Carol Thatcher: I always thought of Mum as being 100% cast-iron damage-proof

By Carol Thatcher
31 aug 2008--I remember the moment it first hit me that my mother's memory was no longer the extraordinary phenomenon it had been all my life. The realisation came as a thunderbolt.
It was the summer of 2000 - a decade after she'd left Downing Street - and I had invited her to lunch at the Mandarin Oriental hotel in Knightsbridge, overlooking Hyde Park.
As an economy gesture on my behalf, my mother insisted we book into the coffee shop rather than the fancy restaurant. We settled into our seats and gazed out across Hyde Park, where joggers, pram-pushers and cyclists were enjoying the summer sunshine
It was such a rare mother-and-daughter occasion, I relished it. Mum was hardly a 'lady who lunched' and I'd had to wait months to find a space in her diary when we could get together.
It's not always easy to make polite, lunchtime conversation with a mother who for decades has had international leaders and statesmen to engage with in potentially world-changing discussions.
Having ordered our lunch, I reminisced about the night she'd become Conservative Party leader in 1975. After finishing my law exam I'd walked through Hyde Park on my way home, wondering what the future would hold.
'Oh, how I wish I could do it all again,' she said, brightening at the mention of her stupendous victory. I guess you can get politicians out of politics, but you can't get politics out of them.
A mutual friend had recently told me he'd attended a dinner party with my parents at which General Sir Michael Rose, commander of the UN Protection Force in Bosnia in the mid-Nineties, was the guest of honour. I mentioned it to Mum and added: 'That must have been interesting.'
'It was,' she replied. Even though Mum had been out of office for ten years, she kept up with international events.
I expected her to give me chapter and verse on Bosnia, and sat back, waiting for a characteristic monologue. But she soon became confused, and a few sentences later discussion of Bosnia had moved to the Falklands as she muddled the Falklands conflict with the Yugoslav wars.
I almost fell off my chair. Watching her struggle with her words and her memory, I couldn't believe it. She was in her 75th year but I had always thought of her as ageless, timeless and 100 per cent cast-iron damage-proof.
The contrast was all the more striking because, until that point, she'd always had a memory like a website.
When she learned Latin at school, she absorbed the vocabulary and declensions with her blotting-paper brain. It was a skill honed to perfection during her chemistry degree at Oxford, when scientific equations added yet another dimension to an already orderly mind.
When she read law and qualified as a barrister, her memory training was complete.
By the time she entered politics she was famous for not only reading and analysing her briefs but also virtually knowing them off by heart. During Prime Minister's Questions, she could rise from the front bench in an economic debate and recite the rate of inflation all the way back to William Gladstone without a note.
From the fateful day of our lunch, telltale signs that something wasn't quite right began to emerge.
Whereas previously you would never have had to say anything to her twice, because she'd already filed it away in her formidable memory bank, Mum started asking the same questions over and over again, unaware she was doing so.
It might be something innocuous - such as 'What time is my car coming?' or 'When am I going to the hairdresser?' - but the fact she needed to repeat them opened a new and frightening chapter in our lives.
I had to learn to be patient, a quality I admit is in short supply. I also had to learn she had an illness and that it wasn't personal.
That's the worst thing about dementia: it gets you every time. Sufferers look and act the same but beneath the familiar exterior something quite different is going on. They're in another world and you cannot enter.
Much of my mother's daily life was affected. Timing became a particular concern.
If I said: 'Oh, do relax, Mum. The car won't be here for ten minutes,' she'd jump up, hook her handbag over her arm and say: 'Ten minutes? I'll go down now,' as if I'd said 30 seconds.
Such memory loss often begins with short-term breakdown. I described this to a friend, who said: 'Carol, it must be awful for you.'
'That's not my worry,' I replied. 'I suspect it's immensely frustrating for her.'
On any visit, I'd pop into the kitchen to scan the noticeboard where her calendar was written out, before going to see her in the sitting room.
'Hi, Mum,' I'd say, 'how was your lunch with so-and-so in the House of Lords?' She'd look up as if she barely recognised me and say: 'Did I, darling?'
Her doctor recommended she make no more public speeches on health grounds, a ban she reluctantly observed.
As she became increasingly frail, many of her friends and colleagues became extraordinarily considerate when dealing with the new Lady T.
The woman who had dominated discussions for so long could no longer lead debates or keep up with the thread of a drinks-party conversation. On bad days, she could hardly remember the beginning of a sentence by the time she got to the end.
One night in March 2004, when I knew there were a couple of political colleagues coming for dinner, I grabbed a copy of the Evening Standard on the way to Mum's house.
The big story was the terrorist bombs that had killed 191 people in Madrid that day. I tried to explain the story to Mum before her guests got there, but she had no recollection of it by the time they arrived and asked: 'Margaret, if you were Prime Minister, what would be the first action you would take?'
Mum's situation began to dominate my life but I couldn't bring myself to see such films as Iris, about novelist Iris Murdoch's slide into dementia, or Away From Her, starring Julie Christie as a septuagenarian who is in the early stages of Alzheimer's and moves into a care home.
I had to remind myself that we were lucky. Friends had to drop everything to race to opposite ends of the country to attend to ailing parents who lived alone or without proper supervision. My mother would always have a driver and a 14-hour police guard, not to mention enough funds to afford the appropriate nursing care.
Of course, there were flashes of Mum's old self every now and again, particularly when events from the past were mentioned. It was as if the dementia had sharpened her powers of long-term recall. She still had good memories of her time at No 10.
When I invited a friend round to Mum's house for tea, he engaged her in conversation about Mikhail Gorbachev. Quick as a flash, she snapped back into Iron Lady mode and was utterly engaging. She even gave my friend the rundown of a portrait painted of her in her Garter robes, which hangs in her drawing room.
It took us all time to realise that she couldn't remember a newspaper headline she had just read, or what she'd had for breakfast that morning.
But when a friend asked, off the cuff: 'Oh, Margaret, do you remember rationing?' he got a full ten minutes of my mother's best grocer's daughter's tips on how to jazz up tinned Spam or powdered egg.
My mother hadn't mentioned her birthplace, Grantham, to me for many years until it started cropping up in sentences and I realised she now thought of it as her 'home'.
It was a case of classic dementia, coupled with a series of mini-strokes. What was most galling was that there was nothing I could do: this cruel disease takes its own course.
Thank goodness she still had Crawfie, Cynthia Crawford, as her personal-assistant-cum-hairdresser-cum-general-dogsbody, and other loyal devotees around her, not to mention her marmalade rescue cat, Pussikins, who gave her great comfort.
I think her illness must have been especially hard on my father. He was always there for support and counsel, from their marriage in 1951 through to the birth of Mark and me in 1953 and her election as Prime Minister in 1979.
Advising her, of course, sometimes meant voicing uncomfortable views. In 1989, Dad had tried to persuade her to retire on a high in the tenth-anniversary year of her becoming Prime Minister. She had declined, feeling she still had much to do.
A few days after the historic polling day that gave her a third term in 1987, Dad and I were in the flat at No10 and he was fixing us a drink. 'In a year,' he told me, 'she'll be so unpopular you won't believe it.'
Dad was right, although the events that led to her downfall took longer than he predicted.
At the beginning of November 1990, Sir Geoffrey Howe had quit as Deputy Prime Minister over European policy and suggested, in his resignation speech a fortnight later, that others do the same. In the light of Howe's speech, Michael Heseltine, the disgruntled former Cabinet Minister, challenged my mother for the leadership and forced a ballot.
Despite my worries and Dad's pessimism, Mum won the first round. My friends believed she could win the second ballot, but Dad felt differently and was canvassing allies to persuade her not to stand.
When my mother saw her Cabinet colleagues one by one the following day, they told her - almost to a man - that, while they would support her if she stood, she should resign to avoid 'humiliation' and let someone else beat Heseltine.
That night I was dining with Dad and the Tory grandee Alistair McAlpine at a club in Mayfair. My mother was at home. As I closed my front door, I thought: 'Thank God I don't have to worry about her for the next few hours.'
Alistair ordered champagne, saying: 'Everyone knows who we are, so we all have to look frightfully up.' But he told me privately that the Cabinet had defected one by one and that Mum had decided to resign. I couldn't believe it.
I accompanied Dad home, asking our driver to drop us at Horse Guards Parade so we could enter the flat without facing the reporters outside Downing Street.
My father rang just after eight the following morning, November 22, his voice sounding strained. 'There have been all sorts of consultations and your mother...' he began.
'I know, Dad,' I interrupted, sparing him the ordeal of telling me she had decided to resign. There was silence and we finally said goodbye. There was nothing more to say.
I called Mum's secretary, Joy Robilliard, at No 10 to be told that my mother was not taking calls. 'She's OK but a bit weepy and liable to break down if anyone says anything nice to her.' Joy's voice, too, sounded strange.
'I'm not going to speak to her because I think I might cry,' I said.
The announcement came at 9.25am. It was brief and explosive.
'Having consulted widely among my colleagues,' she said, 'I have concluded that the unity of the party and the prospects of victory in a General Election would be better served if I stood down to enable Cabinet colleagues to enter the ballot for the leadership.'
