Monday, October 16, 2017

Confusion about long-term treatment of osteoporosis clarified

Osteoporosis is a common disorder among postmenopausal women which results in an increased risk of fractures. While several therapies improve bone strength and reduce the risk of spine and hip fracture, there is no cure for osteoporosis, and long-term treatment is needed. An upcoming presentation at The North American Menopause Society (NAMS) Annual Meeting in Philadelphia October  is scheduled to present new evidence about the long-term effectiveness and safety of treatment with bisphosphonates and denosumab.

06 oct 2017--Bisphosphonates and denosumab are the most commonly prescribed treatments for osteoporosis. Protection from fractures occurs within the first few months of treatment and persists as long as treatment is continued. Upon stopping bisphosphonate therapy, protection from fractures is gradually lost over three to five years. Treatment for more than three years has been associated with an increasing risk of unusual or "atypical" fractures of the femur (thigh bone). After five years of treatment, the risk of these atypical fractures is about 20 per 100,000 patients and increases to about 1/1,000 patients after eight to ten years of treatment.
The combination of increased risk of atypical fracture along with a relatively slow offset of the protection from fractures due to osteoporosis led to the confusing concept of a "bisphosphonate holiday." The American Society for Bone and Mineral Research has recently provided clear recommendations about "bisphosphonate holidays." After three to five years of bisphosphonate treatment, a patient's risk of fracture should be reevaluated. For patients remaining at high risk of fracture (those with previous hip, spine, or multiple other fractures or with bone density values remaining in the osteoporosis range), continuing treatment or changing to a different drug like denosumab is important. For patients whose risk of fracture is lower, stopping treatment for two to three years (the "holiday") can be considered but is not mandatory.
It's important to note that the concept of a "holiday" from therapy applies only to the bisphosphonates and not to any of the other drugs used to treat osteoporosis. The beneficial effects of these other medicines, including raloxifene, teriparatide, and denosumab, are lost quickly when treatment is stopped.
"Because protection from fractures disappears quickly if denosumab treatment is stopped, and since there are no currently known safety issues that limit the duration of denosumab therapy, there is no justification for a drug holiday with this treatment," says Dr. Michael McClung of the Oregon Osteoporosis Center in Portland, Oregon, who will be presenting his recommendations on long-term osteoporosis therapy at the NAMS Annual Meeting. "Just as we do not recommend stopping treatment for high blood pressure or diabetes, it is necessary to have a long-term treatment plan for postmenopausal women with osteoporosis if the benefits of our therapies are to be realized."
"Prevention of osteoporosis should be a goal for those treating menopausal women, as up to 20% of bone loss occurs within the first five years of menopause. Once diagnosed with osteoporosis, the goal becomes lowering the risk of fractures as fractures can be life changing or life limiting. This presentation will offer valuable insights about the need for long-term treatment and will change the way health care providers approach long-term osteoporosis management," says Dr. JoAnn Pinkerton, NAMS executive director.
Drs. McClung and Pinkerton are available for interviews before the presentation at the Annual Meeting.


Provided by The North American Menopause Society

Sunday, October 15, 2017

What is mindfulness? Nobody really knows, and that's a problem

What is mindfulness? Nobody really knows, and that's a problem
You've probably heard of mindfulness. These days, it's everywhere, like many ideas and practices drawn from Buddhist texts that have become part of mainstream Western culture.
15 oct 2017--But a review published today in the journal Perspectives on Psychological Science shows the hype is ahead of the evidence. Some reviews of studies on mindfulness suggest it may help with psychological problems such as anxiety, depression, and stress. But it's not clear what type of mindfulness or meditation we need and for what specific problem.
The study, involving a large group of researchers, clinicians and meditators, found a clear-cut definition of mindfulness doesn't exist. This has potentially serious implications. If vastly different treatments and practices are considered the same, then research evidence for one may be wrongly taken as support for another.
At the same time, if we move the goalposts too far or in the wrong direction, we might lose the potential benefits of mindfulness altogether.

So, what is mindfulness?

Mindfulness receives a bewildering assortment of definitions. Psychologists measure the concept in differing combinations of acceptance, attentiveness, awareness, body focus, curiosity, nonjudgmental attitude, focus on the present, and others.
It's equally ill-defined as a set of practices. A brief exercise in self-reflection prompted by a smart-phone app on your daily commute may be considered the same as a months-long meditation retreat. Mindfulness can both refer to what Buddhist monks do and what your yoga instructor does for five minutes at the start and end of a class.
To be clear, mindfulness and meditation are not the same thing. There are types of meditation that are mindful, but not all mindfulness involves meditation and not all meditation is mindfulness-based.
Mindfulness mainly refers to the idea of focusing on the present moment, but it's not quite that simple. It also refers to several forms of meditation practices that aim to develop skills of awareness of the world around you and of your behavioral patterns and habits. In truth, many disagree about its actual purpose and what is and isn't mindfulness.

What's it for?

Mindfulness has been applied to just about any problem you can think up - from relationship issues, problems with alcohol or drugs, to enhancing leadership skills. It's being used by sportsmen to find "clarity" on and off the field and mindfulness programs are being offered at school. You can find it in workplacesmedical clinics, and old age homes.
More than a few popular books have been written touting the benefits of mindfulness and meditation. For example, in a supposedly critical review Altered Traits: Science Reveals How Meditation Changes your Mind, Brain and Body, Daniel Goleman argues one of the four benefits of mindfulness is improved working memory. Yet, a recent review of about 18 studies exploring the effect of mindfulness-based therapies on attention and memory calls into question these ideas.
Another common claim is that mindfulness reduces stress, for which there is limited evidence. Other promises, such as improved mood and attention, better eating habits, improved sleep, and better weight control are not fully supported by the science either.
And while benefits have limited evidence, mindfulness and meditation can sometimes be harmful and can lead to psychosis, mania, loss of personal identity, anxiety, panic, and re-experiencing traumatic memories. Experts have suggested mindfulness is not for everyone, especially those suffering from several serious  such as schizophrenia or bipolar disorder.

Research on mindfulness

Another problem with mindfulness literature is that it often suffers from poor research methodology. Ways of measuring mindfulness are highly variable, assessing quite different phenomena while using the same label. This lack of equivalence among measures and individuals makes it challenging to generalise from one study to another.
Mindfulness researchers rely too much on questionnaires, which require people to introspect and report on mental states that may be slippery and fleeting. These reports are notoriously vulnerable to biases. For example, people who aspire to mindfulness may report being mindful because they see it as desirable, not because they have actually achieved it.
Only a tiny minority of attempts to examine whether these treatments work compare them against another treatment that is known to work – which is the primary means by which clinical science can show added value of new treatments. And a minority of these studies are conducted in regular clinical practices rather than in specialist research contexts.
A recent review of studies, commissioned by the US Agency for Healthcare Research and Quality, found many studies were too poorly conducted to include in the review and that mindfulness treatments were moderately effective, at best, for anxiety, depression, and pain. There was no evidence of efficacy for attention problems, positive mood, substance abuse, eating habits, sleep or weight control.

What should be done?

Mindfulness is definitely a useful concept and a promising set of practices. It may help prevent psychological problems and could be useful as an addition to existing treatments. It may also be helpful for general mental functioning and well-being. But the promise will not be realised if problems are not addressed.
The mindfulness community must agree to key features that are essential to mindfulness and researchers should be clear how their measures and practices include these. Media reports should be equally specific about what states of mind and practices mindfulness includes, rather than using it as a broad term.
Mindfulness might be assessed, not through self-reporting, but in part using more objective neurobiological and behavioural measures, such as breath counting. This is where random tones could be used to "ask" participants if they are focused on the breath (press left button) or if their mind had wandered (press right button).
Researchers studying the efficacy of mindfulness treatments should compare them to credible alternative treatments, whenever possible. Development of new mindfulness approaches should be avoided until we know more about the ones we already have. Scientists and clinicians should use rigorous randomised control trials and work with researchers from outside the mindfulness tradition.
And lastly, mindfulness researchers and practitioners should acknowledge the reality of occasional negative effects. Just as medications must declare potential side effects, so should mindfulness treatments. Researchers should systematically assess potential side effects when studying mindfulness treatments. Practitioners should be alert to them and not recommend mindfulness treatments as a first approach if safer ones with stronger evidence of efficacy are available.

Friday, October 13, 2017

'Ridiculously healthy' elderly have the same gut microbiome as healthy 30 year-olds

gut bacteria

In one of the largest microbiota studies conducted in humans, researchers at Western University, Lawson Health Research Institute and Tianyi Health Science Institute in Zhenjiang, Jiangsu, China have shown a potential link between healthy aging and a healthy gut.

