Landmark guidelines for optimal quality care of geriatric surgical patients just released

New comprehensive guidelines for the pre- operative care of the nation's elderly patients have been issued by the American College of Surgeons (ACS) and the American Geriatrics Society (AGS). The joint guidelines—published in the October issue of the Journal of the American College of Surgeons—apply to every patient who is 65 years and older as defined by Medicare regulations. The guidelines are the culmination of two years of research and analysis by a multidisciplinary expert panel representing the ACS and AGS, as well as by expert representatives from a range of medical specialties.

30 sept 2012--"The major objective of these guidelines is to help surgeons and the entire perioperative care team improve the quality of surgical care for elderly patients," said Clifford Y. Ko, MD, FACS, Director of the ACS National Surgical Quality Improvement Program (ACS NSQIP®) and the ACS Division of Research and Optimal Patient Care in Chicago, professor of surgery at University of California, Los Angeles (UCLA) and director of UCLA's Center for Surgical Outcomes and Quality.

One of the driving forces behind the guidelines is America's expanding geriatric popu- lation, Dr. Ko explained. The U.S. Census Bureau projects the percentage of men and women 65 years and older will more than double between 2010 and 2050 and will increase by 20 per-cent of the total population by 2030.* In 2006, elderly patients underwent 35 percent of inpatient surgical procedures and 32 percent of outpatient procedures according to study authors.

"For elderly patients undergoing surgical procedures, we want to ensure we are optimiz-ing each patient's medical condition," Dr. Ko said. "This population is growing in numbers and we want to emphasize the depth and breadth of care required for them. These evidence-based guidelines will enhance surgical practice by setting higher standards and performance measures for surgeons and the entire perioperative care team," he said. This is the first time ACS has worked with AGS to develop guidelines for geriatric patients according to Dr. Ko.

The guidelines recommend and specify 13 key issues of preoperative care for the elderly: cognitive impairment and dementia; decision-making capacity; postoperative delirium; alcohol and substance abuse; cardiac evaluation; pulmonary evaluation; functional status, mobility, and fall risk; frailty; nutritional status; medication management; patient counseling; preoperative testing; and patient-family and social support system.

"There is no single magic bullet for rendering this level of surgical care," Dr. Ko said. "Each of the 13 issues covered by the guidelines is very important, comprehensive, and difficult to prioritize. For example, surgeons and perioperative team members may do perfectly well when analyzing a patient's cognitive functioning , but not so well on the polypharmacy issue. So then suddenly, polypharmacy becomes the number-one issue for the surgical team to address during the preoperative care phase," he explained.

Furthermore, the expert panel said there are complex problems specific to the elderly, including use of multiple medications, functional status, frailty, risk of malnutrition, cognitive impairment, and comorbidities. "When surgeons evaluate elderly patients before they undergo operations, they want to know how many and what specific medications their patients are taking. This step will enable them to identify potential medication issues before operations and before the surgeons start adding pain medication to the patient's medication list," Dr. Ko explained.

As the guidelines state: "consider minimizing the patient's risk for adverse drug reac-tions by identifying what should be discontinued before surgery or should be avoided and dose reducing or substituting potentially inappropriate medications."

Additionally, the number and severity of underlying medical problems call for special strategies by the entire surgical team, according to Dr. Ko.

"Patients who are 90 years old tend to have more comorbidities than those who are 65 years," he said. "There may be something wrong with the heart, the lungs, the kidneys, the liver. Surgeons have to plan and deal with these comorbidities simultaneously while the patient is undergoing a surgical procedure."

The guidelines state that evaluating patients for developing heart disease and heart attack is critical to identify patients at higher risk. All patients should be evaluated for perioperative cardiac risk.

"Caring for the elderly generally requires a team approach," said Dr. Ko. "The surgeon knows how to perform surgery and the cardiologist knows how to take care of the heart. It's best for everyone to work together to take care of the patient. We want everyone on the same page of providing good quality care."

These guidelines have been developed in response to a performance measure that the ACS has developed with the Centers for Medicare & Medicaid Services (CMS), according to Dr. Ko. The performance measure evaluates the quality of care in patients eligible for Medicare.

