coming decades," warned Légaré.
Provided by University of Montreal

Friday, November 14, 2014

New Alzheimer's-related memory disorder identified

Alzheimer's disease
Diagram of the brain of a person with Alzheimer's Disease. Credit: Wikipedia/public domain.

14 nov 2014--A multi-institutional study has defined and established criteria for a new neurological disease closely resembling Alzheimer's disease called primary age-related tauopathy (PART). Patients with PART develop cognitive impairment that can be indistinguishable from Alzheimer's disease, but they lack amyloid plaques. Awareness of this neurological disease will help doctors diagnose and develop more effective treatments for patients with different types of memory impairment.
The study, co-led by Peter T. Nelson, MD, PhD, of the University of Kentucky's Sanders-Brown Center on Aging, and John F. Crary, MD, PhD, of Columbia University Medical Center, was published in the current issue of Acta Neuoropathologica.
"To make an Alzheimer's diagnosis you need to see two things together in a patient's brain: amyloid plaques and structures called neurofibrillary tangles composed of a protein called tau," said Dr. Nelson, a professor of neuropathology at the University of Kentucky's Sanders-Brown Center on Aging. "However, autopsy studies have demonstrated that some patients have tangles but no plaques and we've long wondered what condition these patients had."
Plaques in the brain, formed from the accumulation of amyloid protein, are a hallmark of Alzheimer's disease. Until now, researchers have considered cases with only tangles to be either very early-stage Alzheimer's or a variant of the disease in which the plaques are harder to detect. However, previous in-depth biochemical and genetic studies have failed to reveal the presence of any abnormal amyloid in these patients. Although tangle-only patients can have memory complaints, the presence of plaques is a key requirement for an Alzheimer's diagnosis.
In the current study, investigators from the United States (including five from Sanders-Brown), Canada, Europe, and Japan came together to formalize criteria for diagnosing this new neurological disorder. The study establishes that PART is a primary tauopathy, a disease directly caused by the tau protein in tangles. Many of the neurofibrillary tangles in Alzheimer's brain, in contrast, are thought to arise secondarily to amyloid or some other stimuli. The researchers propose that individuals who have tangles resembling those found in Alzheimer's but have no detectable amyloid plaques should now be classified as PART  is most severe in patients of advanced age, but is generally mild in younger elderly individuals. The reason for this is currently unknown, but unlike Alzheimer's disease, in which the tangles spread throughout the brain, in PART cases the tangles are restricted mainly to structures important for memory.
It is too early to tell how common PART is, but given that tangles are nearly universal in the brains of older individuals, it might be more widespread than generally recognized. While further studies are required, new diagnostic tests using brain scans and cerebrospinal fluid biomarkers for amyloid and tau are finding surprisingly high proportions of patients (as many as 25% in some studies) with mild cognitive impairment that are positive for tau but negative for amyloid.
"Until now, PART has been difficult to treat or even study because of lack of well-defined criteria," said Dr. Nelson. "Now that the scientific community has come to a consensus on what the key features of PART are, this will help doctors diagnose different forms of memory impairment early. These advancements will have a big impact on our ability to recognize and develop effective treatments for brain diseases seen in older persons."
Identifying the type of neurological disorder in the early stages of disease is critical if treatment is to begin before irreparable brain damage has occurred. However, in the absence of clear criteria, different forms of neurological disorders have been hard to distinguish. As a result, PART patients may have confounded clinical trials of amyloid-targeting drugs for Alzheimer's disease as these treatments are unlikely to be effective against tangles. Along with the development of better biomarkers and genetic risk factors for dementia, the new diagnosis criteria will help PART patients to receive more targeted therapy and improve the accuracy of clinical trials for Alzheimer's drugs.
Provided by University of Kentucky

Thursday, November 13, 2014

World's oldest people share no genetic secrets, study finds

Think the reason some people live beyond the age of 100 is because of their genes? Think again.
13 nov 2014--US scientists said Wednesday they've found no genetic secrets shared between a group of 17 supercentenarians, or those who have lived beyond 110.
"From this small sample size, the researchers were unable to find rare protein-altering variants significantly associated with extreme longevity compared to control genomes," said the study led by Hinco Gierman of Stanford University.
The research was published in the November 12 issue of the open-access journal PLOS ONE.
People who live to age 100 and beyond are far less likely to get cancer—a 19 percent lifetime incidence compared to 49 percent in the general population—according to background information in the article.
Those who live more than a century also have lower rates of cardiovascular disease and stroke than controls.
There are 74 supercentenarians alive worldwide, and 22 live in the United States.
The 17 people whose genomes were sequenced had lived to age 110 and older.
Their average age at death was 112, and the longest living member of the group lived to age 116.
Fourteen had European ancestry; two were Hispanic and one was African-American.
Even though no genetic clues emerged in this study, scientists said they would make their analysis available to the public as a resource for future research.
"Supercentenarians are extremely rare and their genomes could hold secrets for the genetic basis of extreme longevity," it said.
More information: Gierman HJ, Fortney K, Roach JC, Coles NS, Li H, et al. (2014) Whole-Genome Sequencing of the World's Oldest People. PLoS ONE 9(11): e112430. DOI: 10.1371/journal.pone.0112430

