Tuesday, April 26, 2016

Vaccinations are more effective when administered in the morning

Credit: National Cancer Institute
New research from the University of Birmingham has shown that flu vaccinations are more effective when administered in the morning.

26 april 2016--The findings, published in the journal Vaccine, suggest administering vaccinations in the morning, rather than the afternoon, could induce greater, and thus more protective, antibody responses.
24 general practices in the West Midlands, UK, were analysed between 2011 and 2013 in a cluster-randomised trial during the annual UK influenza vaccination programme.
276 adults aged over 65 were vaccinated against three strains of influenza, either in morning surgeries (9-11am) or afternoon surgeries (3-5pm).
In two of the three given influenza virus strains, those in the morning cohort saw a significantly larger increase in antibody concentration one month following vaccination, when compared with those in the afternoon cohort. In the third strain, there was no significant difference between morning and afternoon.
Dr Anna Phillips, the Principal Investigator of the study from the School of Sport, Exercise and Rehabilitation Sciences at the University of Birmingham explained, "We know that there are fluctuations in immune responses throughout the day and wanted to examine whether this would extend to the antibody response to vaccination. Being able to see that morning vaccinations yield a more efficient response will not only help in strategies for flu vaccination, but might provide clues to improve vaccination strategies more generally."
The influenza vaccination is part of the seasonal vaccination programme carried out by general practices across the UK, and in many other countries, with a particular focus on patients over 65 years old.
Despite this, the influenza virus is responsible for between 250,000 and 500,000 deaths each year worldwide. The age-related decline in immunity reduces the ability of older adults to produce adequate antibody responses following vaccination, compromising the given protection.
Other interventions to improve outcomes of vaccination have been attempted with limited success, including exercise routines and additives to the vaccine itself.
Professor Janet Lord, a co-investigator on the study from the Institute of Inflammation and Ageing at the University of Birmingham, said, "A significant amount of resource is used to try and prevent flu infection each year, particularly in older adults, but less than half make enough antibody to be fully protected. Our results suggest that by shifting the time of those vaccinations to the morning we can improve their efficiency with no extra cost to the health service."
The team will now look to investigate further in a large scale study. This is important to see if the morning vaccination strategy benefits a wide range of over 65s including those with conditions like diabetes, liver and kidney disease that impair immunity. They will also look to see if the morning vaccination strategy is effective for the pneumococcal vaccine that protects against pneumonia; a vaccine recommended to all individuals aged 65 years old in the UK.

More information: "Morning vaccination enhances antibody response over afternoon vaccination: a cluster-randomised trial," VaccineDOI: 10.1016/j.vaccine.2016.04.032

Provided by University of Birmingham

Tuesday, April 19, 2016

Palliative care viewed as a stigma, despite improving quality of life

The term palliative care carries a stigma for patients and their caregivers, who regard it as synonymous with impending death. Education, and possibly a name change, will be necessary to be able to integrate palliative care into routine advanced cancer care, according to new research in CMAJ (Canadian Medical Association Journal).