13 oct 2017--With the establishment of the China-Canada Institute, the researchers studied the gut bacteria in a cohort of more than 1,000 Chinese individuals in a variety of age-ranges from 3 to over 100 years-old who were self-selected to be extremely healthy with no known health issues and no family history of disease. The results showed a direct correlation between health and the microbes in the intestine.
"The aim is to bring novel microbiome diagnostic systems to populations, then use food and probiotics to try and improve biomarkers of health," said Gregor Reid, professor at Western's Schulich School of Medicine & Dentistry and Scientist at Lawson Health Research Institute. "It begs the question - if you can stay active and eat well, will you age better, or is healthy ageing predicated by the bacteria in your gut?"
The study, published this month in the journal mSphere, showed that the overall microbiota composition of the healthy elderly group was similar to that of people decades younger, and that the gut microbiota differed little between individuals from the ages of 30 to over 100.
"The main conclusion is that if you are ridiculously healthy and 90 years old, your gut microbiota is not that different from a healthy 30 year old in the same population," said Greg Gloor, the principal investigator on the study and also a professor at Western's Schulich School of Medicine & Dentistry and Scientist at Lawson Health Research Institute. Whether this is cause or effect is unknown, but the study authors point out that it is the diversity of the gut microbiota that remained the same through their study group.
"This demonstrates that maintaining diversity of your gut as you age is a biomarker of healthy aging, just like low-cholesterol is a biomarker of a healthy circulatory system," Gloor said. The researchers suggest that resetting an elderly microbiota to that of a 30-year-old might help promote health.
"By studying healthy people, we hope to know what we are striving for when people get sick," said Reid.
The study also found a distinct anomaly in the group aged 19 to 24 that has not been observed in large-scale analyses of other populations and they suspect may be unique to this healthy cohort in China. The distinct gut microbiota of this group was a surprising finding and requires further study.

More information: Gaorui Bian et al, The Gut Microbiota of Healthy Aged Chinese Is Similar to That of the Healthy Young, mSphere (2017). DOI: 10.1128/mSphere.00327-17


Provided by University of Western Ontario

Tuesday, October 10, 2017

The benefits of 'being in the present'

The benefits of 'Being in the present'
When you have a full schedule, multitasking might seem like the best way to finish your endless to-do list. But the brain actually benefits from focusing on one activity at a time.
When you commit to training your attention and exerting control over your mind, you're practicing mindfulness. 

10 oct 2017--While it has become a popular psychotherapy technique, mindfulness originated in Buddhism over 2,000 years ago.
The idea of mindfulness is that life should be lived in the present moment. In addition to improving your focus, the practice can bring stress and insomnia relief, and pain reduction.
How?
One explanation comes from a study published in the journal Psychiatry Research. The study found that mindfulness can change the concentration of gray matter in areas of the brain involved in learning, memory, regulating emotion and more.
Yoga and tai chi are two mind-body practices that help increase mindfulness along with their physical and relaxation benefits.
There's also mindfulness meditation, a very focused approach developed by Jon Kabat-Zinn. He is creator of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School.

However, you don't need a formal program to incorporate mindfulness into your day. Here are some ideas:
  • When you start a task, imagine you're doing it for the first time. Be curious. Feel sensations like you've never experienced them before.
  • Focus on your breathing. Take notice as you breathe in and as you breathe out. Follow your breath. It's a reminder that you're alive.
  • When you're overcome with emotion, take a step back and trace the emotion's origin and duration. Mindfulness teaches recognition that emotions are fleeting, which helps to reduce fear and anxiety.
  • Embrace imperfection. Once you understand that the world is filled with it, it becomes less upsetting.
  • Always try to immerse yourself in your surroundings; this helps you be present and connect with the world around you.
More information: The U.S. National Center for Complementary and Integrative Health has more on the positive brain changes from mindfulness and on meditation itself.

Saturday, October 07, 2017

Seven body organs you can live without

Seven body organs you can live without

The human body is incredibly resilient. When you donate a pint of blood, you lose about 3.5 trillion red blood cells, but your body quickly replaces them. You can even lose large chunks of vital organs and live. For example, people can live relatively normal lives with just half a brain). Other organs can be removed in their entirety without having too much impact on your life. Here are some of the "non-vital organs".

Spleen

07 oct 2017--This organ sits on the left side of the abdomen, towards the back under the ribs. It is most commonly removed as a result of injury. Because it sits close the ribs, it is vulnerable to abdominal trauma. It is enclosed by a tissue paper-like capsule, which easily tears, allowing blood to leak from the damaged spleen. If not diagnosed and treated, it will result in death.
When you look inside the spleen, it has two notable colours. A dark red colour and small pockets of white. These link to the functions. The red is involved in storing and recycling red blood cells, while the white is linked to storage of white cells and platelets.
You can comfortably live without a spleen. This is because the liver plays a role in recycling red blood cells and their components. Similarly, other lymphoidtissues in the body help with the immune function of the spleen.

Stomach

The stomach performs four main functions: mechanical digestion by contracting to smash up food, chemical digestion by releasing acid to help chemically break up food, and then absorption and secretion. The stomach is sometimes surgically removed as a result of cancer or trauma. In 2012, a British woman had to have her stomach removed after ingesting a cocktail that contained liquid nitrogen.
When the stomach is removed, surgeons attach the oesophagus (gullet) directly to the small intestines. With a good recovery, people can eat a normal diet alongside vitamin supplements.

Reproductive organs

The primary reproductive organs in the male and female are the testes and ovaries, respectively. These structures are paired and people can still have children with only one functioning.
The removal of one or both are usually the result of cancer, or in males, trauma, often as a result of violence, sports or road traffic accidents. In females, the uterus (womb) may also be removed. This procedure (hysterectomy) stops women from having children and also halts the menstrual cycle in pre-menopausal women. Research suggests that women who have their ovaries removed do not have a reduced life expectancy. Interestingly, in some male populations, removal of both testicles may lead to an increase in life expectancy
.
Colon

The colon (or large intestine) is a tube that is about six-feet in length and has four named parts: ascending, transverse, descending and sigmoid. The primary functions are to resorb water and prepare faeces by compacting it together. The presence of cancer or other diseases can result in the need to remove some or all of the colon. Most people recover well after this surgery, although they notice a change in bowel habits. A diet of soft foods is initially recommended to aid the healing process

Gallbladder

The gallbladder sits under the liver on the upper-right side of the abdomen, just under the ribs. It stores something called bile. Bile is constantly produced by the liver to help break down fats, but when not needed in digestion, it is stored in the gallbladder.
When the intestines detect fats, a hormone is released causing the gallbladder to contract, forcing bile into the intestines to help digest fat. However, excess cholesterol in bile can form gallstones, which can block the tiny pipes that move bile around. When this happens, people may need their gallbladder removed. The surgery is known as (cholecystectomy. Every year, about 70,000 people have this procedure in the UK.
Many people have gallstones that don't cause any symptoms, others are not so fortunate. In 2015, an Indian woman had 12,000 gallstones removed – a world record.

Appendix

The appendix is a small blind-ended worm-like structure at the junction of the large and the small bowel. Initially thought to be vestigial, it is now believed to be involved in being a "safe-house" for the good bacteria of the bowel, enabling them to repopulate when needed.
Due to the blind-ended nature of the appendix, when intestinal contents enter it, it can be difficult for them to escape and so it becomes inflamed. This is called appendicitis. In severe cases, the appendix needs to be surgically removed.
A word of warning though: just because you've had your appendix out, doesn't mean it can't come back and cause you pain again. There are some cases where the stump of the appendix might not be fully removed, and this can become inflamed again, causing "stumpitis". People who have had their appendix removed notice no difference to their life.

Kidneys

Most people have two kidneys, but you can survive with just one – or even none (with the aid of dialysis). The role of the kidneys is to filter the blood to maintain water and electrolyte balance, as well as the acid-base balance. It does this by acting like a sieve, using a variety of processes to hold onto the useful things, such as proteins, cells and nutrients that the body needs. More importantly, it gets rid of many things we don't need, letting them pass through the sieve to leave the kidneys as urine.
There are many reasons people have to have a kidney – or both kidneys – removed: inherited conditions, damage from drugs and alcohol, or even infection. If a person has both kidneys fail, they are placed onto dialysis. This comes in two forms: haemodialysis and peritoneal dialysis. The first uses a machine containing dextrose solution to clean the blood, the other uses a special catheter inserted into the abdomen to allow dextrose solution to be passed in and out manually. Both methods draw waste out of the body.
If a person is placed on dialysis, their life expectancy depends on many things, including the type of dialysis, sex, other diseases the person may have and their age. Recent research has shown someone placed on dialysis at age 20 can expect to live for 16-18 years, whereas someone in their 60s may only live for five years.