ACS NSQIP has worked with CMS to develop "The Elderly Surgery Measure." This is a hospital-based measure that assesses the outcome of elderly patients undergoing surgical procedures. The ACS and CMS will launch a pilot program in October that gives hospitals the opportunity to publicly and voluntarily report the outcome results.

More information: * Source: U.S. Census Bureau Statistical Brief. Sixty-five Plus in the United States. Available at www.census.gov/pop… gebrief.html. Accessed September 26, 2012.

Provided by American College of Surgeons

Ageing and the city: Chronic diseases more prevalent in city-dwellers than country counterparts

Ageing Australian city-dwellers are more likely to suffer from non-infectious chronic diseases such as type 2 diabetes, arthritis, cancer and asthma than their rural counterparts, according to new research from the University of Sydney.

29 sept 2012--The research, conducted by academics from the University's Faculty of Health Sciences and published in this month's edition of the Australasian Journal of Ageing, tracked seven years of longitudinal data for 1256 over-45s who had lived in the same area for at least 20 years.

Results showed people living in urban areas had greater odds of having from a non-infectious chronic disease than people in rural and remote areas.

Every year of age increased the odds of having a long-term health condition by 1.05, or five percent compared with the previous year, while living in the lowest socioeconomic area increased the odds of having a long-term health condition by 90 percent.

"In the city you're exposed to a range of environmental stressors, such as poor air quality, aircraft and road noise, high density housing, lack of adequate transport, poor urban design, a lack of green spaces and shade trees, and so on," says lead author Professor Deborah Black, from the University's Ageing, Work and Health Research Unit.

Lower socioeconomic status was associated with a higher prevalence of non-infectious chronic disease because cheaper housing was generally located in areas with high levels of environmental stressors, such as industrial areas, airports or busy roads.

"As people get older, their bodies are less able to cope physiologically with environmental stressors, and exposure can accelerate the ageing process and trigger or exacerbate disease," Professor Black says.

"With 85 percent of Australians living in the city and 22 percent of Australians estimated to be 65 or older by 2026, it's crucial that we update policy, urban design and primary care in line with the realities of our population."

The research responds to a pressing need to better understand the problems faced by Australia's increasingly urban, ageing population. While the link between urbanisation and population health is well established, until now there has been very little research on the interaction between age and urban living.

According to Professor Black, climate change is one of the most critical issues for the health of ageing Australians.

"In cities, the lack of trees and green spaces create what's called the heat island effect, wherein the sun heats exposed urban surfaces such as roads, roofs, and pavements to temperatures up to 50 degrees Celsius hotter than the air temperature," she says.

"Because older people are less able to cope with high temperatures, they are more at risk of climate change-related health problems than the rest of the population. Effective thermoregulation and hydration are particularly difficult for older people in hot weather, which can lead to problems with heart and kidney function, medication management and falls.

"We also find that because an ageing population is not as mobile, they don't have the opportunity to get away from the environmental stressors around their home and community."

Provided by University of Sydney

Over 65s at increased risk of developing dementia with benzodiazepine

Patients over the age of 65 who begin taking benzodiazepine (a popular drug used to treat anxiety and insomnia) are at an approximately 50% increased risk of developing dementia within 15 years compared to never-users, a study published today on BMJ website suggests.

28 sept 2012--The authors say that "considering the extent to which benzodiazepines are prescribed and the number of potential adverse effects indiscriminate widespread use should be cautioned against".

Benzodiazepine is a widely prescribed drug for the over 65s in many countries: 30% of this age group in France, 20% in Canada and Spain, 15% in Australia. Although less widespread in the UK and US it is still very widely used and many individuals take this drug for years despite guidelines suggesting it should be limited to a few weeks. Previous studies have found an increased risk of dementia, but others have been non-conclusive.

Researchers from France therefore carried out a study on 1063 men and women (average age 78) in France who were all free of dementia at the start. The study started in 1987 and follow-up was 20 years. The researchers used the first 5 years to identifying the factors leading to benzodiazepine initiation and evaluated then the association between new use of this drug and the development of dementia. They also assessed the association between further benzodiazepine initiation during the follow-up period and risk of subsequent dementia. Rates were adjusted for many factors potentially affecting dementia, such as age, gender, educational level, marital status, wine consumption, diabetes, high blood pressure, cognitive decline, and depressive symptoms.