19 april 2016--Palliative care is designed to improve the quality of life of patients with a serious illness and their families. The World Health Organization and all major national and international cancer societies encourage early access to palliative care. Research indicates that for people with advanced cancer, early palliative care benefits both physical and mental health and can even extend life.
However, a new study found that even patients who have benefited from early palliative care feel stigmatized because they see it as being associated with the end of life.
The study, conducted at Princess Margaret Cancer Centre, Toronto, Ontario, included 71 participants (48 patients and 23 caregivers) in a randomized clinical trial of early palliative care versus standard cancer care. Of the participants, 40 had received early referral to palliative care (in addition to standard cancer care), and 31 had received standard cancer care alone. Participants had cancers from the five most common types: lung, gastrointestinal, genitourinary, breast and gynecologic, and had an estimated survival (by their oncologist) of 6-24 months. At the end of the trial, researchers interviewed the 71 patients and caregivers about their attitudes and perceptions to palliative care.
"Patients with advanced cancer and their caregivers described palliative care as carrying a negative stigma associated with death and with care at the very end of life, which provoked fear and avoidance," writes Dr. Camilla Zimmermann, Princess Margaret Cancer Centre, University Health Network, Toronto, and her coauthors. "Participants' perceptions often originated from interactions with health care professionals."
"A prominent theme was that palliative care should be explicitly rebranded," the researchers found, with participants suggesting public education, better explanation by health care professionals and routine involvement of palliative care at cancer diagnosis to break down stigma.
The authors suggest that the study has implications for clinical practice and health care policy.
"[Our findings show that] the persistence of the definition of palliative care as end-of-life care in the minds of patients and their caregivers, despite an international change in that definition more than a decade ago," write the authors. "A name change may be considered, but would achieve nothing without a fundamental shift in the manner in which palliative care is practised and portrayed."
The authors caution that the way in which physicians inform patients and their caregivers about palliative care has a major impact on how it is perceived. Many health care professionals still suggest palliative care as a final option or as an alternative to further treatment.
In a related commentary, Dr. Anthony Caprio, Department of Family Medicine, Carolinas HealthCare System, Charlotte, North Carolina, writes that the study shows that "patients and caregivers view health care professionals as having an important role in explaining and recommending palliative care. Although changing the name to supportive care may help promote a more positive view of palliative care, the stigma will persist if this type of care is recommended only as default treatment when curative or life-prolonging treatments are deemed ineffective or undesired."
Palliative care should begin at diagnosis and continue throughout cancer care, regardless of prognosis.

More information: Canadian Medical Association 

Canadian Medical Association Journalwww.cmaj.ca/lookup/doi/10.1503/cmaj.160206

Provided by Canadian Medical Association Journal

Sunday, April 17, 2016

First diagnosed case of Alzheimer's disease in HIV-positive individual reported

First diagnosed case of Alzheimer's disease in HIV-positive individual reported
R. Scott Turner, M.D., Ph.D., Director, Georgetown Memory Disorders Program. Credit: Georgetown University
Georgetown University researchers are reporting the first case of Alzheimer's disease diagnosed in an HIV-positive individual. The finding in a 71-year-old man triggers a realization about HIV survivors now reaching the age when Alzheimer's risk begins to escalate.

17 april 2016--Published online in the open access journal Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring, neurologist R. Scott Turner, MD, PhD, diagnosed the patient after a PET scan showed deposition of amyloid in the brain. Until this point, Turner says, clinicians thought that individuals with HIV may not develop AD because HIV-related inflammation in the brain may prevent amyloid clumps from forming.
"This patient may be a sentinel case that disputes what we thought we knew about dementia in HIV-positive individuals," says Turner, who leads the Memory Disorders Program at Georgetown University Medical Center.
In addition, Turner says the finding suggests that some older HIV-positive patients with dementia may be misdiagnosed with HIV-associated neurocognitive disorders (HAND) when they may be developing AD. It also may be possible that some patients experience HAND and AD—a new type of mixed dementia, Turner says. "Chronic HIV infection and amyloid deposition with aging may represent a "double-hit" to the brain that results in progressive dementia."
"While it may be challenging to diagnose the cause of dementia in an HIV-positive patient, the diagnosis matters because HAND and AD are treated differently," he says. "For Alzheimer's disease, we now have four FDA-approved drugs and more effective treatments are on the way. For HAND, we prescribe anti-retroviral drugs that have a better chance of penetrating the brain. So getting a correct diagnosis is important, and a critical first step in advancing the field."
HAND will develop in 30-50 percent of individuals with long-term HIV infections. But HAND symptoms are identical to those with AD, Turner says. He adds, "The medical community assumes that dementia with HIV is caused by HAND. Physicians haven't considered Alzheimer's, so it's possible that a number of older HIV-positive individuals may be misdiagnosed."
Published studies to date point to only five individuals with HAND who have undergone amyloid PET imaging, and all were negative; however, the oldest of these patients was 67, Turner says.
Diagnosis of dementia in older HIV-infected individuals is on the rise. HIV-infected adults over 55 comprise the fastest growing age group in the HIV-positive population.
According to the most recent CDC HIV Surveillance Report with data through 2013, 53,000 people in the U.S. living with HIV are 65 and older, the age when Alzheimer's disease risk begins to escalate. That number is expected to double in less than 10 years and doesn't include those who have not been diagnosed. Worldwide, more than 37 million people are living with HIV.
"This case report reveals important new insights into the specific issue of HIV-related neurological impairment," says Jeffrey Crowley, MPH, program director of the National HIV/AIDS Initiative at the O'Neill Institute for National and Global Health Law at Georgetown Law. Crowley is former director of the White House Office of National AIDS Policy and senior advisor on disability policy. "This finding must lead to additional population-based studies, as well as timely clinical and programmatic interventions to better support individuals with HIV who are facing neurological decline."