Orthorexia: When 'healthy eating' ends up making you sick

food

07 oct 2017--People, it seems, have never been so afraid of their food—and, say some experts, an obsession with healthy eating may paradoxically be endangering lives.
Twenty-nine-year-old Frenchwoman Sabrina Debusquat recounts how, over 18 months, she became a vegetarian, then a vegan—eschewing eggs, dairy products and even honey—before becoming a "raw foodist" who avoided all cooked foods, and ultimately decided to eat just fruit.
It was only when her deeply worried boyfriend found clumps of her hair in the bathroom sink and confronted her with the evidence that she realised that she was on a downward path.
"I thought I held the truth to food and health, which would allow me to live as long as possible," said Debusquat.
"I wanted to get to some kind of pure state. In the end my body overruled my mind."
For some specialists, the problem is a modern eating disorder called orthorexia nervosa.
Someone suffering from orthorexia is "imprisoned by a range of rules which they impose on themselves," said Patrick Denoux, a professor in intercultural psychology at the University of Toulouse-Jean Jaures.
These very strict self-enforced laws isolate the individual from social food gatherings and in extreme cases, can also endanger health.
Paris nutritionist Sophie Ortega said she had one patient who was going blind due to deficiency of vitamin B12, which is needed to make red-blood cells.
B12 is not made by the body, and most people get what they need from animal-derived foods such as eggs, dairy products, meat or fish or from supplements.
"A pure, unbending vegan," her patient even refused to take the supplements, said Ortega. "It was as if she preferred to lose her sight... rather than betray her commitment to animals."

'Disease disguised as virtue'

The term orthorexia nervosa was coined in the 1990s by the then alternative medicine practitioner Steven Bratman, a San Francisco-based physician.
To be clear, orthorexia is not an interest in healthy eating—it's when enthusiasm becomes a pathological obsession, which leads to social isolation, psychological disturbance and even physical harm. In other words, as Bratman said in a co-authored book in 2000, it's "a disease disguised as a virtue."
But as is often the case in disorders that may have complex psychological causes, there is a strong debate as to whether the condition really exists.
The term is trending in western societies, prompting some experts to wonder whether it is being fanned by "cyber-chondria"—self-diagnosis on the internet.

'Not medically recognised'

Orthorexia is not part of the Diagnostic and Statistical Manual of Mental Disorders, set down by mental health professionals in the United States that is also widely used as a benchmark elsewhere. The fifth edition of this "bible," published in 2013, includes anorexia nervosa and bulimia nervosa, but not orthorexia.
"The term orthorexia was proposed as a commonly used term but it is not medically recognised," said Pierre Dechelotte, head of nutrition at Rouen University Hospital in northern France and head of a research unit investigating the link between the brain and the intestines in food behaviour.
Even so, says Dechelotte, it has a home in the family of "restrictive food-related disorders—but it's not on the radar screen."
Alain Perroud, a psychiatrist who has worked in France and Switzerland over the course of a 30-year career, says orthorexia "is much closer to a phobia" than to a food disorder.
As with other phobias, the problem may be tackled by cognitive behavioural therapy—talking about incorrect or excessive beliefs, dealing with anxiety-provoking situations and using relaxation techniques and other methods to tackle anxiety, he suggested.
Denoux contends that between two and three percent of the French population suffer from orthorexia, but stresses that there is a lack of reliable data as the condition has not been officially recognised.
Denoux's figure seems coherent to Dechelotte, who says that women seem to be more than twice as susceptible to the problem as men.

'Bubble of restriction'

Outside the world of clinicians, orthorexia seems to be creeping into wider usage.
American blogger Jordan Younger has helped to popularise the term, documenting her own painful downward spiral—since reversed—into unhealthy living.
On her blog, she describes it as "a bubble of restriction," obsessing over a diet that was "entirely vegan, entirely plant-based, entirely gluten-free, oil-free, refined sugar-free, flour-free, dressing/sauce-free, etc."
Those who seem to be most worried about healthy food are often concerned about food scandals in the West, Pascale Hebel from the Paris-based CREDOC research centre told AFP.
Over nearly three decades, Europe has experienced a string of food safety scandals—beginning with mad-cow disease and continuing recently with insecticide-contaminated eggs—as well as mounting opposition to the use of antibiotics, genetically modified foods and corporate farming practices.
The disorder reflects a craving for control, suggested Denoux: food is seen as a form of medicine to fix a western lifestyle that may be seen as polluting or toxic.
"We are living through a time of change in our food culture, which has led us to fundamentally doubt what we are eating," said Denoux.
Among believers, this "suspicion of being poisoned is deemed proof of insight."

Thursday, October 05, 2017

No clear evidence that most new cancer drugs extend or improve life

drugs

Even where drugs did show survival gains over existing treatments, these were often marginal, the results show.
Many of the drugs were approved on the basis of indirect ('surrogate') measures that do not always reliably predict whether a patient will live longer or feel better, raising serious questions about the current standards of drug regulation.

05 oct 2017--The researchers, based at King's College London and the London School of Economics say: "When expensive drugs that lack clinically meaningful benefits are approved and paid for within publicly funded healthcare systems, individual patients can be harmed, important societal resources wasted, and the delivery of equitable and affordable care undermined."
The research team analysed reports on cancer approvals by the European Medicines Agency (EMA) from 2009 to 2013.
Of 68 cancer indications approved during this period, 57% (39) came onto the market on the basis of a surrogate endpoint and without evidence that they extended survival or improved the quality of patients' lives.
After a median of 5 years on the market, only an additional 8 drug indications had shown survival or quality of life gains.
Thus, out of 68 cancer indications approved by the EMA, and with a median 5 years follow-up, only 35 (51%) had shown a survival or quality of life gain over existing treatments or placebo. For the remaining 33 (49%), uncertainty remains over whether the drugs extend survival or improve quality of life.
The researchers outline some study limitations which could have affected their results, but say their findings raise the possibility that regulatory evidence standards "are failing to incentivise drug development that best meets the needs of patients, clinicians, and healthcare systems."
Taken together, these facts paint a sobering picture, says Vinay Prasad, Assistant Professor at Oregon Health & Science University in a linked editorial.
He calls for "rigorous testing against the best standard of care in randomized trials powered to rule in or rule out a clinically meaningful difference in patient centered outcomes in a representative population" and says "the use of uncontrolled study designs or surrogate endpoints should be the exception not the rule."
He adds: "The expense and toxicity of cancer drugs means we have an obligation to expose patients to treatment only when they can reasonably expect an improvement in survival or quality of life." These findings suggest "we may be falling far short of this important benchmark."
This study comes at a time when European governments are starting to seriously challenge the high cost of drugs, says Dr Deborah Cohen, Associate Editor at The BMJ, in an accompanying feature.
She points to examples of methodological problems with trials that EMA has either failed to identify or overlooked, including trial design, conduct, analysis and reporting.
"The fact that so many of the new drugs on the market lack good evidence that they improve patient outcomes puts governments in a difficult position when it comes to deciding which treatments to fund," she writes. "But regulatory sanctioning of a comparator that lacks robust evidence of efficacy, means the cycle of weak evidence and uncertainty continues."
In a patient commentary, Emma Robertson says: "It's clear to me and thousands of other patients like me that our current research and development model has failed."
Emma is leader of Just Treatment, a patient led campaign with no ties to the pharmaceutical industry, which is calling for a new system that rewards and promotes innovation, so that more effective and accessible cancer medicines are brought within reach.

More information: Availability of evidence on overall survival and quality of life benefits of cancer drugs approved by the European Medicines Agency: A retrospective cohort study of drug approvals from 2009-2013,www.bmj.com/content/359/bmj.j4530

Editorial: Do cancer drugs improve survival or quality of life? www.bmj.com/content/359/bmj.j4528

Patient commentary: the current model has failed, www.bmj.com/content/359/bmj.j4568

Feature: Cancer drugs: high price, uncertain value, www.bmj.com/content/359/bmj.j4543


Provided by British Medical Journal

Wednesday, October 04, 2017

One hour of exercise a week can prevent depression

exercise

A landmark study led by the Black Dog Institute has revealed that regular exercise of any intensity can prevent future depression - and just one hour can help.
Published today in the American Journal of Psychiatry, the results show even small amounts of exercise can protect against depression, with mental health benefits seen regardless of age or gender.