95 out of the 1063 patients started taking benzodiazepine during the study. 253 (23.8%) cases of dementia were confirmed, 30 in benzodiazepine users and 223 in non-users. New initiation of the drug was associated with shorter dementia-free survival.

In absolute numbers, the chance of dementia occurring was 4.8 per 100 person years in the exposed group compared to 3.2 per 100 person years in the non-exposed group. A "person year" is a statistical measure representing one person at risk of development of a disease during a period of one year.

The authors say that although benzodiazepine remains useful for treating anxiety and insomnia, there is increasing evidence that its use may induce adverse outcomes in the elderly such as serious falls and fall-related fractures and this study may add dementia to the list. They say that their data add to the accumulating evidence that the use of benzodiazepines is associated with increased risk of dementia and, if true, that this "would constitute a substantial public health concern". Therefore, taken the evidence of potential adverse effects into account, physicians should assess expected benefits, limit prescriptions to a few weeks, and uncontrolled use should be cautioned against. They conclude that further research should "explore whether use of benzodiazepine in those under 65 is also associated with increased risk of dementia and that mechanisms need to be explored explaining the association"

Provided by British Medical Journal

Surfing the net helps the elderly stay connected

Seniors in rural areas are embracing new technology, according to a University of Adelaide study. 

The internet is giving older people in rural areas a new lease on life, according to a report released today by the University of Adelaide.

27 sept 2012--Surfing the net, using Skype, email and social networking sites is literally keeping older people "connected" with their communities, says lead report author Dr Helen Feist.

Dr Feist, the Deputy Director of the Australian Population and Migration Research Centre at the University of Adelaide, has spent the past three years investigating how technology can be used in remote and rural areas of Australia to improve the lives of older people.

The project, which was funded by the Australian Government Department of Health and Ageing, looked at the best ways of encouraging older people to adopt new technology in a non-threatening way.

A survey in the Murray Lands region of South Australia found that nearly 25% of people aged 80 years and over and more than a third of those in the 65-79 year age bracket were open to learning new technologies.

"In order for people to remain integrated within a world that increasingly relies on new technology, it is important that older people are offered opportunities to adopt and use these new technologies such as computers, smart phones, personal tablets and the Internet," says Dr Feist.

Study participants introduced to iPads and laptop computers quickly embraced the new technology, reporting a 30% increase in comfort levels with computers and the internet after using them over a 12-month period.

"Older adults who adopt new skills as they age improve their confidence, health, enjoy richer levels of social and civic engagement and are more resilient to life stressors and crises," Dr Feist says.

"New technology is enabling older people to keep connected regardless of location, distance or mobility."

Dr Feist says the most important motivator among the elderly for taking up new technologies is to stay connected to family and friends.

"Their willingness to learn suggests there is indeed an untapped market for information and communication technology training in rural areas.

"Given the right device, along with personalised training and support, older people of all ages will take up and continue to use new technology," Dr Feist says.

The report makes a number of recommendations, including better financial support for seniors for learning new technologies; subsidies for Internet connections; and the introduction of `come and try' programs in local community centres.

Provided by University of Adelaide

Population aging will have long-term implications for economy

The aging of the U.S. population will have broad economic consequences for the country, particularly for federal programs that support the elderly, and its long-term effects on all generations will be mediated by how—and how quickly—the nation responds, says a new congressionally mandated report from the National Research Council. The unprecedented demographic shift in which people over age 65 make up an increasingly large percentage of the population is not a temporary phenomenon associated with the aging of the baby boom generation, but a pervasive trend that is here to stay.

26 sept 2012--"The bottom line is that the nation has many good options for responding to population aging," said Roger Ferguson, CEO of TIAA-CREF and co-chair of the committee that wrote the report. "Nonetheless, there is little doubt that there will need to be major changes in the structure of federal programs, particularly those for health. The transition to sustainable policies will be smoother and less costly if steps are taken sooner rather than later."