Provided by Georgetown University Medical Center

Friday, April 15, 2016

Self-management group rehab benefits persons with dementia

Self-management group rehab benefits persons with dementia
15 april 2016—Self-management group rehabilitation is beneficial for persons with dementia (PwD) and their spouses, according to a study published online April 5 in the Journal of the American Geriatrics Society.
Marja-Liisa Laakkonen, M.D., Ph.D., from Laakso Hospital in Helsinki, Finland, and colleagues conducted a randomized controlled trial in primary care and memory clinics involving 136 PwD and their 136 spouses. Couples were randomly allocated to receive usual care or eight weekly sessions of self-management group rehabilitation.
The researchers found that the spouse physical component of the RAND-36 improved for those undergoing the intervention and worsened for controls at three months (P = 0.006 after adjustment for age, sex, and baseline value). No between-group differences were seen on the mental component of the RAND-36, the Spousal Sense of Competence Questionnaire, or the 15-dimensional health-related quality of life (HRQoL) of PwD instrument. PwD change in verbal fluency was −0.38 in the intervention group and −1.60 in the control group at nine months (P = 0.011 after adjustment for age, sex, and Mini-Mental State Examination score); similar scores were seen on the Clock Drawing Test. Differences in incremental costs between the groups were −436€ and −896€ per person per year for PwD (P = 0.35) and spouses (P = 0.51), respectively.
"The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs," the authors write.

More information: Abstract

Saturday, April 09, 2016

New dietary guidelines for Americans issued for 2015-2020

New dietary guidelines for americans issued for 2015-2020
09 april 2016—New U.S. dietary guidelines have been released for 2015 to 2020, according to a health policy brief published online March 31 in Health Affairs.
T.R. Goldman, a freelance journalist based in Washington, D.C., reviewed the most recent guidelines, which are officially known by their five-year range rather than a single year. The recommendations were formulated after extensive review of 300 studies, which were used to address 83 questions. In addition, 29,000 public comments were reviewed.
Goldman notes that although most of the new guidelines are consistent with previous advice, there are some differences. The guidelines' overall emphasis is on eating patterns, rather than individual food groups and nutrients. There is a newly introduced recommended limit for added sugars (10 percent of daily calories). Drinking three to five cups of coffee per day is considered part of a healthy eating pattern. The dietary cholesterol limit has been lifted and the recommendation that specific populations reduce their sodium intake from 2,300 to 1,500 mg/day has been removed. In addition, men and teenage boys are encouraged to reduce protein consumption.
"The guidelines undeniably shape the general perception of what healthy eating means, and that perception is ultimately reflected in the food sold everywhere," Goldman writes.

More information: Full Text

Wednesday, April 06, 2016

Successful dying: Researchers define the elements of a 'good death'

For most people, the culmination of a good life is a "good death," though what that means exactly is a matter of considerable consternation. Researchers at the University of California, San Diego School of Medicine surveyed published, English-language, peer-reviewed reports of qualitative and quantitative studies defining a "good death," ultimately identifying 11 core themes associated with dying well.