04 oct 2017--In the largest and most extensive study of its kind, the analysis involved 33,908 Norwegian adults who had their levels of exercise and symptoms of depression and anxiety monitored over 11 years.
The international research team found that 12 percent of cases of depression could have been prevented if participants undertook just one hour of physical activity each week.
"We've known for some time that exercise has a role to play in treating symptoms of depression, but this is the first time we have been able to quantify the preventative potential of physical activity in terms of reducing future levels of depression," said lead author Associate Professor Samuel Harvey from Black Dog Institute and UNSW.
"These findings are exciting because they show that even relatively small amounts of exercise - from one hour per week - can deliver significant protection against depression.
"We are still trying to determine exactly why exercise can have this protective effect, but we believe it is from the combined impact of the various physical and social benefits of physical activity.
"These results highlight the great potential to integrate exercise into individual mental health plans and broader public health campaigns. If we can find ways to increase the population's level of physical activity even by a small amount, then this is likely to bring substantial physical and mental health benefits."
The findings follow the Black Dog Institute's recent Exercise Your Mood campaign, which ran throughout September and encouraged Australians to improve their physical and mental wellbeing through exercise.
Researchers used data from the Health Study of Nord-Trøndelag County (HUNT study) - one of the largest and most comprehensive population-based health surveys ever undertaken - which was conducted between January 1984 and June 1997.
A healthy cohort of participants was asked at baseline to report the frequency of exercise they participated in and at what intensity: without becoming breathless or sweating, becoming breathless and sweating, or exhausting themselves. At follow-up stage, they completed a self-report questionnaire (the Hospital Anxiety and Depression Scale) to indicate any emerging anxiety or depression.
The research team also accounted for variables which might impact the association between exercise and common mental illness. These include socio-economic and demographic factors, substance use, body mass index, new onset physical illness and perceived social support.
Results showed that people who reported doing no exercise at all at baseline had a 44% increased chance of developing depression compared to those who were exercising one to two hours a week.
However, these benefits did not carry through to protecting against anxiety, with no association identified between level and intensity of exercise and the chances of developing the disorder.
According to the Australian Health Survey, 20 percent of Australian adults do not undertake any regular physical activity, and more than a third spend less than 1.5 hours per week being physically active. At the same time, around 1 million Australians have depression, with one in five Australians aged 16-85 experiencing a mental illness in any year.
"Most of the mental health benefits of exercise are realised within the first hour undertaken each week," said Associate Professor Harvey.
"With sedentary lifestyles becoming the norm worldwide, and rates of depression growing, these results are particularly pertinent as they highlight that even small lifestyle changes can reap significant mental health benefits."


Provided by University of New South Wales

Tuesday, October 03, 2017

Biological clock discoveries by three Americans earn Nobel prize 

3 Americans win Nobel medicine prize for circadian rhythms
Winners of the 2017 Nobel Prize for Medicine are displayed, from left, Jeffrey C. Hall, Michael Rosbash and Michael W. Young, during a press conference in Stockholm, Monday Oct. 2, 2017. The Nobel Prize for Medicine has been awarded to the three Americans for discoveries about the body's daily rhythms.
03 oct 2017--Three Americans won a Nobel Prize on Monday for discovering key genetic "gears" of the body's 24-hour biological clock, the mechanism best known for causing jet lag when it falls out of sync.
Problems with our body clock also been linked to such disorders as sleep problems, depression, heart disease, diabetes and obesity. Researchers are now trying to find ways to tinker with the clock to improve human health, the Nobel committee said in Stockholm.
It awarded the $1.1 million (9 million kronor) Nobel Prize in Physiology or Medicine to Jeffrey C. Hall and Michael Rosbash, who worked together at Brandeis University in Massachusetts, and Michael W. Young of Rockefeller University in New York.
They "were able to peek inside our biological clock" and discover details of its inner workings, the Nobel citation said.
The work, done in fruit flies and dating back to 1984, identified genes and proteins that work together in people and other animals to synchronize internal activities throughout the day and night. Various clocks in the brain and elsewhere in the body, working together, regulate things like sleep patterns, eating habits and the release of hormones and blood pressure. Such 24-hour patterns are called circadian rhythms.
At age 72, the retired Hall wryly noted that he was already awake when the call about the prize came around 5 a.m., because of age-related changes in his own circadian rhythms.
"I said 'Is this a prank'?" he told The Associated Press by telephone from his home in Cambridge, Maine.
Rosbash, a 73-year-old professor at Brandeis, told the AP that he and his two colleagues worked to understand "the watch ... that keeps time in our brains."
"You recognize circadian rhythms by the fact that you get sleepy at 10 or 11 at night, you wake up automatically at 7 in the morning, you have a dip in your alertness in the midday, maybe at 3 or 4 in the afternoon when you need a cup of coffee, so that is the clock," he explained.
"The fact that you go to the bathroom at a particular time of day, the fact if you travel over multiple time zones your body is screwed up for several days until you readjust—all that is a manifestation of your circadian clock."
3 Americans win Nobel medicine prize for circadian rhythms
This undated photo provided by The Rockefeller University shows Michael W. Young, who was one of three Americans awarded the Nobel Prize in Physiology or Medicine on Monday, Oct. 2, 2017, for discoveries about the body's daily rhythms. The other winners are are Jeffrey C. Hall and Michael Rosbash. 
Jay Dunlap, who studies biological clocks in bread mold at Dartmouth College's medical school, called the Nobel-winning work "beautiful." It helped expose the molecular details behind daily rhythms, he said. Such knowledge can be important in telling when to deliver drugs for maximum effect, and perhaps for developing new ones, he said.
Michael Hastings, a scientist at the U.K. Medical Research Council, said the field of body clock study "has exploded massively, propelled by the discoveries by these guys." Nobel committee member Carlos Ibanez said the work helped in understanding how people adapt to shiftwork.
3 Americans win Nobel medicine prize for circadian rhythms
Michael Rosbash takes a phone call at his home, Monday, Oct. 2, 2017, in Newton, Mass. Rosbach is one of the Americans awarded this year's Nobel Prize in physiology or medicine for discovering the molecular mechanisms that control humans' circadian rhythm. 
Young, 68, said genes that control our body clock were revealed "just like puzzle pieces." The research showed "the way they worked together to provide this beautiful mechanism."
Hall said that once scientists understand how the clock normally works, "that gives you a chance, not an inevitability, but a chance to influence the internal workings of the clock and possibly to improve a patient's well-being."
3 Americans win Nobel medicine prize for circadian rhythms
Thomas Perlmann, Chariman of the Nobel Committee of Medicine, announces the winners of the 2017 Nobel Prize for Medicine during a press conference at the Nobel Forum in Stockholm, Monday Oct. 2, 2017. The Nobel Prize for Medicine has been awarded to three Americans for discoveries about the body's daily rhythms. The laureates are Jeffrey Hall, Michael Rosbash and Michal Young. 
Rosbash said he thinks most of the practical applications of the work lie in the future.
A genetic mutation has already been found in some people who have a chronic sleeping problem, Young said.
"This gives us a target to work on (and) ways of thinking we didn't have before," he said. "I think we're going to run into this over and over."
3 Americans win Nobel medicine prize for circadian rhythms
Anna Wedell, chairman of the Nobel committee, center, and members of the committee Juleen Zierath, left, and Carlos Ibanez, announce the winners of the 2017 Nobel Prize for Medicine during a press conference at the Nobel Forum in Stockholm, Monday Oct. 2, 2017. The Nobel Prize for Medicine has been awarded to three Americans for discoveries about the body's daily rhythms. The laureates are Jeffrey c. Hall, Michael Rosbash and Michael W. Young. 
Monday's award was the first of this year's Nobel Prizes to be announced. The physics prize will be given Tuesday, followed by the chemistry prize on Wednesday. The prizes were established by the will of Swedish industrialist Alfred Nobel, who died in 1896.
3 Americans win Nobel medicine prize for circadian rhythms
In this Thursday, Oct. 13, 2016 file photo, permanent Secretary of the Swedish Academy Sara Danius announces that Bob Dylan is awarded the 2016 Nobel Prize in Literature during a presser at the Old Stockholm Stock Exchange Building in Stockholm, Sweden. The panel that awards the Nobel Prize in literature says this year's winner will be announced Thursday, Oct. 5, 2017. In 2015 and 2016, the award went to writers outside the conventional conception of "literature" as novels and poetry. Svetlana Alexievich's books are artistic sociopolitical reportage, and Bob Dylan's lyrics arguably have more power as song than on the page. 