Social Security, Medicare, and Medicaid are on unsustainable paths, and the failure to remedy the situation raises a number of economic risks, the report says. Together, the cost of the three programs currently amounts to roughly 40 percent of all federal spending and 10 percent of the nation's gross domestic product. Because of overall longer life expectancy and lower birth rates, these programs will have more beneficiaries with relatively fewer workers contributing to support them in the coming decades. Combined with soaring health care costs, population aging will drive up public health care expenditures and demand an ever-larger fraction of national resources.

Population aging is also occurring in other industrialized nations, so any consequences for the U.S. must be considered in the broader context of a global economy. Adapting to this new economic landscape entails costs and policy options with different implications for which generations will bear the costs or receive the benefits. Recent policy actions have attempted to address health care costs, but their effects are as yet unclear. According to the report, the ultimate national response will likely be some combination of major structural changes to public support programs, more savings during people's working years, and longer working lives.

"The nation needs to rethink its outlook and policies on working and retirement," said Ronald Lee, professor of demography and economics at the University of California, Berkeley, and committee co-chair. "Although 65 has conventionally been considered a normal retirement age, it is an increasingly obsolete threshold for defining old age and for setting benefits for the elderly." The committee found that there is substantial potential for increased labor force participation at older ages, which would boost national output, slow the draw-down on retirement savings, and allow workers to save longer. The report adds that longer working lives would have little effect on employment opportunities for younger workers, productivity, or innovation.

In addition, workers can better prepare for retirement by planning ahead and adapting their saving and spending habits, the report suggests. Improved financial literacy will be critical, since between one-fifth and two-thirds of today's older population have not saved enough for retirement and therefore rely heavily on Social Security and Medicare.

More research in areas such as health measurement and projections, capacity to work, and changes in consumption and saving will help to inform decision making, but the report emphasizes the need to act now in order to craft a balanced response.

"Population aging does not pose an insurmountable challenge provided that sensible policies are implemented with enough lead time to allow people, companies, and other institutions to respond," Ferguson said.

A follow-up study from the National Research Council will look more in-depth at the long-term macroeconomic effects of population aging and provide quantitative assessments of specific policy choices.

Provided by National Academy of Sciences

For a health reform model, try Brazil

During the Harvard-Brazil Symposium, Luciana Mendes Santos Servo (pictured), health coordinator at the Institute for Applied Economic Research in Brazil, traced the changes in that country to Brazil’s 1988 constitution, which recognized health as a right for citizens and created a government obligation to improve it. 

With the 2015 deadline to meet the United Nations' Millennium Development Goals (MDG) approaching, scholars and government officials gathered at the Harvard School of Public Health (HSPH) on Tuesday to search for lessons in the dramatic progress that Brazil has made in recent decades.

25 sept 2012--The eight Millennium Development Goals, adopted in 2000, set targets to attain international development objectives, including reducing extreme poverty and hunger; reducing child mortality; improving maternal health; achieving universal primary education; increasing equality for women; fighting AIDS, malaria, and other diseases; ensuring environmental sustainability; and fostering global partnerships for development.

The Harvard-Brazil Symposium, held in HSPH's Kresge Building, featured discussions of the health-related goals and of Brazil's progress in meeting them. It was sponsored by the Department of Global Health and Population, which is marking its 50th anniversary, as well as the Harvard Global Health Institute and Fundação Maria Cecilia Souto Vidigal.

Harvard School of Public Health Dean Julio Frenk, who sits on UN Secretary General Ban Ki-Moon's MDG Advocacy Group, introduced the event, saying that the goals' adoption marked the first time the world's nations agreed on common development objectives and on indicators to measure progress.

The result, he said, has been an unprecedented level of funding for the needs outlined, as well as progress that has been, in some cases, spectacular. Yet much remains to be done, making the search for examples that might be adapted to other situations an important strategy.

"The challenges that remain are enormous," Frenk said.

Luciana Mendes Santos Servo, health coordinator at the Institute for Applied Economic Research in Brazil, traced the changes in that country to Brazil's 1988 constitution, which recognized health as a right for citizens and created a government obligation to improve it.