I was distressed at the way my mother had been treated and was worried about the impact such rejection would have on a woman whose adult life had been devoted to politics. She knew no other.
Change is always hard but particularly when your home for the past decade has been one of the most famous addresses in the world.
It wasn't just that my mother and father no longer lived at No 10. Chequers - that splendid weekend retreat where staff even leave the Radio Times open at the correct day - had been lost to them, too.
The first Sunday after her departure from Downing Street, I found Mum in the sitting room of her newly bought house in Dulwich, South London, reading the newspapers with the aid of a magnifying glass.
This may not seem unusual, but in the previous 11 years she had rarely lifted a Sunday paper from the neatly laid-out selection on the sideboard at Chequers.
'I must keep in touch, keep up with the news,' she explained, desperate to remain in the loop.
More than once I saw her, while watching some crisis on television, instinctively reach for the phone before realising it was now someone else's problem.
She was at least able to retain her driver and police protection after leaving office, but the former told me he avoided driving up Whitehall because as their car passed Downing Street she would look up wondering why they hadn't turned in. Then she would remember.
In truth, neither of my parents handled each other's old age and ailing health well.
In early 2003, Dad decided to go on an extended trip to South Africa, which he had loved all his life. As a precaution, and because he was 84 and getting a little breathless, his doctor gave him a check-up. An irregular heart murmur was detected and he was booked in for heart surgery.
Characteristically, the minute Dad was out of hospital - ten days after a six-hour heart bypass operation - he set himself a rigorous convalescence schedule, determined to get well enough to make his trip.
He checked into a country-house hotel on the edge of the New Forest to recuperate and I went to visit him.
As we went into the restaurant for lunch, the maitre d' told me how much they admired Dad because when he first arrived he'd needed a walking stick to get across the room and now he could manage without.
True to his plan, two months after his operation Dad went to South Africa, where my brother Mark was living and where my father had worked in earlier years. Mark took him to Victoria Falls in Zimbabwe and other places my father hadn't visited for many years.
When asked, I publicly stated that his remarkable recovery must be down to 'copious gin-drinking'.
The first time I saw him on his return, I found him in the sitting room of his London home. 'Hi, Dad,' I said, thrilled to see him looking tanned and well and relaxed.
'Sorry, Carol Jane,' he said, 'can't get up to greet you. Bit of a problem with my knees.'
'Oh, what a bore!' I cried. 'What about physiotherapy?'
'No. I'm going to see the doc about replacement kneecaps.'
'What?' I spluttered. 'You've just had major heart surgery. What is this? Your year for new spare parts?' He laughed.
None of us knew that he was within a few weeks of the end. Soon afterwards he was again taken to hospital, and pancreatic cancer was diagnosed.
He died on June 23, 2003. We were all by his bedside. His death was a huge shock, but when I look back I am grateful that it was mercifully quick.
Dad's funeral was on a glorious summer's day in the chapel designed by Christopher Wren at the Royal Hospital, Chelsea, where my parents had been frequent Sunday worshippers.
Three months later, a memorial service for 600 friends and family - including at least ten former Cabinet Ministers - was held at the Guards Chapel in Wellington Barracks.
Veteran journalist Bill Deedes described Dad as a vast improvement on the 'Private Eye model', referring to the satirical magazine's portrayal of Dad as a golf fan fond of copious snifters at the 19th hole. Lord Deedes added: 'A lot more than golf and gin and funny friends went into the making of that Denis Thatcher.'
We posed for a family photograph afterwards; images of my mother's tearful face dominated the next day's newspapers.
My mother once said of my father: 'I could never have been Prime Minister for more than 11 years without Denis by my side ...
'He was a fund of shrewd advice and penetrating comment. And he very sensibly saved these for me rather than the outside world ...
'Being Prime Minister is a lonely job. In a sense, it ought to be - you cannot lead from a crowd. But with Denis there I was never alone. What a man, what a husband, what a friend.'
The BBC reported that my father's motto as a Prime Minister's consort was: 'Always present, never there.'
On my loo wall at home, outnumbered heavily by cartoons starring my mother, is just one remembering Dad but it's probably the one I treasure the most. It's a newspaper cartoon featuring an imaginary tombstone for my father with the words: 'Gone to the 19th hole.'
It makes me smile every time. Losing Dad, however, was truly awful for Mum, not least because her dementia meant she kept forgetting he was dead. I had to keep giving her the bad news over and over again.
Every time it finally sank in that she had lost her husband of more than 50 years, she'd look at me sadly and say 'Oh,' as I struggled to compose myself. 'Were we all there?' she'd ask softly.
These days, my mother cannot remember every detail of her time at No 10 or particular pieces of legislation she created but she has told me she thinks her place in history is assured.
I recently heard her enlightening some American visitors that in her day you went into politics to do something and today, it seems, people enter Parliament to be someone.
I have constant reminders of her practical contributions to British life. One morning, I got into a car taking me to a television studio and started chatting to the driver. He enthused that he had bought his council house at the very first opportunity under Tory legislation and, unsurprisingly, sang my mother's praises. Now that truly is a political legacy.
Angry miners, EU battles - and nice earrings
I recently rediscovered a bundle of letters from my mother. Mum somehow found the time to write newsy letters to me, which often started with her wearing her Prime Ministerial hat before she slipped into Mum mode.
Her 1980 Christmas letter on Downing Street notepaper is a good example:
My dear Carol,
Here is the second part of your Christmas present. Alas, we still haven't been able to get nice earrings for pierced ears.
I don't know what kind of Christmas it will be for us. You remember that last year [the Soviet invasion of] Afghanistan happened on Boxing Day. This year we keep a watchful eye on Poland [where the Solidarity trade union was making waves] but at home we have the [Republican] hunger strike in the Maze Prison and it looks as if those on it are going to continue until death - and that would be about Christmas time. Our fear is that those deaths would cause violence and strife on the streets in Northern Ireland.
The next six months will be difficult politically, especially with rising unemployment, but we shall have to ride the storm. Economically things will get better before the unemployment figures fall.
Some correspondence was spread over several weeks, especially when foreign affairs intervened, as this extract, the second half of a letter, shows:
Dear Carol,
The [EU] budget question is now assuming enormous proportions and France is making difficult statements. I fear we shall have another very nasty session at the summit in Brussels.
This evening after Questions in the House, I am going up to Yorkshire for a tour. We are going to the new Selby coal mine, if we can get in. News has reached us that [National Union Of Mineworkers leader Arthur] Scargill is organising a mass picket of miners and steelworkers to try to prevent me from getting in!
Just to add to our problems, one of the firms I was due to visit chose this week to make 150 research workers redundant and they now have a real problem on their hands with the unions! Not a very nice prospect but we just have to go through with it.
Another came after my mother had given a television interview to Granada's World In Action programme in January 1978. Her comment that British people feared they might be 'rather swamped by people with a different culture' had ignited the immigration debate. This is how Mum described the furore:
My darling Carol,
I seem to have come through a battering these last few weeks. It all started with laryngitis, but as there was no possibility of time off I just had to carry on and it had to come at a particularly busy time. I had some radio and television interviews to do.
As events happened, they asked questions about immigration which I answered in my usual straightforward way - but the commentators haven't stopped talking about it for three whole weeks!
The Labour Party have called me everything under the sun, but we have had about ten thousand letters (extra) - all of them, save a handful, in fervent support. Ted Heath said I hadn't got it right and Enoch Powell said I hadn't got it right, so I must have got it about right if they are both disgruntled!
This letter revealed her emotions at the time of the IRA's assassination of Lord Louis Mountbatten in Sligo Bay, Ireland, on August 27, 1979. Hours later, 18 British soldiers were killed in two bomb attacks at Warrenpoint, South Down:
Dear Carol,
The terrible events of last Monday still dominate one's feelings and the news. We feel equally strongly about the Mountbatten family murders and the . . . British soldiers killed. I decided to go to Ulster last Wednesday to demonstrate togetherness with the people and concern for our soldiers.
Three of those killed in the Army were only 18 - others 19 and 20. It was an appalling waste of young life. I visited the hospital where some of the injured were being treated. I spoke to one policeman who had lost both a leg and an arm in an IRA radio remote-controlled explosion. He was remarkable. He only wanted to get back into the police force.
I did a walkabout in the shopping centre [in Belfast]. The people were marvellous - and they were so glad to see me there and so anxious to express their horror and concern and begged one to 'do something' to stop it. The question is precisely what. So long as there is a safe haven south of the border for terrorists we shall not be able to get on top of the situation.
In the afternoon I flew by helicopter down to the border areas and went to the military post from which our boys were lost. As I came away one of the privates said to me: 'Thank you for coming, at least someone cares.'