3 Americans win Nobel medicine prize for circadian rhythms
In this Jan. 12, 2012, file photo, Bob Dylan performs in Los Angeles. The panel that awards the Nobel Prize in literature says this year's winner will be announced Thursday, Oct. 5, 2017. In 2015 and 2016, the award went to writers outside the conventional conception of "literature" as novels and poetry. Svetlana Alexievich's books are artistic sociopolitical reportage, and Bob Dylan's lyrics arguably have more power as song than on the page. 
3 Americans win Nobel medicine prize for circadian rhythms
Michael Rosbash smiles during an interview at his home, Monday, Oct. 2, 2017, in Newton, Mass. Rosbach is one of the Americans awarded this year's Nobel Prize in physiology or medicine for discovering the molecular mechanisms that control humans' circadian rhythm. 
3 Americans win Nobel medicine prize for circadian rhythms
Michael Rosbash smiles during an interview at his home, Monday, Oct. 2, 2017, in Newton, Mass. Rosbach is one of the Americans awarded this year's Nobel Prize in physiology or medicine for discovering the molecular mechanisms that control humans' circadian rhythm. 
3 Americans win Nobel medicine prize for circadian rhythms
Michael Rosbash takes a phone call at his home, Monday, Oct. 2, 2017, in Newton, Mass. Rosbach is one of the Americans awarded this year's Nobel Prize in physiology or medicine for discovering the molecular mechanisms that control humans' circadian rhythm. 

Recent winners of the Nobel Medicine Prize
Here is a list of the winners of the Nobel Medicine Prize in the past 10 years, awarded on Monday to US geneticists Jeffrey Hall, Michael Rosbash and Michael Young for their work on internal biological clocks:
2017: US geneticists Jeffrey Hall, Michael Rosbash and Michael Young for their discoveries on the internal biological clock that governs the wake-sleep cycles of most living things.
2016: Yoshinori Ohsumi of Japan for his work on autophagy—a process whereby cells "eat themselves"—which when disrupted can cause Parkinson's and diabetes.
2015: William Campbell (US citizen born in Ireland) and Satoshi Omura (Japan), Tu Youyou (China) for unlocking treatments for malaria and roundworm.
2014: John O'Keefe (Britain, US), Edvard I. Moser and May-Britt Moser (Norway) for discovering how the brain navigates with an "inner GPS".
2013: Thomas C. Suedhof (US citizen born in Germany), James E. Rothman and Randy W. Schekman (US) for work on how the cell organises its transport system.
2012: Shinya Yamanaka (Japan) and John B. Gurdon (Britain) for discoveries showing how adult cells can be transformed back into stem cells.
2011: Bruce Beutler (US), Jules Hoffmann (French citizen born in Luxembourg) and Ralph Steinman (Canada) for work on the body's immune system.
2010: Robert G. Edwards (Britain) for the development of in-vitro fertilisation.
2009: Elizabeth Blackburn (Australia-US), Carol Greider and Jack Szostak (US) for discovering how chromosomes are protected by telomeres, a key factor in the ageing process.
2008: Harald zur Hausen (Germany), Francoise Barre-Sinoussi and Luc Montagnier (France) for work on the viruses causing cervical cancer and AIDS.

More information: www.nobelprize.org/nobel_prize … ates/2017/press.html

Monday, October 02, 2017

Study ranks safety, effectiveness of cognitive enhancers for Alzheimer's


Study ranks safety, effectiveness of cognitive enhancers for Alzheimer's
Dr. Andrea Tricco.
A new study ranking the safety and effectiveness of four drugs taken to enhance concentration, memory, alertness and moods, found that donepezil was most likely to effectively improve cognition in patients with Alzheimer's dementia.

02 oct 2017--However, patients who took donepezil were more likely to experience side effects including nausea, vomiting and diarrhea than those who received a placebo, according to the study, published online today in the Journal of the American Geriatrics Society.
In 2015, 46 million people worldwide had Alzheimer's disease, according to the study. In 2013, 146,593 people aged 65 and older in Ontario alone used cognitive enhancers, according to a 2016 Ontario Drug Policy Research report.
"Alzheimer's dementia is the most common form of dementia in North America, and most people who have moderate to severe Alzheimer's will be on these medications," said Dr. Andrea Tricco, a scientist in the Li Ka Shing Knowledge Institute of St. Michael's Hospital and lead author of the study. "This analysis will give both patients and clinicians a full picture of how each of these drugs will likely affect their cognition, as well as their overall health."
Although there have been previous reviews of the safety and effectiveness of cognitive enhancers in treating Alzheimer's dementia, the authors said this was the first to rank their comparative safety and effectiveness.
The study used network meta-analysis, an advanced statistical analysis technique, to systematically review existing evidence from 142 clinical trials of four common cognitive enhancers administered alone or in combination published between 1996 and 2015. The number of patients in each study ranged from 13 to 2,045, and the review evaluated a total of 33,889 patients.
The researchers compared the safety and effectiveness of any combination of donepezil, rivastigmine, galantamine or memantine in treating moderate to severe Alzheimer's dementia based on the results of the clinical trials that examined a number of patient outcomes, including cognition, function behaviour, global status, mortality, serious adverse events, falls, bradycardia, headache, diarrhea, vomiting and nausea. Donepezil was likely the most effective medication for Alzheimer's dementia across all effectiveness outcomes, including cognition, behavior and overall health, according to the study.
Donepezil was also the only cognitive enhancer that reached the minimal clinically important threshold—meaning effects on outcomes were observed clinically, as well as statistically—on the Alzheimer's Disease Assessment cognition scale, making it the likely first choice for those patients and clinicians considering these medications, the authors said.
Although no significant risk of serious harm, falls or reduced heart rate was associated with any of the medications in the study, the data was limited on these specific outcomes.
Previous research by the authors found that cognitive enhancers do not improve cognition or function in people with mild cognitive impairment, and these patients experience significantly more nausea, diarrhea, vomiting and headaches.
The findings of the current study will help guide patients and clinicians who are making decisions about the best course of treatment for Alzheimer's dementia, said Dr. Tricco.
"The more information we are able to gather about how each of these medications can affect a patient's cognition and health, the more likely we are to be able to improve their health outcomes," she said.


Provided by St. Michael's Hospital

Saturday, September 30, 2017

One in three older adults take something to help them sleep but many don't talk to their doctors

1 in 3 older adults take something to help them sleep but many don't talk to their doctors
The percentage of Americans age 65-80 who report trouble falling asleep. 
Sleep doesn't come easily for nearly half of older Americans, and more than a third have resorted to some sort of medication to help them doze off at night, according to new results from the National Poll on Healthy Aging.

30 sept 2017--But most poll respondents said they hadn't talked to their doctor about their sleep, even though more than a third said their sleep posed a problem. Half believe—incorrectly—that sleep problems just come naturally with age.
The poll was conducted by the University of Michigan Institute for Healthcare Policy and Innovation, and is sponsored by AARP and Michigan Medicine, U-M's academic medical center.
Those who turn to medications may not realize that prescription, over-the-counter and even "natural" sleep aids carry health risks, especially for older adults, either alone or in combination with other substances. In fact, national guidelines strongly warn against prescription sleep medicine use by people over age 65.
Despite this, the nationally representative poll of people ages 65 to 80 finds that 8 percent of older people take prescription sleep medicine regularly or occasionally. Among those who report sleep troubles three or more nights a week, 23 percent use a prescription sleep aid. Most who use such drugs to help them sleep had been taking them for years. Manufacturers and the U.S. Food and Drug Administration say such drugs are only for short-term use.

Medication: not the only option

"Although sleep problems can happen at any age and for many reasons, they can't be cured by taking a pill, either prescription, over-the-counter or herbal, no matter what the ads on TV say," says poll director Preeti Malani, M.D., a U-M physician trained in geriatric medicine. "Some of these medications can create big concerns for older adults, from falls and memory issues to confusion and constipation," even if they're sold without a prescription.
"The first step for anyone having trouble sleeping on a regular basis should be to talk to a doctor about it," she continues. "Our poll shows that nearly two-thirds of those who did so got helpful advice - but a large percentage of those with sleep problems simply weren't talking about it."
She notes that non-medication-based sleep habits are the first choice for improving sleep in older people. Sleep and health
In all, 46 percent of those polled had trouble falling asleep one or more nights a week. Fifteen percent of the poll respondents said they had trouble falling asleep three or more nights a week.
1 in 3 older adults take something to help them sleep but many don't talk to their doctors
This image shows what older Americans (age 65-80) are taking to help them get to sleep. National guidelines recommend that prescription sleep aids not be used by people in this age group. 
Other health conditions can contribute to sleep difficulties. Twenty-three percent of poll respondents who had trouble sleeping said it was because of pain. And 40 percent of those with frequent sleep problems said their overall health was fair or poor. Other reasons for sleep troubles included having to get up to use the bathroom at night, and worry or stress.
Insomnia and other irregular sleep patterns can interfere with daytime functioning, and are associated with memory issues, depression and an increased risk of falls and accidents. Even so, many said they didn't see sleep issues as a health problem - in fact, this belief was the most common reason that poll respondents said they didn't talk to their doctor about sleep.
This also highlights the need for doctors to ask their older patients about their sleep habits and what they're doing to address any issues they may be having
"We know that sleep is a critical factor for overall health as we age, and this new research highlights sleep problems as both a significant health issue for older adults and an underacknowledged one both by patients and their providers," says Alison Bryant, Ph.D., senior vice president of research for AARP. "We need to help people understand that lack of sleep is not just a natural part of aging."