That sparked the creation of several social welfare programs and reform of the health care system from one that was centered on hospitals and financed by private insurance, held mainly by those in the formal labor pool, to one that emphasized primary care and was open to all.

Brazil has already achieved the goals for reducing poverty and hunger and is on track to achieve the goals involving child mortality and universal education. Maternal health in the nation has improved, but the goal appears out of reach by 2015. Mendes credited three programs with the bulk of the change: a social security benefit for the elderly, a cash-transfer program for poor families, and a family health program that focuses on primary care.

The programs have provided additional benefits beyond health. The cash-transfer program for poor families, called Bolsa Familia, requires children to attend school, which has boosted school attendance, helping the nation to achieve universal primary school education.

While those programs appear to have been effective, some audience members questioned whether the cost burdens they put on government, particularly in an economic downturn, are sustainable. Mendes said that future financing will be a challenge, because she believes the government can't raise taxes further.

Eduardo Rios Neto, a professor at Brazil's Federal University of Minas Gerais, said the government programs were helped along by a period of economic growth and improvement of the labor market, and that, despite recent progress, social and income inequality in Brazil remain a major problem.

Brazil's progress doesn't mean its health challenges are over either, Mendes said. The rise of noncommunicable diseases, like heart disease, diabetes, and cancer, is a growing challenge.

"We have progressed, but we have some challenges," Mendes said.

Provided by Harvard University

Reduced physical activity reduces life span

24 sept 2012— A regular exercise regimen will increase life expectancy in the elderly, new research has found.

The Monash University-led study examined the significance of weight and physical function and the interaction on mortality in 1435 men and women aged 65 to 97 years, living in the community and representative of the Taiwanese population.

The results of the eight-year study were recently published in the Journal of Nutrition, Health and Aging. The study also included researchers from the National Health Research Institutes, Taiwan and the National Defense Medical Centre, Taiwan.

Lead author, Emeritus Professor Mark Wahlqvist from Monash University's Department of Epidemiology and Preventive Medicine and the Monash Asia Institute, said being frail or losing weight was generally regarded as a major risk for reduced survival among the elderly.

"We found thin, elderly Taiwanese with sarcopenia – a condition of age-related loss of muscle mass and strength - and less skeleton are at the most risk of death, especially if physical function is limited. Those within the normal weight range or even overweight and active had a longer life expectancy with fewer health problems," Emeritus Professor Wahlqvist.

Survival was assessed in relation to weight and body composition, along with physical function such as walking, climbing, performing daily chores and personal care.

The researchers found weight in relation to height (body mass index (BMI) = weight/height2) was twice as likely to shorten the survival of the elderly when low (BMI < 18.5) than high (above 24.0). This increased to nine times more likely when combined with limited physical function. The findings took into account factors such as age, gender, socio-economics and personal behaviours that could have explained the association.

Emeritus Professor Wahlqvist said although this was not an intervention study, it raised the possibility that if physical function could be maintained, then mortality could be markedly reduced in this older age group.

"In light of these figures, both those in public health and clinicians need to look at preventive approaches or intervention strategies that might achieve better survival in older people in regard to thinness and physical dysfunction," Emeritus Professor Wahlqvist said.

"Even small changes involving modest regular physical aerobic and strengthening activities for several days a week could make a substantial difference in health outcomes for the elderly."

More information: DOI: 10.1007/s12603-012-0379-3

Physiotherapy beneficial for people with Parkinson's disease in the short term

23 sept 2012—Results from a systematic review and meta-analysis led by the University of Birmingham in the UK suggest that physiotherapy benefits people with Parkinson's disease in the short term (< 3 months).

The management of Parkinson's disease has traditionally centred on drug treatment, however, there has been increasing support for the inclusion of rehabilitation therapies, such as physiotherapy, to supplement pharmacological and neurosurgical treatment.

Dr Claire Tomlinson, from the University of Birmingham Clinical Trials Unit, and colleagues selected 39 randomised controlled trials including 1827 participants for review.  The review included trials assessing a variety of different physiotherapy methods used to treat participants including general physiotherapy, exercise, treadmill training and dance. 