A Swim-On Part In The Goldfish Bowl: A Memoir, by Carol Thatcher, will be published by Headline on September 4 .

A Doctor Transformed, Into a Patient

By ABIGAIL ZUGER, M.D.
31 aug 2008--Doctors get seriously ill just like ordinary people, and some of them never recover from the shock. If of a literary bent, they are often moved to reflect for posterity on this disruption of the natural order, detailing their former hubris and the enlightening misery of health care experienced from the other side of the bed.
Against this generally lackluster collection of memoirs, Dr. Thomas Graboys’s stands out as a small wonder. Unsentimental and unpretentious, it manages to hit all its marks effortlessly, creating a version of the old fable as touching, educational and inspiring as if it had never been told before.
The story’s success lies partly in its almost mythic dimensions: Dr. Graboys rose high, and he fell hard. Until age 50 he was a medical version of one of Tom Wolfe’s masters of the universe: a noted Harvard cardiologist beloved by colleagues and patients, happily married to a tall, beautiful blonde. He was a marathon runner, a demon on the tennis courts and ski slopes, and, if he says so himself, a particularly handsome guy.
Then everything fell apart. Over a terrible two-year period Dr. Graboys’s wife died a lingering death from colon cancer. In his grief he barely noticed that he was not functioning quite as well as usual. Those around him figured his fatigue and uncharacteristic fumbling were only to be expected. He pulled himself together, met another woman, and then collapsed on the wedding day — the beginning of physical problems that could no longer be ignored.
It was Parkinson’s disease, the neurological condition that makes the body stiffen and shake, but it took Dr. Graboys many months to take the irrevocable step of giving his problems a name. During that time he went through every rationalization that sick people use to wish away their symptoms, then moved smoothly from denial to deception. “I’m just tired,” he snapped to concerned colleagues, even as he began taking surreptitious clinical notes on his own case.
Only when the chief of neurology at his hospital cheerfully hailed him in the parking garage — “Tom, who is taking care of your Parkinson’s?” — was the terrible word said aloud. Dr. Graboys finally understood that the jig was up.
From this moment his memoir unfolds in multiple layers, some predictable, some quite unexpected.
Dr. Graboys is not the first athlete to go from tennis and skiing to cautious walking and gym work. Nor is he the first good-looking man to watch his body deteriorate, the first father to become increasingly dependent on his children or the first master of the universe to contemplate the loss of his driver’s license.
His reflections as a husband are more unusual. He courted his second wife while still ostensibly healthy, although privately he knew something was wrong. He writes candidly about this duplicity, and the complicated grief and anger that infuse their relationship now as she faces a future of caretaking far different from the one she signed up for.
As a writer, Dr. Graboys is also unusual. Like many patients with Parkinson’s he suffers from a slowly progressive dementia, and is losing not only his physical but also his intellectual self. The memoir is written with a co-author, an arrangement always a little uneasy-making. Yet the voice here is true, somehow almost Parkinsonian in its steady, unadorned, slightly stiff prose.
Finally, Dr. Graboys is hardly the first doctor to find that without the practice of medicine — progressive disability forced him to retire a few years after his diagnosis, at age 62 — he is barely recognizable to himself. But he does one of the best jobs on record of doggedly unpeeling the onion-skin layers of alternating ego and vulnerability that encase the doctor turned patient.
While in practice, Dr. Graboys was a master clinician who often rejected the glittery technology of his specialty for older, slower medicine. His excellence made the transition to patient more difficult than most. He knew how good a doctor he was, and surrendering control of his own case to someone possibly not quite as competent was just impossible. Every instinct told him to be his own doctor, his very own “dream team.”
As he ruefully reports, he is still learning over and over that the doctor who is his own dream team has a fool for a patient. And yet, enough of the old Dr. Graboys comes through that a reader might conclude he would also be foolish to sign off his own case completely.
As he once made a point of involving patients’ families in their care, he invites his own family members to talk directly to the reader. As Dr. Graboys once gave each of his patients a handwritten care plan (“I never gave the patients a photocopy”), he provides readers with Parkinson’s a set of suggestions for improving their own lot.
This is the kind of book inevitably given to medical students to inculcate them in the humanistic dimensions of medicine. I wouldn’t waste it on them. Save it for older doctors, still at the top of their game, gleaming and self-confident. Each of them could use this textbook of the graceful and courageous exit.

The Claim: Manipulating Your Neck Could Lead to a Stroke

By ANAHAD O’CONNOR

THE FACTS
31 aug 2008--Manipulating your neck is supposed to relieve pain, not cause it. But years ago neurologists noticed a strange pattern of people suffering strokes shortly after seeing chiropractors, specifically for neck adjustments.
Their hypothesis was that a chiropractic technique called cervical spinal manipulation, involving a forceful twisting of the neck, could damage two major arteries that lead through the neck to the back of the brain. Strokes in people under age 45 are relatively rare, but these cervical arterial dissections are a leading cause of them.
Studies that followed suggested a link. One at Stanford that surveyed 177 neurologists found 55 patients who suffered strokes after seeing chiropractors. Another, published in the journal Neurologist, said young stroke patients were five times more likely to have had neck adjustments within a week of their strokes than a control group. It estimated an incidence of 1.3 cases for every 100,000 people under 45 receiving neck adjustments.
But other studies have cast doubt. One published this year examined 818 cases of stroke linked to arterial dissections at the back of the neck. Before their strokes, younger patients who saw chiropractors were more likely to have complained beforehand of head and neck pain — symptoms often preceding a stroke — suggesting they had undiagnosed dissections and had sought out chiropractors for relief, not realizing a stroke was imminent.
THE BOTTOM LINE
Forceful neck manipulation seems to carry a small risk of arterial tears.

H.I.V. Is Spreading in New York City at Three Times the National Rate, a Study Finds

By SEWELL CHAN
31 aug 2008--The virus that causes AIDS is spreading in New York City at three times the national rate — an incidence of 72 new infections for every 100,000 people, compared with 23 per 100,000 nationally — according to a study released on Wednesday by the city’s Department of Health and Mental Hygiene.
The findings, based on a new formula developed by the federal Centers for Disease Control and Prevention, estimated that 4,762 New Yorkers contracted H.I.V. in 2006, the most precise estimate the city had ever offered.
But the city stressed that because the method of estimating infections was new, it could not be said definitively whether the number of new infections in the city had increased or decreased from previous years.
Blacks, and men who have sex with other men, are the groups at greatest risk of contracting H.I.V., the study found. A summary of the new data:
¶Men accounted for 76 percent of new H.I.V. infections and women for 25 percent. (The figures exceed 100 percent because of rounding.)
¶Blacks made up 46 percent of the newly infected; Hispanics, 32 percent; and whites, 21 percent. (Figures for other racial or ethnic groups were not provided.)
¶Those under age 20 made up 4 percent of the newly infected; those 20 to 29 years old, 24 percent; those 30 to 39 years old, 29 percent; those 40 to 49 years old, 29 percent; and those 50 and older, 15 percent.
¶Sex between men was the main cause in 50 percent of new infections; high-risk heterosexual sex in 22 percent; intravenous drug use in 8 percent; and unknown or uncertain causes in 18 percent.
Manhattan accounted for 35 percent of new infections; Brooklyn, 26 percent; the Bronx, 19 percent; and Queens, 17 percent.
As the health department has repeatedly noted, gay minority men were particularly at risk. For example, of new H.I.V. infections among men under age 30 who have sex with men, 77 percent were in black or Hispanic men, as were 59 percent of new H.I.V. infections among men ages 30 to 50 who have sex with men.
Over all, the study found some interesting differences between national and local rates of new H.I.V. infections.
Nearly two-thirds of the city’s new infections occurred in people 30 to 50 years old. Nationally, people under 30 accounted for 41 percent of new infections, compared with 28 percent in New York City.
Also, within New York City, whites were infected at four times the national rate, Hispanics at three times the national rate, and blacks at almost twice the national rate.
The health department said in a news release:
“The analytic technique is new, and the estimates may be imprecise, but even a rough gauge of H.I.V. incidence is a valuable tool for understanding — and combating — the spread of H.I.V. The health department’s new estimate includes 2006 incidence figures for different age groups, racial groups and both genders. By repeating the exercise for subsequent years, researchers may be able to discern increases and decreases over time, and target their prevention efforts accordingly.”
Over the past year, the health department has warned that H.I.V. infections among young gay men have risen and that unsafe sex remains common.

Look Closely, Doctor: See the Camera?