More about medication use

In all, 14 percent of the poll respondents said they regularly took a prescription sleep medication, prescription pain medication, OTC sleep aid or herbal supplement to help them sleep. Another 23 percent took one of these options occasionally; most of the occasional users said they chose OTC sleep aids.
The most recent Beers Criteria established by the American Geriatrics Society, which guides the use of medications among older people, gives a strong warning against use of prescription sleep drugs, which are sold under such names as Ambien, Lunesta and Sonata.
Meanwhile, even though OTC sleep aids can be purchased without a doctor's guidance or prescription, they still carry health risks for older people, Malani notes. Most of them contain diphenhydramine, an antihistamine that can cause side effects such as confusion, urinary retention and constipation.
Among poll respondents with frequent sleep problems who took something occasionally to help them sleep, OTC sleep remedies were the most common choice. But among those with frequent sleep issues who took something on a regular basis to try to sleep, prescription sleep medications were the most common option, with 17 percent reporting use.
Use of melatonin and other herbal remedies may be perceived as safer, but less is known about their potential side effects and they are not subject to the FDA's approval process for medications, says Malani. But any issue that prompts someone to buy an OTC or herbal remedy on a regular basis is something they should discuss with their doctor, she adds.
The poll results are based on answers from a nationally representative sample of 1,065 people ages 65 to 80, who answered a wide range of questions online. Questions were written, and data interpreted and compiled, by the IHPI team. Laptops and Internet access were provided to poll respondents who did not already have it.
A full report of the findings and methodology is available at www.healthyagingpoll.org


Provided by University of Michigan

Friday, September 29, 2017

Aging populations often thoroughly contemplate housing decisions, researchers find

Aging populations often thoroughly contemplate housing decisions, researchers find

As people approach their final stage of life, whether they decide to remain in their home or seek to move to a more supportive place, it's often a well-thought-out choice and not a reactive decision, according to a new study that includes a University of Kansas researcher.

29 sept 2017--"The literature discusses housing choices and decisions as people reacting to events, such as they become sick or the neighborhood changes around them," said David Ekerdt, professor of sociology and gerontology. "This model is that people are reacting to external events, but our view is that people are proactive and always thinking about what might happen and whether their living arrangement is good for them."
Ekerdt is the corresponding author of a study, "Residential Reasoning and the Tug of the Fourth Age," which will appear in the October issue of the journal The Gerontologist. His co-author on the paper is Catheryn Koss, a KU graduate, who is now at Sacramento State University.
The researchers interviewed 30 community-dwelling retirees ages 67-97 in the United States about how they prepared for the future, including their housing decisions.
Gerontology researchers have termed the "third age" as an active retirement where people have left their traditional work and family roles though they are still relatively independent. The "fourth age" refers to the next phase, which might include disability or a health decline toward the end of one's life.
The study is part of the larger international project "Aging as Future" supported by a grant from the Volkswagen Foundation in Germany. Ekerdt has joined with researchers from the Chinese University of Hong Kong, North Carolina State University at Raleigh, the University of Erlangen-Nuremberg in Germany and the University of Jena in Germany.
Ekerdt said the findings about how people later in life think about their housing decisions is important because it provides a different angle to the perception that people often wait and react based on a health event or some other immediate circumstance.
"In this case, people are constantly having the specter of the fourth age ahead of them. They are continually thinking about, 'Where is the best place that I should grow old?'" he said. "People are continually thinking about and evaluating the residences where they live."
The researchers did identify two categories of people based on how they did approach their housing decisions: pre-emptive and contingent. Participants who used pre-emptive reasoning anticipated their current homes would be suitable over the long term, and they explained why. Those who engaged in contingent reasoning imagined a possible future move to more supportive housing and possibly had a destination in mind.
Several factors could also influence which camp respondents landed in, Ekerdt said, including the effects of peers and relationship with spouses and children.
Either way, the process was something that seemed to be well thought out, he said.
"The fourth age is remarkably present to people's imagination about the future," Ekerdt said. "'What would happen if I was to become unable to function in the place that I'm living?'—as opposed to other decisions you might make and put aside."
These findings might be good news for companies who market senior housing or for those who renovate homes, he said.
"There is a great opportunity to try to reach people as they are processing their setting and their dwellings," Ekerdt said. "Later-life housing also has other implications. Homes are very important to health care and people's ability to fit into their environments. A dwelling not just a place to live. It's a place to manage your health."

More information: Catheryn Koss et al. Residential Reasoning and the Tug of the Fourth Age, The Gerontologist (2016). DOI: 10.1093/geront/gnw010


Provided by University of Kansas

Thursday, September 28, 2017

Exercise, not vitamin D, recommended to prevent falls

Exercise, not vitamin D, recommended to prevent falls
Falls and fractures are a major cause of disability in old age. An influential U.S. medical task force is recommending exercise and, in some cases, medical evaluation to help seniors stay on their feet.

28 sept 2017--But the new draft recommendations from the U.S. Preventive Services Task Force (USPSTF) say there isn't enough evidence at this time to either endorse or advise against taking vitamin D or calcium supplements to prevent broken bones.
And based on current evidence, the panel recommends against taking vitamin D solely to prevent falls.
For Americans 65 and older, falls are the leading cause of injuries and injury-related deaths, according to the U.S. Centers for Disease Control and Prevention. On average, one older person falls every second in the United States, the CDC says.
"Fortunately, there are things we can do to help prevent falls," said Dr. Alexander Krist, a task force member.
However, "we found that it is unclear whether vitamin D and calcium can help prevent fractures at higher doses," said Krist, an associate professor of family medicine and population health at Virginia Commonwealth University. "They do not prevent fractures at lower doses."
More research is needed to evaluate the potential benefit of high-dose calcium and vitamin D supplementation for fracture prevention after menopause, the task force noted.
"We hope that you talk to your primary care provider about exercise to prevent falls if you have any concerns about falling, as well as vitamin D or calcium supplementation if you have any questions about your personal risk of fractures," Krist added.
The USPSTF, an independent panel of experts, provides guidance to physicians about how to prevent medical problems.
The proposed guidelines are intended to help prevent falls and fractures in generally healthy adults aged 65 and older who live at home and don't have medical problems such as osteoporosis, vitamin D deficiency, Parkinson's disease or dementia.
After reviewing the available studies, "we found that exercise had a moderate benefit in preventing falls in older adults at increased risk for falls," Krist said.
The task force didn't suggest any particular type of exercise. Still, "supervised exercise that improves balance, the way someone walks, and helps with completing common tasks are helpful," Krist said.
"These can be done in group or individual classes and either at home or in the community. Patients should talk with their clinician about what exercise programs are best for them," he added.
The task force also recommends that health care providers "selectively check older adults' risks for falls, and then offer tailored interventions that address those specific risks."
However, one expert doubts that such risk assessments will become common.
"Medical offices are businesses. Anything that adds time to the office visit, without adding revenue, is unlikely to be added to the majority of visits," said Dr. Chris Sciamanna, a professor of medicine and public health sciences at Penn State College of Medicine. He wasn't involved in writing the draft recommendations.
Sciamanna suggested that seniors test themselves: "If you can't stand on either leg for 10 seconds without grabbing onto something, you're at risk and should talk to your doctor," he said.
But, he added, "the reality is that there's little for doctors to do other than to refer you to an exercise program or, in some cases, reduce the dose of a medicine that may be hurting your balance, like a blood pressure medicine."
In a perfect world, Sciamanna said, he would have his patients enroll in a strength and balance program three times each week, and also "get aerobic exercise, preferably something that would be fun and build their agility."
Although the task force recommends against taking vitamin D to prevent falls, there's no recommendation regarding whether seniors should take vitamin D for general health.
As for other ideas, the task force said there's not enough evidence to show the value of single strategies like managing medications or making the home environment safer.
The task force released its draft recommendations Sept. 26 and is accepting comments about them on their website until Oct. 23.

More information: Alexander Krist, M.D., MPH, associate professor of family medicine and population health, Virginia Commonwealth University, Richmond, Va.; Chris Sciamanna, M.D., MPH, professor, medicine and public health sciences and vice chair, research, department of medicine, Penn State College of Medicine, Hershey, Pa.; U.S. Preventive Services Task Force, draft recommendations, Sept. 26, 2017.