Of the 18 potential physiotherapy outcomes assessed, physiotherapy resulted in improvements in nine areas.  For three outcomes (gait speed, the Berg balance scale and a clinician-rated disability scale) there is existing evidence to suggest that these improvements may be clinically meaningful to people with Parkinson's disease.  For example, participants demonstrated that with physiotherapy intervention they were able to walk faster or maintain their balance better compared to no intervention.

Dr Tomlinson, said: "This study indicates that physiotherapy could provide clinically meaningful benefits in the short term for people with Parkinson's disease. Further improved studies are needed; these will shed more light on how beneficial physiotherapy can be for patients in the longer term.  Once a larger and better quality of evidence is achieved, there might be scope for a recommendation for change in practice to be made."

More information: Physiotherapy intervention in Parkinson's disease: systematic review and meta-analysis, published by the British Medical Journal (BMJ) 2012;345(7872).

Provided by University of Birmingham

New strategies needed to combat disease in developing countries

So-called lifestyle diseases are gaining ground with epidemic speed in low-income countries. The traditional health focus in these countries has been to combat communicable diseases such as malaria, HIV and tuberculosis. However, research from the University of Copenhagen suggests that dividing campaigns into combating either non-communicable or communicable diseases is ineffective and expensive. A new article by Danish scientists published in the well-reputed journal Science provides an overview.

22 sept 2012--A prognosis from WHO in 2002 indicates that by 2030, we can expect the relationship between non-communicable and communicable diseases to have shifted so that non-communicable diseases are the most common cause of death in the world's poorest countries. The shift is anticipated due to longer lifespan as well as increased urbanisation in low-income countries:

"This development means that 57% of the world's deaths in 2030 will be due to the major non-communicable killers we know from the developed world: cardiovascular diseases, chronic lung diseases, diabetes and many types of cancer," explains Professor Ib Bygbjergfrom the Department of International Health, Immunology and Microbiology at the University of Copenhagen. In an article recently published in the well-reputed journal Science, he explains the need for new strategies to combat disease globally.

Ignoring new research

In 2011 the UN member countries drew up a political declaration on the prevention and control of non-communicable diseases. And even though it was a large step forward for the UN to put non-communicable disease on the agenda, the situation is still problematic, according to Professor Bygbjerg:

"The declaration continued an unfortunate tradition of dividing campaigns into communicable and non-communicable diseases. This practice ignores many new research results showing, among other things, that many types of cancer are caused by viral infections, while communicable diseases such as tuberculosis, for example, can only be fought effectively by also looking at tobacco and alcohol consumption," states Ib Bygbjerg.

In the article published in Science, Professor Bygbjerg gives several examples of the necessity of having a joint campaign against communicable and non-communicable diseases. The simplest example is probably that since we know that diabetes increases the risk of tuberculosis – just as tuberculosis can bring on or exacerbate diabetes – why do we try to combat them separately?

"Naturally the main idea is that since we know that patients often suffer from several diseases, and that various diseases and their treatments influence each other, it is pointless to continue to develop large health programmes that only focus on fighting one single disease," continues Ib Bygbjerg.

Integrated health programmes are the key

We can kill several birds with one stone by focusing on known common risk factors, such as poor nutrition, and developing strategies that integrate efforts to combat diabetes and tuberculosis, for example.

Stimulated by Danish support, China, India and other countries with major diabetes and tuberculosis problems have begun developing integrated health programmes with double-screening for these diseases. However, in many other cases, structural problems have prevented this type of integration.

"Researchers, healthcare workers and politicians are often forced to meet short-term results contracts as part of 'new public management'. This practice can easily turn efforts to deal with current and impending health problems into a battlefield over money needed to combat one disease or another, instead of addressing the actual double burden of communicable and non-communicable disease that will be borne by the large populations in developing countries, now and in future," concludes Professor Ib Bygbjerg.

Provided by University of Copenhagen

Non-communicable diseases prevention 'more important than life or death'

Proposals designed to prevent non-communicable diseases (NCDs) such as "fat taxes" will have wide-ranging effects on the economy and health but wider research is needed to avoid wasting resources on ineffective measures, according to an economist from the London School of Hygiene & Tropical Medicine.