Wednesday, November 12, 2014

Beta-blockers have no mortality benefit in post-heart attack patients, say researchers

Beta-blockers have been a cornerstone in the treatment of heart attack survivors for more than a quarter of a century. However, many of the data predate contemporary medical therapy such as reperfusion, statins, and antiplatelet agents, and recent data have called the role of beta-blockers into question. Two new studies published in The American Journal of Medicine evaluated the traditional management of these patients after their discharge from the hospital and in the light of changing medical treatment, as well as the impact of the discharge heart rate and conventional treatment with beta-blockers.
12 nov 2014--In a study by Bangalore et al. researchers analyzed 60 randomized trials with 102,003 patients evaluating beta-blockers in myocardial infarction. Each of these trials enrolled at least 100 patients. Fourteen trials (20,418 patients) provided data on a follow-up longer than one year. Trials were stratified into those that took place in the reperfusion era (more than 50% undergoing reperfusion or receiving aspirin/statin) and those that took place before the reperfusion era.
Researchers evaluated the impact of contemporary treatment (reperfusion/aspirin/statin) status on the association of beta-blocker use and outcomes in heart attack patients; the role of early intravenous beta-blocker; and the required duration of beta-blocker use. They found that beta-blockers have no mortality benefit in contemporary treatment of heart attacks.
"In patients undergoing contemporary treatment, our data support the short-term (30 days) use of beta-blockers to reduce recurrent heart attacks and angina, but this has to be weighed at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation, without prolonging life," explains lead investigator Sripal Bangalore, MD, MHA, of NYU Langone Medical Center, New York. "The guidelines should reconsider the strength of recommendations for beta-blockers post myocardial infarction."
In the second study, researchers led by senior investigator François Schiele, MD, PhD, Chief of Cardiology at the University Hospital Jean Minjoz, Besançon, France, aimed to describe the determinants of discharge heart rate in acute coronary syndrome patients and assess the impact of discharge heart rate on five-year mortality in hospital survivors. Over the last twenty years there has been growing interest in the use of heart rate as a marker for risk stratification in cardiovascular diseases, and as a prognostic factor for global and cardiovascular mortality. However, few data are available regarding the long-term impact of discharge heart rate.
The discharge heart rate was recorded in over 3,000 patients discharged over a one month period in 223 participating institutions in the French Registry of Acute ST Elevation or non-ST-Elevation Myocardial Infarction (FAST-MI). Patients were followed over five years. The objective of FAST-MI is to evaluate practices for managing heart attacks (myocardial infarctions) in "real life" conditions, and to measure their relationship with acute and long-term outcomes of patients admitted to coronary care units for heart attack in France, irrespective of the type of health care establishment to which the patients were admitted. An elevated ST segment seen on an electrocardiogram indicates that a relatively large amount of heart muscle damage is occurring, and is what gives this type of heart attack its name.
Heart rate was categorized into four groups: over 60, 61-67, 68-75, and over 75 beats per minute. High heart rate was defined as more than 75 beats per minute. Landmark analysis was performed at one year.
"We found several factors related to a high heart rate. They included ST-elevation myocardial infarction, diabetes, chronic obstructive pulmonary disease, bleeding/transfusion during hospitalization, left ventricular dysfunction, renal dysfunction, and prescription of beta-blockers at discharge. Women were also more likely to have a high heart rate," says Dr. Schiele.
"We found that the discharge heart rate is significantly related to one-year mortality, and that patients discharged with a high heart rate are at higher risk of death during the first year, irrespective of beta-blocker use," he concludes.
More information: "Clinical Outcomes with Beta-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials," by Sripal Bangalore, MD, MHA, Harikrishna Makani, MD, Martha Radford, MD, Kamia Thakur, MD, Bora Toklu, MD, Stuart D. Katz, MD, James J. DiNicolantonio, PharmD, P.J. Devereaux, MD, PhD, Karen P. Alexander, MD, Jorn Wetterslev, MD, PhD, and Franz H. Messerli, MD.
"Discharge Heart Rate and Mortality after Acute Myocardial Infarction," by Marie France Seronde, MD, PhD, Raghed Geha, MD, Etienne Puymirat, MD, Aurès Chaib, MD, Tabassome Simon, MD, PhD, Laurence Berard, MD, Elodie Drouet, MSc, Vincent Bataille, MD, Nicolas Danchin, MD, PhD, and François Schiele, MD, PhD 06.034
Both are published in The American Journal of Medicine, Volume 127/Issue 10 (October 2014) published by Elsevier.
Provided by Elsevier