Evidence Review 1
Draft Recommendation Statement 1
Comment on Recommendation 1
Evidence Review 2
Draft Recommendation Statement 2
Comment on Recommendation 2

Tuesday, September 26, 2017

How ketogenic diets curb inflammation

How ketogenic diets curb inflammation
Ketogenic diets – extreme low-carbohydrate, high-fat regimens that have long been known to benefit epilepsy and other neurological illnesses – may work by lowering inflammation in the brain, according to new research by UC San Francisco scientists.

26 sept 2017--The UCSF team has discovered a molecular key to the diet's apparent effects, opening the door for new therapies that could reduce harmful brain inflammation following stroke and brain trauma by mimicking the beneficial effects of an extreme low-carb diet.
"It's a key issue in the field – how to suppress inflammation in the brain after injury," said Raymond Swanson, MD, a professor of neurology at UCSF, chief of the neurology service at the San Francisco Veterans Affairs Medical Center, and senior author of the new study.
In the paper, published online Sept. 22 in the journal Nature Communications, Swanson and his colleagues found the previously undiscovered mechanism by which a low-carbohydrate diet reduces inflammation in the brain. Importantly, the team identified a pivotal protein that links the diet to inflammatory genes, which, if blocked, could mirror the anti-inflammatory effects of ketogenic diets.
"The ketogenic diet is very difficult to follow in everyday life, and particularly when the patient is very sick," Swanson said. "The idea that we can achieve some of the benefits of a ketogenic diet by this approach is the really exciting thing here."

Low-Carb Benefits

The high-fat, low-carbohydrate regimen of ketogenic diets changes the way the body uses energy. In response to the shortage of carb-derived sugars such as glucose, the body begins breaking down fat into ketones and ketoacids, which it can use as alternative fuels.
In rodents, ketogenic diets – and caloric restriction, in general – are known to reduce inflammation, improve outcomes after brain injury, and even extend lifespan. These benefits are less well-established in humans, however, in part because of the difficulty in maintaining a ketogenic state.
In addition, despite evidence that ketogenic diets can modulate the inflammatory response in rodents, it has been difficult to tease out the precise molecular nuts and bolts by which these diets influence the immune system.

Intricate Molecular Waltz

In the new study, the researchers used a small molecule called 2-deoxyglucose, or 2DG, to block glucose metabolism and produce a ketogenic state in rats and controlled laboratory cell lines. The team found that 2DG could bring inflammation levels down to almost control levels.
"I was most surprised by the magnitude of this effect, because I thought ketogenic diets might help just a little bit," Swanson said. "But when we got these big effects with 2DG, I thought wow, there's really something here."
The team further found that reduced glucose metabolism lowered a key barometer of energy metabolism – the NADH/NAD+ ratio – which in turn activated a protein called CtBP that acts to suppress activity of inflammatory genes.
In a clever experiment, the researchers designed a drug-like peptide molecule that blocks the ability of CtBP to enter its inactive state – essentially forcing the protein to constantly block inflammatory gene activity and mimicking the effect of a ketogenic state.
Peptides, which are small proteins, don't work well themselves as drugs because they are unstable, expensive, and people make antibodies against them. But other molecules that act the same way as the peptide could provide ketogenic benefits without requiring extreme dietary changes, Swanson said.
The study has applications beyond brain-related inflammation. The presence of excess glucose in people with diabetes, for example, is associated with a pro-inflammatory state that often leads to atherosclerosis, the buildup of fatty plaques that can block key arteries. The new study could provide a way of interfering with the relationship between the extra glucose in patients with diabetes and this inflammatory response.

More information: Yiguo Shen et al. Bioenergetic state regulates innate inflammatory responses through the transcriptional co-repressor CtBP, Nature Communications (2017). DOI: 10.1038/s41467-017-00707-0


Provided by University of California, San Francisco

Saturday, September 23, 2017

Bicycling 'overloads' movement networks with Parkinson's

Bicycling 'Overloads' movement networks with parkinson's
Bicycling suppresses abnormal beta synchrony in the Parkinsonian basal ganglia, according to a study published online Sept. 11 in the Annals of Neurology.

23 sept 2017--Lena Storzer, Ph.D., from Heinrich Heine University Düsseldorf in Germany, and colleagues compared bicycling and walking in Parkinson's disease patients (five patients with and eight patients without freezing of gait) with electrodes implanted in the subthalamic nuclei for deep brain stimulation. Low (13 to 22 Hz) and high (23 to 35 Hz) beta power changes were analyzed in 13 patients (57.5 years; four female).
The researchers found that in patients without freezing of gait, both bicycling and walking led to a suppression of subthalamic beta power (13 to 35 Hz), and this suppression was stronger for bicycling. For those with freezing of the gait, a similar pattern was observed, in general. However, a movement-induced, narrowband power increase around 18 Hz was evident even in the absence of freezing.
"Abnormal ~18 Hz oscillations are implicated in the pathophysiology of freezing of gait, and suppressing them may form a key strategy in developing potential therapies," the authors write.
Several authors disclosed financial ties to the medical device industry.

More information: Abstract
Full Text (subscription or payment may be required)

Friday, September 22, 2017

Pelvic Floor Society statement—use of mesh surgeries for constipation and rectal prolapse

In light of ongoing concerns by the media and the public surrounding the use of mesh in women with pelvic organ prolapse and urinary incontinence, the Pelvic Floor Society has issued a consensus statement addressing the use of mesh for the treatment of constipation and rectal prolapse (via a surgical procedure called ventral mesh rectopexy, or VMR). The Statement is published in Colorectal Disease.

22 sept 2017--Mesh is a synthetic or biological material used to offer extra internal support. In a small number of patients, such meshes may cause problems, but according to the Pelvic Floor Society, evidence suggests that mesh-related complications for VMR are far lower than those seen in transvaginal procedures. The Society's statement addresses proper training and accreditation regarding VMR, as well as recommendations on tracking and recording complications and providing detailed consent forms and information booklets to patients.
"This important paper presents the evidence to support the use of Ventral Mesh Rectopexy in the treatment of constipation and rectal prolapse. It should reassure the profession and public that we take potential mesh complications very seriously," said Andrew Williams, Chair of the Pelvic Floor Society. "We are doing everything possible to improve education, provide detailed patient information, and record any complications to better understand the outcomes following this surgery."

More information: Colorectal DiseaseDOI: 10.1111/codi.13893


Provided by Wiley

Thursday, September 21, 2017

Do ketogenic diets help you lose weight?

Do ketogenic diets help you lose weight?
Ketogenic diets involve eating mostly fats. 
Is a ketogenic diet effective for weight loss? The answer depends on whether it achieves a reduction in total kilojoule intake or not.

What is a ketogenic diet?

A classical ketogenic diet follows a strict ratio for total grams of fat to combined grams of carbohydrate and protein and typically has 80-90% of total kilojoules coming from fat, which is very high fat. Carbohydrate intake varies from 20 to 50 grams a day, or 5-10% of total energy, while protein intakes are moderate.
The difference between a strict ketogenic diet and diets that are described as low-carb is that ketogenic diets specifically aim to achieve elevated blood levels of ketone bodies which are chemicals produced as a consequence of your body burning fat. Hence general low-carb diets are not as high in fat as classical ketogenic diets.
Research on the use of classical ketogenic diets for weight loss is limited. But there are many studies that compare lower-carb diets to other approaches.
These show that aiming for a carbohydrate restriction of 20-30 grams a day, without setting a daily kilojoule target, leads to 2-4 kilograms greater weight loss compared to a low kilojoule diet, in studies up to six months.
In longer studies with follow-up between one to five years there is no difference in weight loss. A review of weight loss diets with a moderate carbohydrate restriction (45% or less of total energy intake) compared to low fat diets (under 30% fat) found they were equally effective in reducing body weight in studies from six months to two years.

How much carbohydrate do we eat?

In Australia, current carbohydrate intakes range from approximately 210 to 260 grams a day, or about 45% of total energy intake. More than a third of what Australians currently eat comes from discretionary, or "junk" foods. It is definitely a good idea to cut down on discretionary foods. These are commonly ultra-processed and contain refined carbohydrates and include burgers, chips, pizza, crumbed foods, biscuits, cake, pastry, lollies, cordial, sugar sweetened juices and soft drink.
The problem is most people do not eat enough minimally processed, nutrient rich foods that contain carbohydrate, like legumes, wholegrain breads, cereals and other grains, vegetables, fruit, nuts, milk and yoghurt. These foods contain important nutrients, from dietary fibre, to B vitamins, and minerals and trace elements like iron, zinc, magnesium, calcium, selenium and iodine.
Your body needs these nutrients for digestion, metabolism, growth and repair of cells and to help protect the brain, heart, muscles and nerves.