21 sept 2012--Writing in Science, Professor Richard Smith says that effective prevention of the increasing problem of NCDs will require changes in how we live our lives, which will in turn lead to significant economic changes across populations, industries and countries. But unless evidence is provided about who and what is positively or negatively affected, it is impossible to know which policies will benefit both economies and health.

He calls for global studies concerning the whole economy and suggests lessons should be learned from infectious diseases such as AIDS where clear demonstration of the overall economic impact played a key role in securing funding initiatives at the highest level.

With increasing numbers of people in the developed and developing world suffering from ill health associated with both genetic and lifestyle factors, the problem is more than just a medical concern. NCDs affect the economy "profoundly and pervasively" and using the example of Liverpool Football Club manager Bill Shankly who said football was "not just a matter of life and death, it's more important than that", Professor Smith claims that for economists so are NCDs.

The target set at the 65th World Health Assembly to reduce premature deaths from NCDs by 25% by 2025 adds to the urgency and there is a growing swell of opinion about the importance of tackling the problem. The School's Centre for Global Non-Communicable Diseases is just one example of a high-level response to the worldwide call for action.

Purely micro-economic approaches will not work, however, Prof Smith argues. Prices are "pivotal" for economics and this concept provides the logic for the current enthusiasm for the introduction (already implemented in Denmark and Hungary) of a "fat tax" to reduce consumption of foods high in saturated fat by increasing their price through tax.

But Prof Smith sets out the various potential effects of such a mechanism which have not been analysed such as the alternative products consumers might turn to instead and changes in farming practices. According to the paper, there is a major gap in knowledge about the "macro-economic" big picture perspective which needs to be filled before society-wide NCD prevention can move forward.

He writes: "A food tax will affect the risk of NCDs in an unpredictable manner as it begins to indirectly influence other sectors in the national economy and interface with the rest of the world," he writes. "If the net effect is to increase health, then this should feed positively into theeconomy itself, by reducing healthcare costs and by improving workforce productivity. However, we do not know that this will be the effect, because we do not consider the broader macro-economic picture."

More information: "Can Noncommunicable Diseases Be Prevented? Lessons from Studies of Populations and Individuals," by M. Ezzati et al., Science, 2012.

Provided by London School of Hygiene & Tropical Medicine

Diseases of aging map to a few 'hotspots' on the human genome

20 sept 2012—Researchers have long known that individual diseases are associated with genes in specific locations of the genome. Genetics researchers at the University of North Carolina at Chapel Hill now have shown definitively that a small number of places in the human genome are associated with a large number and variety of diseases. In particular, several diseases of aging are associated with a locus which is more famous for its role in preventing cancer.

For this analysis, researchers at UNC Lineberger Comprehensive Cancer Center catalogued results from several hundred human Genome-Wide Association Studies (GWAS) from the National Human Genome Research Institute. These results provided an unbiased means to determine if varied different diseases mapped to common 'hotspot' regions of the human genome. This analysis showed that two different genomic locations are associated with two major subcategories of human disease.

"Our team is interested in understanding genetic susceptibility to diseases associated with aging, including cancer," said PhD student William Jeck, who was first author on the study, published in the journal Aging Cell.

The team examined the large NHGRI dataset and first eliminated hereditable traits such as eye or hair color and other non-disease traits like drug metabolism. The group then focused on variants identified from GWAS that contributed to actual diseases. Combining results from all of these studies, there was enough data to arrive at statistically valid conclusions. The team then mapped the disease associations to the appropriate locations of the genome, counting the number of unique diseases mapping to specific genomic regions, in order to see if disparate diseases mapped randomly throughout the genome, or clustered in hotspots.

"What we ended up with is a very interesting distribution of disease risk across the genome. More than 90 percent of the genome lacked any disease loci. Surprisingly, however, lots of diseases mapped to two specific loci, which soared above all of the others in terms of multi-disease risk. The first locus at chromosome 6p21, is where the major histocompatibility (MHC) locus resides. The MHC is critical for tissue typing for organ and bone marrow transplantation, and was known to be an important disease risk locus before genome-wide studies were available. Genes at this locus determine susceptibility to a wide variety of autoimmune diseases such as arthritis, celiac disease, Type I diabetes, asthma, psoriasis, and lupus," said Jeck.