By SARAH KERSHAW
31 aug 2008--PSYCHOSIS in the 21st century looks something like this: You think your every move is being filmed for a reality television show starring you, and that everyone in your life is an actor.
Or you think you are under intense surveillance by an army of spies, whom you refer to as the “www people,” as in the World Wide Web, and they wiretap your furniture and appliances.
Or else you refuse to drink water because you fear that another cup drawn from your faucet will, once and for all, deplete the world’s water supply.
Those thoughts are from three case studies of what psychiatrists interested in the intersection of mental illness, culture and society are calling, respectively, Truman Show delusion, Internet delusion and climate change delusion; all of them a window, through madness, into the modern world.
If you have delusions of grandeur in this century, you are probably not Napoleon, but you may be Bill Gates.
The Truman Show delusion, or Truman Syndrome, has drawn attention in recent months, in the United States and Britain, as psychiatrists in both countries describe a small but growing number of psychotic patients who describe their lives as mirroring that of the main character in the 1998 film “The Truman Show.”
Played by Jim Carrey, Truman Burbank leads a mundane existence in the suburbs, starting from the time he was in the womb, while being filmed for a documentary television show that he cannot escape. Everyone is in on it, including his wife, and no one will believe Truman when he discovers clues that his life is being chronicled all the time by cameras.
With Internet delusion, patients typically incorporate the Internet into paranoid thoughts, including a fear that the Web is somehow monitoring or controlling their lives, or being used to transmit photographs or other personal information.
The delusions are fueling a chicken-and-egg debate in psychiatry: Are these merely modern examples of classic paranoia fed by the current cultural landscape, or is there something about media like reality television and the Internet that can push people over the sanity line?
“Most likely these people would be delusional anyway,” said Dr. Joel Gold, a psychiatrist at Bellevue Hospital Center in New York, who said he saw five patients at the hospital from 2002 to 2004 with Truman Show delusion. Dr. Gold and his brother, Dr. Ian Gold, the Canada research chair in philosophy and psychiatry at McGill University in Montreal, came up with the term “Truman Show delusion.”
“But the more radical view is that this pushes some people over the threshold; the environment tips them over the edge,” said Dr. Joel Gold, who is a clinical assistant professor of psychiatry at New York University. “And if culture can make people crazy, then we need to look at it.”
One way of looking at the delusions and hallucinations of the mentally ill is that they represent extreme cases of what the general population, or the merely neurotic, are worried about. Schizophrenics and other paranoid patients can take common fears — like identity theft because of information transmitted on the Internet, or the loss of privacy because of the prevalence of security cameras to fight crime — and magnify them, psychiatrists say.
“There is the old saying that just because you’re paranoid doesn’t mean there’s not somebody after you,” said Dr. Jeffrey A. Lieberman, chairman of the Department of Psychiatry at Columbia University.
The prevailing view in psychiatry is that a delusion is just a delusion, psychosis is psychosis, and the scenery is incidental. Fear, a sense of persecution and grandiosity are static features of delusional thinking, many psychiatrists say.
During World War II, for example, psychotics might have believed a neighbor was a Nazi. During the cold war, they might have thought the K.G.B. or C.I.A. was following them. In a post-Sept. 11 world, the persecutor might be Al Qaeda or the Department of Homeland Security.
“Cultural influences don’t tell us anything fundamental about delusion,” said Vaughan Bell, a psychologist at the Institute of Psychiatry at King’s College in London, who has studied Internet delusion.
“We can look at the influence of television, computer games, rock ’n’ roll, but these things don’t tell us about new forms of being mentally ill,” said Dr. Bell, who said he had also treated patients who believed they were part of a reality television show.
British psychiatrists, writing in this month’s edition of the British Journal of Psychiatry about the phenomenon, called it the Truman syndrome and said they had seen a growing number of patients claiming to be the stars of a filmed reality show.
The Diagnostic and Statistical Manual of Mental Disorders defines a delusion, considered still to be little understood in psychiatry, as, essentially, a false belief that is not grounded in reality and that is held with absolute conviction despite proof to the contrary. The manual lists a caveat that a belief is not delusional if it is something widely accepted by other members of a person’s culture or subculture — for example, religious faith. But some psychiatrists say the exception is too vague.
Some experts studying conditions like Truman Show delusion and other culture-bound delusions, which are specific to a time or place, are questioning the premise that culture is only incidental to psychosis, even as a growing body of evidence has pointed to brain abnormalities and other biological causes for illnesses like schizophrenia.
Psychiatrists have studied delusions like turabosis, which is the belief that one is covered in sand, and which has been documented in Saudi Arabia but would be unlikely to occur in, say, North Dakota.
Another study found a delusion occurring only in rural West Bengal, India, in which women and men bitten by dogs believe they have become pregnant with puppies.
Dr. Joel Gold, who is writing a book about Truman Show delusion with his brother, said that three of the five patients he saw with the condition specifically mentioned the film. He said what distinguishes this delusion from most others is that it involves the patient’s entire world, and everything real is unreal.
Other delusions are typically narrowly focused — there is a microchip in my brain, aliens are trying to abduct me, I’ve been to Mars — and in those, things that are not real become real.
One of Dr. Gold’s patients told him, “My family and everyone I knew were actors in a script, a charade whose entire purpose is to make me the focus of the world’s attention.”
Another patient traveled to New York City and showed up at a federal building in downtown Manhattan seeking asylum so he could get off his reality show, Dr. Gold said.
The patient reported that he also came to New York to see if the Twin Towers were still standing, because he believed that seeing their destruction on Sept. 11 on television was part of his reality show. If they were still standing, he said, then he would know that the terrorist attack was all part of the script.
Psychiatrists say that other movies whose characters are living in a unreal world or being watched by malevolent forces, including “The Matrix,” “Edtv” and even the film based on George Orwell’s “1984,” have come up in conversations with psychotic patients. But the premise of “The Truman Show” (“What if you were watched every moment of your life?” according to a promotional blurb) is strikingly similar to what patients describe as their own experiences.
Reinforcing their beliefs is the fact that in the movie, Truman is right about being watched and recorded at all times. Every other character is part of the conspiracy.
Since the Golds first presented their findings in 2006, they have learned of about 40 cases of people who say they are experiencing the delusion or have in the past. Sometimes patients contact them directly.
Recently, Joel Gold received an e-mail message from a woman who told him, “It’s my show.”

Cialis, Viagra Labels to Note Amnesia
Rare Reports of Transient Global Amnesia Going on Cialis, Viagra Labels; Already on Levitra Label

By Miranda Hitti
31 aug 2008-- All three erectile dysfunction drugs -- Cialis, Levitra, and Viagra -- now list rare reports of transient global amnesia on their labels.
Transient global amnesia, or TGA, is a brief bout of amnesia, not lasting longer than a day, without causing other problems.
Levitra added transient global amnesia to its label earlier this year. And now, FDA records show that Cialis and Viagra will make similar additions to their labels.
Those label changes don't amount to warnings or precautions. Instead, they'll be listed in the "Post-Marketing" section of the drugs' labels.
There's no proof that any of the erectile dysfunction drugs cause transient global amnesia, which can happen for various reasons; it can even be triggered by sex.
Drug Companies Respond
The drug company Pfizer makes Viagra; Eli Lilly and Company makes Cialis. WebMD asked both companies for their comments on their drug's label change.
Sally Beatty, director of Worldwide Communications for Pfizer, emailed Pfizer's statement, which notes that Pfizer "regularly monitors and evaluates any adverse events reported to Pfizer directly or indirectly through secondary sources. We also routinely conduct reviews of both clinical and post-marketing safety surveillance data. To date, the data do not suggest a causal relationship between the use of Viagra and transient global amnesia."
Pfizer also states that when used as prescribed, Viagra has been shown to be a "safe and effective treatment for erectile dysfunction across a broad range of men with ED," and has been used by more than 35 million worldwide since 1998.
Keri McGrath, a spokeswoman for Lilly, tells WebMD that "we carefully monitor safety data associated with the use of Cialis and we review this data for adverse events on an ongoing basis, and this data is regularly shared with the regulatory bodies globally."