What happens when you go on a ketogenic diet to lose weight?

If you severely limit all foods that contain carbohydrate, such as during a ketogenic diet, you end up cutting out many foods. This means you eat less total kilojoules and therefore lose weight.
Whether you follow a classical ketogenic diet or a very low energy diet you may end up producing "ketone bodies", which may help with weight loss, particularly fat mass.
Carbohydrate is used in the body as the major source of fuel, like petrol is used to fuel a car. Your body has a store of carbohydrate in the liver and muscles called glycogen. When glycogen stores are low your body switches to burning fat, which leads to production of ketone bodies.
Glycogen becomes limited when your total energy intake is very low, such as during a strict weight loss diet, a fast, or when you do not eat foods containing carbohydrate. This means your body burns the fat you eat, as well as body fat, leading to a loss of stored body fat. You still produce small amounts of glucose through a process called gluconeogenesis by breaking down protein and some fat.
Ketogenic diets and appetite
A systematic review evaluated how people perceived their appetite before and during a very low energy diet that contained less than 3,300 kilojoules a day or a ketogenic low carbohydrate diet containing less than 10% energy from carbohydrate (50 grams or less per day). Those following the very low energy diet reported less hunger and greater fullness and satiety during weight loss, while those following the ketogenic diet reported feeling less hunger and having less desire to eat. The authors concluded that although the absolute change in subjective appetite ratings were small, they were important in terms of helping people stick to a weight loss diet.
One research study followed 18 obese men during eight weeks of a ketogenic very low energy diet of 2300-2700 kilojoules per day, followed by four weeks of weight maintenance. They measured changes in appetite and blood concentrations of appetite hormones and ketones.
While hunger increased significantly by day three and up until the men lost 5% of their starting body weight, it did not get worse after that while they were dieting. Once they increased their food intake during maintenance, they had an increase in hunger. The good news was that while they were producing ketones, they appeared to be able to tolerate feeling hungry.

Ketogenic diets and weight loss

One randomised controlled trial randomly allocated 45 obese adults to either a ketogenic low energy diet of 2500-300 kilojoules per day for about two months or a low kilojoule diet where total daily energy intake was reduced by 10%.
As you would expect, those in the low energy group lost significantly more weight after one year. After two years, and accounting for those who dropped out, both groups lost weight (low energy 7kg versus 5.3kg low kilojoule). Of note was that a greater number in the low energy group lost 5% or more of their initial body weight at 12 months.
systematic review of nine studies in adults with type 2 diabetes following lower-carb diets (less than 130 grams a day or less than 25% energy from carbohydrate) compared to control weight loss diets found weight loss was greater up to one year in the lower-carb groups.
While there was no long-term difference in weight loss between dietary approaches, blood triglyceride concentrations were significantly lower and HDL (good) cholesterol concentrations were higher, but there was no reduction in total or LDL (bad) cholesterol.

Should you or shouldn't you?

If you have a family history of bowel cancer then don't follow a ketogenic weight loss diet. The World Cancer Research Fund has shown convincing evidence for a higher risk of colorectal cancer in association with low fibre and higher red and processed meat intakes.
Prevention guidelines recommend having greater variety, and higher intakes, of legumes, wholegrains, non-starchy vegetables and fruit.
When it comes to weight management, reduce your carbohydrate intake by reducing energy-dense, nutrient-poor foods. Increase minimally processed foods high in fibre and phytonutrients, including vegetables, legumes/pulses and wholegrains and only use classical ketogenic diets under supervision of your health care team.
This article was originally published on The Conversation. Read the original article.The Conversation

Provided by The Conversation

Sunday, September 17, 2017

Seven steps to keep your brain healthy from childhood to old age

brain

A healthy lifestyle benefits your brain as much as the rest of your body—and may lessen the risk of cognitive decline (a loss of the ability to think well) as you age, according to a new advisory from the American Heart Association/American Stroke Association.

17 sept 2017--Both the heart and brain need adequate blood flow, but in many people, blood vessels slowly become narrowed or blocked over the course of their life, a disease process known as atherosclerosis, the cause of many heart attacks and strokes. Many risk factors for atherosclerosis can be modified by following a healthy diet, getting enough physical activity, avoiding tobacco products and other strategies.
"Research summarized in the advisory convincingly demonstrates that the same risk factors that cause atherosclerosis, are also major contributors to late-life cognitive impairment and Alzheimer's disease. By following seven simple steps—Life's Simple 7—not only can we prevent heart attack and stroke, we may also be able to prevent cognitive impairment," said vascular neurologist Philip Gorelick, M.D., M.P.H., the chair of the advisory's writing group and executive medical director of Mercy Health Hauenstein Neurosciences in Grand Rapids, Michigan.
Life's Simple 7 outlines a set of health factors developed by the American Heart Association to define and promote cardiovascular wellness. Studies show that these seven factors may also help foster ideal brain health in adults.
The Life's Simple 7 program urges individuals to:
  • Manage blood pressure
  • Control cholesterol
  • Keep blood sugar normal
  • Get physically active
  • Eat a healthy diet
  • Lose extra weight
  • Don't start smoking or quit
A healthy brain is defined as one that can pay attention, receive and recognize information from our senses; learn and remember; communicate; solve problems and make decisions; support mobility and regulate emotions. Cognitive impairment can affect any or all of those functions.
The advisory, which is published in the American Heart Association's journal Stroke, stresses the importance of taking steps to keep your brain healthy as early as possible, because atherosclerosis—the narrowing of the arteries that causes many heart attacks, heart failure and strokes—can begin in childhood. "Studies are ongoing to learn how heart-healthy strategies can impact brain health even early in life," Gorelick said. Although more research is needed, he said, "the outlook is promising."
Elevations of blood pressure, cholesterol and blood sugar can cause impairment of the large and smaller blood vessels, launching a cascade of complications that reduce brain blood flow. For example, high blood pressure—which affects about 1 in 3 U.S. adults—is known to damage blood vessels that supply oxygen and nutrients to the heart and the brain, Gorelick noted. The damage can lead to a buildup of fatty deposits, or atherosclerosis as well as associated clotting. This narrows the vessels, can reduce blood flow to the brain, and can cause stroke or "mini-strokes." The resulting mental decline is called vascular cognitive impairment, or vascular dementia.
Previously, experts believed problems with thinking caused by Alzheimer's disease and other, similar conditions were entirely separate from stroke, but "over time we have learned that the same risk factors for stroke that are referred to in Life's Simple 7 are also risk factors for Alzheimer's disease and possibly for some of the other neurodegenerative disorders," Gorelick said.
The advisory also recognizes that it is important to follow previously published guidance from the American Heart Association, Institute of Medicine and Alzheimer's Association, which include controlling cardiovascular risks and suggest social engagement and other related strategies for maintaining brain health.
The action items from Life's Simple 7, which are based on findings from multiple scientific studies, meet three practical rules the panel developed in pinpointing ways to improve brain health—that they could be measured, modified and monitored, Gorelick said. Those three criteria make it possible to translate knowledge into action because healthcare providers can assess Life's Simple 7 elements—like blood pressure—easily; they can encourage proven, health-promoting steps and they can gauge changes over time.
The AHA advisory provides a foundation on which to build a broader definition of brain health that includes other influential factors, Gorelick said, such as the presence of atrial fibrillation, a type of irregular heartbeat that has been linked to cognitive problems; education and literacy; social and economic status; the geographic region where a person lives; other brain diseases and head injuries.
It is also a starting point for expanding research into areas such as whether there might be detectable markers, like genetic or brain imaging findings, that represent a susceptibiity for cardiovascular or brain illness, Gorelick said. "At some point in our lives, a 'switch' may be getting ready to 'flip,' or activate, that sets us in a future direction whereby we become at-risk for cognitive impairment and dementia."
Dementia is costly to treat. Direct care expenses are higher than for cancer and about the same for heart disease, estimates show. Plus, the value of unpaid caregiving for dementia patients may exceed $200 billion a year.
As lives stretch longer in the U.S. and elsewhere, about 75 million people worldwide could have dementia by 2030, according to the advisory. "Policy makers will need to allocate healthcare resources for this," Gorelick said. Monitoring rates of dementia in places where public health efforts are improving heart health "could provide important information about the success of such an approach and the future need for healthcare resources for the elderly," he said.
The authors of the advisory reviewed 182 published scientific studies to formulate their conclusions that following Life's Simple 7 has the potential to help people maintain a healthy brain throughout life.

More information: Stroke: Journal of the American Heart AssociationDOI: 10.1161/STR.0000000000000148


Provided by American Heart Association