06 april 2016--The findings are published in the April 2016 issue of the American Journal of Geriatric Psychiatry.
The research team, headed by senior author Dilip Jeste, MD, Distinguished Professor of Psychiatry and Neurosciences and director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego School of Medicine, focused on three groups of stakeholders: patients, family members (before or during bereavement) and health care providers.
"This is the first time that data from all of the involved parties have been put together," said Jeste, who is also associate dean for healthy aging and senior care at UC San Diego School of Medicine. "Death is obviously a controversial topic. People don't like to talk about it in detail, but we should. It's important to speak honestly and transparently about what kind of death each of us would prefer."
The literature search culled through 32 qualifying studies. It identified 11 core themes of good death: preferences for a specific dying process, pain-free status, religiosity/spirituality, emotional well-being, life completion, treatment preferences, dignity, family, quality of life, relationship with the health care provider and "other."
The top three themes across all stakeholder groups were preferences for specific dying process, pain-free status and emotional well-being. For other themes, however, different stakeholders put somewhat different levels of emphasis. For example, patients more often cited religiosity/spirituality as important than did family members, who believed dignity and life completion were more critical to a good death. Health care providers tended to represent a middle ground between patients and family members.
"Clinically, we often see a difference between what patients, family members and health care providers value as most important near the end of life", said first author Emily Meier, PhD, a psychologist at Moores Cancer Center at UC San Diego Health. "Ultimately, existential and other psychosocial concerns may be prevalent among patients, and this serves as a reminder that we must ask about all facets of care that are essential at the end of life."
The bottom line, said Jeste, is "ask the patient."
"Usually, patients know what they want or need and there is relief in talking about it. It gives them a sense of control. I hope these findings spur greater conversation across the spectrum. It may be possible to develop formal rating scales and protocols that will prompt greater discussion and better outcomes. You can make it possible to have a good death by talking about it sometime before."

More information: Emily A. Meier et al. Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue, The American Journal of Geriatric Psychiatry (2016). DOI: 10.1016/j.jagp.2016.01.135

Provided by University of California - San Diego

Tuesday, April 05, 2016

Exercise may slow brain aging by 10 years for older people

old person
Credit: Peter Griffin/public domain
Exercise in older people is associated with a slower rate of decline in thinking skills that occurs with aging. People who reported light to no exercise experienced a decline equal to 10 more years of aging as compared to people who reported moderate to intense exercise, according to a population-based observational study published in the March 23, 2016, online issue of Neurology, the medical journal of the American Academy of Neurology.

05 april 2016--"The number of people over the age of 65 in the United States is on the rise, meaning the public health burden of thinking and memory problems will likely grow," said study author Clinton B. Wright, MD, MS, of the University of Miami in Miami, Fla., and member of the American Academy of Neurology. "Our study showed that for older people, getting regular exercise may be protective, helping them keep their cognitive abilities longer."
For the study, researchers looked at data on 876 people enrolled in the Northern Manhattan Study who were asked how long and how often they exercised during the two weeks prior to that date. An average of seven years later, each person was given tests of memory and thinking skills and a brain MRI, and five years after that they took the memory and thinking tests again.
Of the group, 90 percent reported light exercise or no exercise. Light exercise could include activities such as walking and yoga. They were placed in the low activity group. The remaining 10 percent reported moderate to high intensity exercise, which could include activities such as running, aerobics, or calisthenics. They were placed in the high activity group.
When looking at people who had no signs of memory and thinking problems at the start of the study, researchers found that those reporting low activity levels showed a greater decline over five years compared to those with high activity levels on tests of how fast they could perform simple tasks and how many words they could remember from a list. The difference was equal to that of 10 years of aging. The difference also remained after researchers adjusted for other factors that could affect brain health, such as smoking, alcohol use, high blood pressure and body mass index.
"Physical activity is an attractive option to reduce the burden of cognitive impairment in public health because it is low cost and doesn't interfere with medications," said Wright. "Our results suggest that moderate to intense exercise may helpolder people delay aging of the brain, but more research from randomized clinical trials comparing exercise programs to more sedentary activity is needed to confirm these results."