Flu shot does not reduce risk of elderly death

30 aug 2008--The widely-held perception that the influenza vaccination reduces overall mortality risk in the elderly does not withstand careful scrutiny, according to researchers in Alberta. The vaccine does confer protection against specific strains of influenza, but its overall benefit appears to have been exaggerated by a number of observational studies that found a very large reduction in all-cause mortality among elderly patients who had been vaccinated.
The results will appear in the first issue for September of the American Journal of Respiratory and Critical Care Medicine, a publication of the American Thoracic Society.
The study included more than 700 matched elderly subjects, half of whom had taken the vaccine and half of whom had not. After controlling for a wealth of variables that were largely not considered or simply not available in previous studies that reported the mortality benefit, the researchers concluded that any such benefit "if present at all, was very small and statistically non-significant and may simply be a healthy-user artifact that they were unable to identify."
"While such a reduction in all-cause mortality would have been impressive, these mortality benefits are likely implausible. Previous studies were likely measuring a benefit not directly attributable to the vaccine itself, but something specific to the individuals who were vaccinated—a healthy-user benefit or frailty bias," said Dean T. Eurich,Ph.D. clinical epidemiologist and assistant professor at the School of Public Health at the University of Alberta. "Over the last two decades in the United Sates, even while vaccination rates among the elderly have increased from 15 to 65 percent, there has been no commensurate decrease in hospital admissions or all-cause mortality. Further, only about 10 percent of winter-time deaths in the United States are attributable to influenza, thus to suggest that the vaccine can reduce 50 percent of deaths from all causes is implausible in our opinion."
Dr. Eurich and colleagues hypothesized that if the healthy-user effect was responsible for the mortality benefit associated with influenza vaccination seen in observational studies, there should also be a significant mortality benefit present during the "off-season".
To determine whether the observed mortality benefits were actually an effect of the flu vaccine, therefore, they analyzed clinical data from records of all six hospitals in the Capital Health region in Alberta. In total, they analyzed data from 704 patients 65 years of age and older who were admitted to the hospital for community-acquired pneumonia during non-flu season, half of whom had been vaccinated, and half of whom had not. Each vaccinated patient was matched to a non-vaccinated patient with similar demographics, medical conditions, functional status, smoking status and current prescription medications.
In examining in-hospital mortality, they found that 12 percent of the patients died overall, with a median length of stay of approximately eight days. While analysis with a model similar to that employed by past observational studies indeed showed that patients who were vaccinated were about half as likely to die as unvaccinated patients, a finding consistent with other studies, they found a striking difference after adjusting for detailed clinical information, such as the need for an advanced directive, pneumococcal immunizations, socioeconomic status, as well as sex, smoking, functional status and severity of disease. Controlling for those variables reduced the relative risk of death to a statistically non-significant 19 percent.
Further analyses that included more than 3,400 patients from the same cohort did not significantly alter the relative risk. The researchers concluded that there was a difficult to capture healthy-user effect among vaccinated patients.
"The healthy-user effect is seen in what doctors often refer to as their 'good' patients— patients who are well-informed about their health, who exercise regularly, do not smoke or have quit, drink only in moderation, watch what they eat, come in regularly for health maintenance visits and disease screenings, take their medications exactly as prescribed— and quite religiously get vaccinated each year so as to stay healthy. Such attributes are almost impossible to capture in large scale studies using administrative databases," said principal investigator Sumit Majumdar, M.D., M.P.H., associate professor in the Faculty of Medicine & Dentistry at the University of Alberta.
The finding has broad implications:
For patients: People with chronic diseases such as chronic respiratory diseases such as chronic obstructive pulmonary disease, immuno-compromised patients, healthcare workers, family members or friends who take care of elderly patients and others with greater exposure or susceptibility to the influenza virus should still be vaccinated. "But you also need to take care of yourself. Everyone can reduce their risk by taking simple precautions," says Dr. Majumdar. "Wash your hands, avoid sick kids and hospitals during flu season, consider antiviral agents for prophylaxis and tell your doctor as soon as you feel unwell because there is still a chance to decrease symptoms and prevent hospitalization if you get sick— because flu vaccine is not as effective as people have been thinking it is."
For vaccine developers: Previously reported mortality reductions are clearly inflated and erroneous–this may have stifled efforts at developing newer and better vaccines especially for use in the elderly.
For policy makers: Efforts directed at "improving quality of care" are better directed at where the evidence is, such as hand-washing, vaccinating children and vaccinating healthcare workers.
Finally, Dr. Majumder said, the findings are a reminder to researchers that "the healthy-user effect is everywhere you don't want it to be."

National guidelines released for earwax removal

Alexandria, Va, 30 aug 2008 - The American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) will issue the first comprehensive clinical guidelines to help health care practitioners identify patients with cerumen (commonly referred to as earwax) impaction. The guidelines emphasize evidence-based management of cerumen impaction by clinicians, and inform patients of the purpose of ear wax in hearing health.
"Approximately 12 million people a year in the U.S. seek medical care for impacted or excessive cerumen," said Richard Rosenfeld, MD, MPH, Chair of the AAO-HNSF Guideline Development Task Force. "This leads to nearly 8 million cerumen removal procedures by health care professionals. Developing practical clinical guidelines for physicians to understand the harm vs. benefit profile of the intervention was essential."
Cerumen, commonly called "earwax," is not really a "wax" but a water-soluble mixture of secretions (produced in the outer third of the ear canal), plus hair and dead skin, that serves a protective function for the ear. Cerumen is a natural product that should not be routinely removed unless impacted.
Cerumen impaction occurs when enough earwax accumulates to cause symptoms (pain, fullness, itching, odor, tinnitus, discharge, cough, or hearing loss), or to prevent needed assessment of the ear. The problem affects 1 in 10 children, 1 in 20 adults, and greater than one-third of the elderly and cognitively impaired.
"Unfortunately, many people feel the need to manually 'remove' cerumen from the ears," said Peter Roland, MD, Chair of the Cerumen Impaction Guideline Panel. "This can result in further impaction and other complications to the ear canal."
Any excessive cerumen normally migrates out of the ear canal automatically, assisted by motion of the jaw (e.g., chewing), and carries with it dirt, dust, and other small particles in the ear canal.
Recognizing that patients may seek care from many different types of health care providers, the guidelines are intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction.
Key features of the new guidelines include:
Cerumen is a beneficial, self-cleaning agent, with protective, lubricating (emollient), and antibacterial properties.
Clinicians should examine patients with hearing aids for cerumen impaction because it may cause feedback, reduce sound intensity, or damage the hearing aid.
Cerumen may cause reversible hearing loss when it blocks 80 percent or more of the ear canal diameter.
Appropriate options for cerumen impaction are (1) cerumenolytic (wax-dissolving) agents, which include water, saline, and other agents of comparable efficacy, (2) irrigation or ear syringing, which is most effective when a cerumenolytic is instilled 15-30 minutes prior, and (3) manual removal with special instruments or a suction device, which is preferred for patients with narrow ear canals, eardrum perforation or tube, or immune deficiency.
Inappropriate or harmful interventions are cotton-tipped swabs, oral jet irrigators, and ear candling.
Clinicians should assess patients at the conclusion of in-office treatment for cerumen impaction and document resolution of the impaction.
There are no proven ways to prevent cerumen impaction, but not inserting cotton-tipped swabs or other objects in the ear canal is strongly advised; individuals at high risk (e.g., hearing aid users) should consider seeing a clinician every 6-12 months for routine cleaning.
"The complications from cerumen impaction can be painful and ongoing, including infections and hearing loss," says Dr. Roland. "It is hoped that these guidelines will give clinicians the tools they need to spot an issue early and avoid serious outcomes."
The guidelines were created by a multidisciplinary panel of clinicians representing the fields of otolaryngology, audiology, family medicine, geriatrics, internal medicine, nursing, and pediatrics.
###
"Clinical Practice Guideline on Cerumen Impaction" will appear as a supplement to the September 2008 issue of Otolaryngology – Head and Neck Surgery, the peer-reviewed scientific journal of the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) and the American Academy of Otolaryngic Allergy. The guidelines will also be presented in a seminar during the 2008 AAO-HNSF Annual Meeting & OTO EXPO in Chicago, September 21 – 24, 2008.

Sex differences seen in response to common antidepressant

30 aug 2008--Women are 33 percent more likely than men to experience full remission with citalopram (Celexa), suggesting a biological basis for difference in response
ANN ARBOR, Mich. — Women with depression may be much more likely than men to get relief from a commonly used, inexpensive antidepressant drug, a new national study finds. But many members of both sexes may find that it helps ease their depression symptoms.
The persistence of a gender difference in response to the drug — even after the researchers accounted for many complicating factors — suggests that there's a real biological difference in the way the medication affects women compared with men. The reasons for that difference are still unclear, but further studies are now examining hormonal variations that may play a role.
The study involved citalopram, a commonly used antidepressant that is available both as a generic drug and under the brand name Celexa.
Researchers from the University of Michigan Depression Center and their colleagues from around the country tested the drug's ability to help depression patients achieve remission, or total relief from their symptoms, in a multi-year study called STAR*D.
The gender differences emerged from a detailed analysis of data from 2,876 men and women who had a clear diagnosis of major depression, and took citalopram over a number of weeks, with the doses increasing over time.
In the end, women were 33 percent more likely to achieve a full remission of their depression, despite the fact that women in the study were more severely depressed than the men when the study began.
The study showed no differences between men and women in side effects, the amount of time that patients stuck to taking the drug, or the amount of time it took for them to achieve remission of their symptoms.
The new findings, which represent the largest and most rigorous analysis ever of gender differences in response to an antidepressant, are published online in the Journal of Psychiatric Research.
Elizabeth Young, M.D., a professor and associate chair of psychiatry at the U-M Medical School and member of the Depression Center, is the study's lead author. "Other studies have suggested that there are differences between men and women in response to different antidepressants, but the evidence has been conflicting," she says. "This study is large enough, and we were able to control for enough complicating factors, that we feel confident there is a true difference. These results have clear implications for the clinical treatment of depression."
Young and her colleagues, including Susan Kornstein, M.D., of Virginia Commonwealth University, and John Rush, M.D., formerly of the University of Texas Southwestern Medical Center at Dallas, conducted the analysis of data from men and women between the ages of 18 and 75, many of whom were being treated by primary care physicians and not psychiatrists. All of the patients had been experiencing depression for years, with the average length of experience around 12 years.
The study was funded by the National Institute of Mental Health. Unlike many previous industry-sponsored studies of antidepressants, it included a "real world" sample of people with major depression, and did not exclude people who had a history of suicidal thinking. The study did not include people with bipolar disorder. Participants in the study could continue with psychotherapy that they had been undergoing before the start of the study, but could take no other antidepressants.
Citalopram is one of a class of medicines known as SSRIs, or selective serotonin reuptake inhibitors. In earlier decades, gender differences had been seen in studies of patients taking an older generation of drugs called tricyclics, with men tending to respond better to such medications. But for more than 15 years, SSRIs have been the first choice for treating depression.
Although the current study didn't look at hormonal variations between men and women that might account for the difference in response to citalopram, Young and her colleagues note that animal studies have shown that estrogen modifies the brain systems involved in the activity of serotonin, a key brain chemical.
Kornstein is leading further analysis of the STAR*D results to look for possible differences among women according to their menopausal status and their use of hormone replacement therapy. Meanwhile, Young's research as a member of the U-M Molecular & Behavioral Neuroscience Institute focuses on the interactions of sex hormones and stress response in depression and other mood disorders.
Overall, women are more affected by depression than men, with about 12 percent of women suffering from some form of depression in a given year compared with 6 percent of men. Depression and other mood disorders are the leading cause of disability among women under the age of 45.
But the study's authors are quick to caution that their findings don't mean that citalopram should only be used in women. Raw data from the study show that 24 percent of men achieved remission with the drug, compared with 29 percent of women. The difference in remission rates grew larger once the researchers adjusted for other factors, but the fact remains that many men were helped.
Rather, they note that STAR*D and other studies have shown that many people with depression need to try several treatments to find the one that's right for them and will produce lasting results.
That's why a new study called CO-MED has begun. Young and colleagues from U-M and around the country are now enrolling people with depression for this study that will assess the impact of combinations of medications. One of the medications in that study is escitalopram, a cousin of citalopram, but it also includes other common SSRI antidepressants.
###
More information on the CO-MED study is available at www.depressioncenter.org/research/co-med.asp. Information on STAR*D is available at www.nimh.nih.gov/health/trials/practical/stard.
In addition to Young, Kornstein and Rush, the study's authors include Sheila Marcus of the U-M Depression Center, Madhukar Trivedi and Diane Warden of UT-Southwestern, Anne Harvey of Via Christi Research, Stephen Wisniewski and G.K. Balasubramani of the University of Pittsburgh and Maurizio Fava of Harvard Medical School.
Reference: Journal of Psychiatric Research, doi:10.1016/j.jpsychires.2008.07.002

Growth factor predicts poor outcome in breast cancer

30 aug 2008--The response to insulin-like growth factor 1 (IGF-I) in breast cancer cells predicts an aggressive tumor that is less likely to respond to treatment, said researchers at Baylor College of Medicine in a report that appears in the current issue of the Journal of Clinical Oncology. The finding gives impetus to the movement to tailor cancer treatments to attributes of the various tumors.
"These findings come at a critical time," said Dr. Adrian Lee, associate professor in the Lester and Sue Smith Breast Center at BCM. "Our goal is to identify biomarkers that will help predict which patients will respond to therapy against insulin-like growth factor. Several inhibitors of the IGF pathway are in patient studies right now. There's a large movement to understand which patients will respond to these drugs. This is a step toward that goal"
In this study, Lee and his colleagues stimulated breast cancer cells with IGF-I in the laboratory and defined how more than 800 genes in the cells responded to the growth factor. They then examined samples of patient breast tumors with this "gene signature" and correlated the gene signatures with the fate of the patients.
"We have technology now to allow us to globally assess what IGF is doing in breast cancer at the whole gene expression level," said Lee. "This is one of the first studies to do that. We know that IGF is bad in cancer, but now we can globally understand it in a more comprehensive manner. It could lead to finding biomarkers for patients response" to breast cancer treatments.
"We found that IGF-I is a major regulator of cell growth and cell survival," said Lee. "It also regulates DNA repair."
This has major implications for anti-cancer treatments that seek to cause DNA damage and tumor cell death.
"If you have something regulating DNA repair, you want that turned off," said Lee.
They found that tumors in which IGF (insulin-like growth factor) affected the way in which genes were activated or translated into messages were more aggressive and more likely to grow. They also found that the effect of IGF was independent of whether the tumor was affected by estrogen or not.
"This is very important," said Lee. "Once patients are resistant to hormone treatment (as with tamoxifen), their treatment options are limited. A treatment that inhibited receptors for IGF might give them another option."
Currently, the Breast Center is studying the effects of an IGF receptor antibody combined with a drug called exemestane (Aromasin® or an aromatase inhibitor that blocks estrogen production) in postmenopausal women. One group of women take the combination and the other takes exemestane.
Bioinformatics – the ability to analyze large amounts of data – proved key to the study, said Lee. In fact, the first author, Dr. Chad J. Creighton of BCM, is a bioinformatician, said Lee.
###
Others who took part in this research include Angelo Casa, ZaWaunyka Lazard, Shixia Huang, Anna Tsimelzon, Susan G. Hilsenbeck and C. Kent Osborne, all of BCM.
Funding for this work came from the National Institutes of Health and the Baylor College of Medicine/AstraZeneca Alliance.
The full article is available at http://jco.ascopubs.org/.

Activity key to breast cancer patients' survival

By Anne Harding
30 aug 2008--Women who stay active after being diagnosed with breast cancer -- and even those who take up exercise for the first time after diagnosis -- have a better chance of surviving the disease, a new study shows.
"Anything is better than nothing," Dr. Melinda L. Irwin of the Yale School of Medicine in New Haven, Connecticut, one of the researchers on the study, told Reuters Health. "We actually observed benefits with just doing a little bit of exercise."
Dozens of studies over the past two decades have shown that exercising can reduce breast cancer risk by up to 40 percent, while more recent research has found that activity has equal or even greater benefits for survival among women with the disease.
To better understand the timing and amount of physical activity necessary to improve survival, Irwin and her team looked at 933 women who had been diagnosed with breast cancer between 1995 and 1998 and were followed until 2004.
They found that women who got the equivalent of at least two to three hours of brisk walking each week in the year before they were diagnosed with breast cancer were 31 percent less likely to die of the disease than women who were sedentary before their diagnosis.
Two years after diagnosis, the women who did any recreational activity at all had a 64 percent lower risk of dying than women who were inactive at that point, while women who got at least two to three hours of brisk walking in weekly reduced their risk of death by 67 percent.
Women who decreased their physical activity after diagnosis were actually four times more likely to die of breast cancer than those who were sedentary and remained so, Irwin and her colleagues found. But those who had been inactive and started exercising after being diagnosed cut their death risk by 45 percent.
Women undergoing breast cancer treatment should think of exercise as a part of their therapy, Irwin said, and be sure to make the time for it, even just by beginning with a 15-minute walk every other day.
Being active isn't only beneficial for survival, Irwin said; it may also help with the increased cardiovascular disease risk that may accompany treatment, and will certainly improve women's quality of life in many ways. "Hopefully this study shows what a major benefit exercise can be," she said.
SOURCE: Journal of Clinical Oncology, August 20, 2008.

All types of antipsychotic drugs increase the risk of stroke

29 aug 2008--All drugs used to treat psychosis are linked to an increased risk of stroke, and dementia sufferers are at double the risk, according to a study published on bmj.com today.
Previous research has shown that second generation (atypical) antipsychotic drugs can increase the chances of patients having a stroke. But the risk of stroke associated with first generation (typical) antipsychotics, and whether the risk differs in people with and without dementia, is not known.
Concerns about an increased risk of stroke among people taking atypical antipsychotic drugs were first raised in 2002, particularly in people with dementia. In 2004, the UK's Committee on Safety of Medicines recommended that these drugs should not be used in people with dementia, despite a lack of clear evidence.
A team of researchers from the London School of Hygiene and Tropical Medicine, examined data from the General Practice Research Database (GPRD), which contains the clinical information of more than six million patients registered at over 400 general practices in the UK.
They assessed the effect of exposure to antipsychotic medication on the incidence of stroke in 6 790 patients with a recorded incident of stroke and at least one prescription of any antipsychotic between January 1988 and the end of 2002.
The authors found that during periods when patients were receiving an antispychotic drug they were 1.7 times more likely to have a stroke, whereas people with dementia were 3.5 times more likely to have a stroke whilst taking any antipsychotic.
The likelihood of having a stroke was slightly higher for people taking atypical antipsychotics than people taking typical antipsychotics.
The study did not look at the specific mechanisms linking antipsychotics and stroke or why the risk is greater with atypical antipsycotics.
Previously, the risk of stroke associated with typical antipsychotics was unclear, say the researchers, but "we have established that all types of antipsychotics carry an increased risk, although the risk might be somewhat higher with the atypical drugs."
They conclude: "We reaffirm that the risks associated with antipsychotic use in patients with dementia generally outweigh the potential benefits, and in this patient group, use of antipsychotic drugs should be avoided wherever possible."