Provided by American Academy of Neurology

Saturday, April 02, 2016

Endocrine Society encourages clinicians to avoid prescribing compounded hormones

A new Scientific Statement issued today by the Endocrine Society advises clinicians to avoid using compounded hormone medications to treat menopausal symptoms, female sexual dysfunction and other hormone conditions.

02 april 2016--Sometimes called bioidentical compounded hormones, these products are typically a mixture of hormones. Compounded hormone medications are prepared by licensed professionals or facilities specifically for an individual's use. Compounded medications are meant to be an alternative when an individual does not have access to or has an adverse reaction to a medication approved by the U.S. Food & Drug Administration.
Compounded hormone medications can be unsafe when inappropriate practices are used. More than 60 people died from cases of fungal meningitis attributed to compounded medications in a 2010 case.
"In extreme cases, advertisers have marketed compounded products as being able to prevent the ravages of aging and implied they are risk free," said Nanette Santoro, MD, and the chair of the Society task force that developed the statement. "Few, if any, of these claims are supported by science."
Widely available hormone treatments that are 100 percent chemically identical to the native hormones found in the body and that are approved by the U.S. Food & Drug Administration (FDA) offer effective and safe options for people with hormone disorders, and those approved treatments should be prescribed whenever possible, Santoro said.
Despite limited oversight of quality and dosage, bioidentical compounded hormones are used by millions of women to treat menopausal symptoms such as hot flashes and night sweats. Several market surveys indicate that custom-compounded menopausal hormone therapies earn $1 billion dollars in annual sales - enough to treat 2 million to 3 million women. The sales are equivalent to a quarter to a third of sales of menopausal hormone therapies approved by the U.S. Food & Drug Administration.
Although a large 2002 government study called the Women's Health Initiative (WHI) raised concerns about menopausal hormone therapy raising the risks of blood clots, stroke, breast cancer and heart attacks in postmenopausal women, additional research conducted in the ensuing years has found that the level of risk depends on the individual woman's health history, age and other factors. Experts have formed a consensus that the benefits of menopausal hormone therapy exceed the risks for most healthy women seeking relief from menopausal symptoms.
Some women turned to custom-compounded menopausal hormone therapy (MHT) because of a misconception that is was safer than FDA-approved treatments. No large-scale, long-term studies have been conducted to examine the effectiveness and safety of custom-compounded MHT. When women use a customized preparation of estrogen and/or progestin, there are concerns that it could be harmful due to an overdose of the hormones or ineffective due to under-dosing. There is no scientific or medical reason to use a custom-compounded treatment that could have an unknown effect on the body when there are numerous FDA-approved options for treating menopausal symptoms, according to the statement.
The statement also examined compounded hormone treatments used to boost testosterone levels in women experiencing sexual dysfunction. There are no FDA-approved testosterone or dehydroepiandrosterone (DHEA) therapies for women, and scientific studies, while indicating some effectiveness for testosterone in specific circumstances, do not support the use of DHEA for sexual dysfunction. There are also concerns about under- or overdosing as well as side effects from these treatments.
Compounded medications also are used to treat thyroid disorders. FDA-approved thyroid medications to supplement the body's naturally produced thyroid hormone remain the treatment of choice because they are highly effective and safe, according to the statement. However, some patients may benefit from compounded thyroid medications or desiccated thyroid hormone exacted from animals. Patients prescribed these alternatives need to have their Thyroid-Stimulating Hormone (TSH) levels and symptoms monitored carefully.
New regulations being developed by the FDA may lead to improved safety and quality control for compounded medications, Santoro said. In the meantime, compounded therapies should be used in limited situations due to concerns about the risks of under-dosing, overdosing or contamination.
"Custom-compounded hormones should be reserved for situations in which a patient is allergic to or does not tolerate any of the FDA-approved therapies, and treatment is necessary for his or her health," Santoro said.

More information: Nanette Santoro et al. Compounded Bioidentical Hormones in Endocrinology Practice: An Endocrine Society Scientific Statement, The Journal of Clinical Endocrinology & Metabolism (2016). DOI: 10.1210/jc.2016-1271

Provided by The Endocrine Society