Amyloid-Beta Changes Seen in Injured Brains

By Michael Smith
ST. LOUIS, 29 aug 2008-- In patients with brain injury, recovery is correlated with increased levels of some of the peptides associated with Alzheimer's disease, researchers here said. The finding emerged from the first direct measurement of amyloid-beta levels in the interstitial fluid of the brains of living humans, according to David Brody, M.D., Ph.D., of Washington University and colleagues. The analysis, using a technique called microdialysis, showed that levels of amyloid-beta rose as patients' neurological status improved and fell when it worsened, Dr. Brody and colleagues reported in the Aug. 29 issue of Science. He and colleagues undertook the study -- in 18 patients already undergoing invasive intracranial monitoring after either brain trauma or aneurysmal subarachnoid hemorrhage -- to increase their understanding of the dynamics of amyloid-beta peptides.
Amyloid-beta (especially the 42-amino acid form) plays a central role in the development of Alzheimer's, and people with brain injuries are known to be at higher risk of later developing the illness.
"Amyloid-beta is normally present in the cerebrospinal fluid and it was generally believed to be a normal component of the brain extracellular fluid," he said. "This is the first time that has been demonstrated."
The key finding of the analysis was the close link between neurological status, as measured by the Glasgow Coma Score, and levels of amyloid-beta, he said.
Because the clinical significance of a one-point change in the coma score isn't clear, the researchers assessed changes in the amyloid-beta levels only when the score changed by two or more points.

The correlation "was markedly strong," they found, with a Spearman r of 0.82, which was significant at P<0.0001, and remained "quite robust" when the analysis allowed one-point coma score changes. (The Spearman r was 0.52, which was also significant at P<0.0001).
The correlation was present both in patients with traumatic injury and subarachnoid hemorrhage, Dr. Brody and colleagues reported.
Levels of amyloid-beta were also correlated with physiological markers, they said. Specifically, they were:
Positively correlated with glucose in the brain interstitial fluid (where the Spearman r was 0.45, significant at P<0.0001).
Negatively correlated with the lactate/pyruvate ratio, with a Spearman r of minus 0.40, which was significant at P<0.0001.
Negatively correlated with elevated intracranial pressure (greater than 20 mm Hg) with a Spearman r of minus 0.56, which was significant at P<0.0001.
Negatively correlated with extremes of cerebral temperature, with a Spearman r of minus 0.26, which was significant at P<0.0001.
One implication of the finding is that the level of amyloid-beta reflects brain activity.
The "most likely" explanation, Dr. Brody said, is that the levels rose as patients improved "because synaptic activity in their brains increased concomitantly with the improvement in neurological status."
The study is only a first step in understanding how amyloid-beta levels vary over time, Dr. Brody said. Among other things, the researchers were unable to measure what was happening within the cells of the damaged brains, so that analysis is incomplete.
One immediate clinical implication, he said, is that amyloid-beta levels "could be used as a marker for neurological status," which is now difficult for clinicians to measure.
The study was supported by the NIH, a Burroughs Wellcome Career Award in the Biomedical Sciences, and the Cure Alzheimer's Fund. Eli Lilly and Co. provided antibodies. The researchers reported no conflicts.
Primary source: ScienceSource reference:Brody DL, et al "Amyloid-b dynamics correlate with neurological status in the injured human brain" Science 2008; 321: 1221-24.

DCC: Cost of Alzheimer's Drugs Pales in Comparison with Treatment for Comorbidities

By Crystal Phend
GARDEN GROVE, Calif., 29 aug 2008-- Most of the amount spent on medications for patients with Alzheimer's disease goes to treat other conditions, researchers found.
Drugs to treat Alzheimer's accounted for less than a third of patients' total prescription costs, reported Anna Theodorou, R.Ph., of CVS Caremark in Scottsdale, Arizona, and colleagues, at the Alzheimer's Association Dementia Care Conference here.
These findings from a prescription claims database put costs into perspective, Theodorou said.
"A lot of physicians feel the number one reason for drug discontinuation is cost," she said.
Alzheimer's patients often have multiple comorbidities that contribute to higher annual prescription costs than seen among adults without Alzheimer's, the researchers noted.
But the Alzheimer's-specific medications might have been expected to contribute a larger proportion of drug costs, commented Elizabeth Gould, L.C.S.W., of the Alzheimer's Association, in an interview.
"Most of the medications used to treat Alzheimer's disease are new" without a generic option, she noted.
Theodorou's group had previously studied drug utilization in Caremark's computerized prescription claims database in 2005 before Medicare Part D came into effect.
So they revisited the database, doing a retrospective study of the 367 million prescription claims in the database for 2006 among the 22.9 million members covered by prescription plans administered by Caremark.
These plans included those for Medicaid, Medicare Part D, national and local employers, managed care organizations, and government agencies.
Among the members included in the 2006 analysis, 107,236 used Alzheimer's drug therapy with a particularly high rate among members ages 75 to 84 (663.5 per 10,000 eligible members).
Use of Alzheimer's drugs rose substantially over 2005 (46.7 versus 27.0 users per 10,000 eligible members), primarily because of the introduction of the Medicare Part D benefit, the researchers said.
Donepezil (Aricept) dominated the market, prescribed for 69.6% of all Alzheimer's drug users. The drug also accounted for 52.2% of all Alzheimer's drug prescriptions and 54.4% of drug costs.
Memantine (Namenda) was used by 40.7% of Alzheimer's drug users and accounted for 31.9% of prescriptions and 28% of drug costs.
Although patients taking Alzheimer's drugs averaged a total prescription cost of $3,990 per user annually, only $1,054 of that cost was for Alzheimer's drugs (26%).
Other medication classes accounted for most of the costs. These agents included:
Statins at 8.1% of annual non-Alzheimer's drug costs, which were used by 43.9% of Alzheimer's patients.
Proton pump inhibitors at 6.6% of annual non-Alzheimer's drug costs, which were used by 34.2% of Alzheimer's patients.
Dibenzapines, used by 17.5% of Alzheimer's patients and accounting for 6.5% of yearly non-Alzheimer's drug costs.
Selective serotonin reuptake inhibitors at 5.5% of annual non-Alzheimer's drugs costs and used by 46.3% of Alzheimer's patients.
Altogether, patients who filled a prescription for at least one Alzheimer's drug had lower out-of-pocket costs than other adults insured in Caremark's array of private and public insurers. The average contribution to prescription costs was 16% for Alzheimer's drug users compared with 21.7% for the average member.
The reason for this difference may be that a higher proportion of the Alzheimer's patients were on Medicare or Medicaid, Theodorou suggested.
Theodorou reported being employed by CVS Caremark, which was responsible for the study. Gould reported no conflicts of interest.
Primary source: Dementia Care ConferenceSource reference:Theodorou A, et al "Utilization of Alzheimer Agents in the United States" DCC 2008; PS-22.

UC team studies link between Parkinson's disease and depression

CINCINNATI, 29 aug 2008—A patient who receives a diagnosis of Parkinson's disease might become depressed, and understandably so. But does the depression then exacerbate the progression of Parkinson's?
That's one of the questions a team of University of Cincinnati researchers is studying, with the help of a $1.7 million grant from the National Institutes of Health (NIH).
Parkinson's disease is a degenerative neurological disorder involving the death of dopamine-producing cells, or neurons, deep within the brain. Depression is highly prevalent in Parkinson's disease, previous research has found.
Principal investigator Kim Seroogy, PhD, and co-investigator James Herman, PhD, are studying a stress-induced model of depression and Parkinson's in rodents. Seroogy is a professor of neurology and director of the Selma Schottenstein Harris Lab for Research in Parkinson's at the James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders. Herman is a professor of psychiatry and director of the university's neuroscience graduate program.
Parkinson's-induced rodents are stressed in a variety of ways, such as being placed briefly in a cold room or a crowded setting. In studying the results, the UC team hopes to gain insight into a problem Seroogy likens to the classic chicken-and-egg question: Which comes first, Parkinson's or depression?
"There are two schools of thought on co-morbidity of depression and Parkinson's," says Seroogy. "One is that the onset of depression precedes and possibly leads to Parkinson's. The other is that Parkinson's disease predisposes for depression. Clinically, there's evidence for both of those lines of thinking."
The NIH grant will enable the UC team to examine the question and, as Seroogy puts it, "have it surrounded."
"We're going to have some groups that undergo depression first, then the Parkinson's, and then we'll do the reverse," he says. "Then there will be some that are combined—depression, then parkinsonism, then further depression."
In pilot models so far, Seroogy and Herman have found that in those animals that have stress combined with Parkinson's, their normal loss of dopamine cells in the brain is accelerated. In addition, the movements of their impaired limbs also worsened in the behaviors that were tested.
"So stress-induced depression exacerbates problems with movement, and also causes the relevant brain cells to die faster," Seroogy says.
Learning more about the relationship between depression and Parkinson's will provide insight into possible treatments of Parkinson's, Seroogy says.
"You might ask, 'Why don't we just prescribe antidepressants?'" he adds. "Well, we do. But there are no really definitive epidemiological studies or long-term assessments of the effects of antidepressants on the progression of Parkinson's."
Seroogy and Herman will explore that, plus the possibility that antidepressants can protect the brain from Parkinson's disease.
"Not only could they reduce depression, but they might actually protect dopamine cells in the brain and thus slow the progression of Parkinson's," says Seroogy.
Seroogy and Herman began their research into depression and Parkinson's with a $14,000 grant from the Sunflower Revolution Encore, a private fund-raiser hosted by Melody Sawyer Richardson in 2005. Two years later, they received a $50,000 grant from the Davis Phinney Foundation to continue their research, which was also supported in the interim by about $20,000 from the Parkinson's Disease Support Network of Ohio, Kentucky and Indiana.
"We're gratified that an investment in our research by the local community and the Davis Phinney Foundation has now led to a five-year NIH grant that will allow us to investigate how stress causes enhanced parkinsonian symptoms, and how to prevent stress from causing further damage to the parkinsonian brain," says Seroogy.
###
The Sunflower Revolution is an annual gala, symposium and bike ride that raises funds for the Neuroscience Institute at UC and University Hospital. Sunflower funds flow into discovery programs at the Gardner Center, one of the institute's centers of excellence, through the Davis Phinney Foundation, a UC fund-raising partner.

Class of diabetes drugs carries significant cardiovascular risks

WINSTON,29 aug 2008 –A class of oral drugs used to treat type 2 diabetes may make heart failure worse, according to an editorial published online in Heart Wednesday by two Wake Forest University School of Medicine faculty members.
"We strongly recommend restrictions in the use of thiazolidinediones (the class of drugs) and question the rationale for leaving rosiglitazone on the market," write Sonal Singh, M.D., M.P.H., assistant professor of internal medicine, and Curt D. Furberg, M.D., Ph.D., professor of public health sciences. Rosiglitazone and pioglitazone are the two major thiazolidinediones.
In the editorial Singh and Furberg say, "At this time, justification for use of thiazolidinediones is very weak to non-existent."
Oral drugs are given to control diabetes by lowering blood sugar.
But diabetics also experience elevated rates of high blood pressure and high levels of cholesterol and triglyceride, which "further compound their already increased risk of developing ischemic heart disease," Singh and Furberg say. Heart disease and high blood pressure "represent conditions that are major precursors of congestive heart failure."
About 22 percent of diabetics have heart disease. Among elderly patients with diabetes, more than half will develop congestive heart failure over a 10-year period, the editorial says.
The thiazolidinediones were approved for use based on the ability to reduce blood sugar.
In contrast, "we reported [in the journal Diabetes Care] in June 2007 that thiazolidinediones doubled the risk of congestive heart failure in patients with type 2 diabetes," is says. "The increased heart failure appears to be a class effect."
Singh and Furberg reported in The Journal of the American Medical Association in 2007 after an analysis of four long-term trials that use of rosiglitazone was associated both with increased heart attacks and a doubling of heart failure.
They said that results from three large randomized clinical trials published this past June all failed to demonstrate that intensive control of blood sugar reduces mortality or events from cardiovascular disease in patients with type 2 diabetes.
The three trials were ACCORD, ADVANCE, and the Veterans Affairs Diabetes study. In ACCORD, the patients who received intensive treatment to control blood sugar actually had more cardiovascular disease mortality than patients receiving standard treatment.
In ADVANCE, intensive control of blood sugar produced no benefit; there was no effect on cardiovascular events or deaths from cardiovascular causes compared to standard oral diabetes agents.
In the VA Diabetes trial, when intensive blood sugar control produced levels of blood sugar that were too low and led to loss of consciousness, that was a strong predictor of future cardiovascular events.
"The unfavorable findings from the three trials have not been fully realized by the medical community," Singh and Furberg say.
They say that at a recent U.S. Food and Drug Administration advisory committee meeting, there was "overwhelming support for requiring reductions" of heart disease and heart failure "before approval of new oral hypoglycemic agents."
Singh said in an interview, "Safer, cheaper and more effective treatment alternatives are available that do not carry these negative cardiovascular risks in patients with diabetes. The rationale for the use of the thiazolidinediones is unclear."
###
Media Relations Contacts: Jessica Guenzel, jguenzel@wfubmc.edu, (336) 716-3487, Bonnie Davis, bdavis@wfubmc.edu, (336) 716-4977, or Shannon Koontz, shkoontz@wfubmc.edu, (336) 716-2415

Mistaken Beliefs About Cancer Abound

28 aug 2008-- People throughout the world have major misconceptions when it comes to what causes cancer, new research suggests.
Results from a survey released Aug. 27 at the International Union Against Cancer's (UICC's) World Cancer Congress in Geneva, found that people tend to inflate the threat from environmental factors and minimize the threat of behaviors that are well-established cancer risk factors.
Researchers interviewed 29,925 people in 29 countries last year to compare data on perceptions about cancer risk factors among high-, middle-, and low-income countries.
Among their findings was the fact that people in high-income countries were least likely to believe that drinking alcohol increases the risk of cancer, when, in fact, cancer risk rises as alcohol intake increases. Specifically, 42 percent of the people in the high-income countries said alcohol does not increase the risk, compared with 26 percent of those in middle-income countries and 15 percent of those in low-income countries.
Another finding was that people in high-income countries felt that not eating enough fruits and vegetables was more risky than drinking alcohol. The truth is that the evidence supporting the protective effect of produce consumption is weaker than the evidence that alcohol intake is harmful.
In addition, people in rich countries thought that stress and air pollution were greater risk factors than alcohol intake, even though stress is not recognized as a cause of cancer and air pollution is a minor contributor compared with alcohol intake.
The people in middle- and low-income countries were more likely than those in high-income countries to say that "not much can be done" to cure cancer or that they didn't know whether anything could be done. And a surprising 75 percent of survey respondents in low-income countries preferred for their doctor to make all their cancer treatment decisions, while 72 percent of the people in high-income countries said that the decisions should be made between the doctor and patient, or by the patient alone.
Finally, people in all countries were more ready to accept that things they could not control (e.g., air pollution) were risk factors than things they could control (e.g., overweight, which is an established cancer risk factor).
The researchers hope that their data will be used to put into action cancer education campaigns that address some of these misconceptions.
"This survey reveals that there are some big unheard messages. These kind of data help us to quantify the differences between countries and to highlight where additional efforts are needed. Some of these countries have rarely had any population survey data to help their programme planning efforts," researcher David Hill, president-elect of UICC and director of the Cancer Council Victoria in Melbourne, Australia, said in a UICC press release.
The survey was conducted by Roy Morgan Research and Gallup International on behalf of the UICC.
More information
The National Cancer Institute has more about cancer.

Fat Cells in Obese People Are 'Sick'

28 aug 2008-- Fat cells in obese people are "sick" compared to those in lean people, a new study shows.
Published in the September issue of Diabetes, a group of researchers from the Temple University School of Medicine analyzed fat samples from the upper thighs of six lean and six obese people.
They found significant differences in the fat cells of the obese participants compared with the lean participants.
"The fat cells we found in our obese patients were deficient in several areas," study author Guenther Boden, the Laura H. Carnell Professor of Medicine and chief of endocrinology, said in Temple press release.
Boden said that the obese people's fat cells showed stress on the endoplasmic reticulum (ER), which helps cells synthesize proteins and monitor how they are folded. When the ER is stressed, Boden explained, it produces several proteins that ultimately lead to insulin resistance. Insulin resistance, in turn, plays a major role in the development of obesity-related conditions.
The differences in the fat cells between obese and lean people may help explain the link between obesity and a higher risk of diabetes, heart disease, and stroke, Boden theorized.
More information
The National Heart, Lung, and Blood Institute has more about overweight and obesity.