"The second place where disease associations clustered is the INK4/ARF (or CDKN2a) tumor suppressor locus. This area, in particular, was the location for diseases associated with aging: atherosclerosis, heart attacks, stroke, Type II diabetes, glaucoma and various cancers." he added.

"The finding that INK4/ARF is associated with lots of cancer, and MHC is associated with lots of diseases of immunity is not surprising—these associations were known. What is surprising is the diversity of diseases mapping to just two small places: 30 percent of all tested human diseases mapped to one of these two places. This means that genotypes at these loci determine a substantial fraction of a person's resistance or susceptibility to multiple independent diseases," said Ned Sharpless, MD, Wellcome Distinguished Professor of Cancer Research and Associate Director of Translational Research at UNC Lineberger.

Another interesting finding was the apparent role of two biological processes in multi-disease association. In addition to the MHC and INK4/ARF loci, five less significant hotspot loci were also identified. Of the seven total hotspot loci, however, all contained genes associated with either immunity or cellular senescence. Cellular senescence is a permanent form of cellular growth arrest, and it is an important means whereby normal cells are prevented from becoming cancerous. It has been long known that senescent cells accumulate with aging, and may cause aspects of aging. This new analysis provides evidence that genetic differences in an individual's ability to regulate the immune response and activate cellular senescence determine their susceptibility to many seemingly disparate diseases.

"We call the absence of disease 'wellness', and our results suggest the genetics of wellness may be much more simple than previously suspected. Put another way, these unbiased data from about two million people suggest that your eccentric Uncle Joe, who drank and smoked, but who also lived to be 110 and was never sick a day in his life—well Uncle Joe may have just been genetically fortunate at a couple of loci," said Sharpless.

More information: www.wiley.com/Wile… Cd-ACEL.html

Provided by University of North Carolina Health Care

Organisations must increase flexibility to keep elderly population connected and engaged

19 sept 2012—Staying mobile and socially connected is crucial to the quality of life of older people, but awareness of the issues they face is low, say Massey University researchers.

Dr Juliana Mansvelt, from the School of People, Environment and Planning, says that it is important that organisations don't dismiss older people as inactive just because they require physical assistance to leave their homes.

"It would be a shame for organisations to view these people as unwilling or unable to engage with them, simply because they find it difficult to get out of the house. The truth is that the older people we have interviewed desire meaningful social connections," she says.

"In the face of adversity, many of them are actively and creatively mobilising people and resources in order to remain active and connected to their communities. They want to interact with a range of people and organisations."

In a new paper titled "The Problems and Possibilities of Mobility for Home-Based Elders in New Zealand," Dr Mansvelt and her co-author Professor Ted Zorn argue that organisations need to be more flexible in their systems and customer service behaviour or they will isolate and disempower their older customers.

Professor Zorn, who heads Massey University's College of Business, says there are good business reasons to do so. "This is one of the fastest growing demographics – and that's why the banks and supermarkets we have been working with are really eager to engage with us."

The paper is part of a three-year research project led by Professor Zorn for the Ministry of Business, Innovation and Employment. The research programme aims to improve the engagement of older people with organisations and their communities to create more positive ageing experiences.

Dr Mansvelt found that it wasn't just an older person's physical ability that determined their level of mobility. The built environments they had to negotiate and ageist attitudes were also important factors, and negative experiences could affect a person's subsequent desire to engage with an organisation.

"I found that for those with significant physical mobility and hearing and/or eyesight impairments, everyday practices that more able-bodied people might take for granted could be difficult," she says. "For example, going into a shopping centre becomes a series of encounters involving everything from transport and parking, to finding one's way around and purchasing, with each practice posing a different set of challenges."

Massey researchers are currently working with a number of organisations to improve their interactions with older people. In many cases, simple, practical changes like training staff to be respectful and flexible, not over-filling shopping bags, supplying shallow-tray supermarket trolleys, and providing practical seating and rest areas, can make large differences to the satisfaction levels of older customers.

"What comes through most strongly in our research is the need to raise the awareness of organisations," Professor Zorn says. "These changes are often not rocket science. Most organisations can immediately identify things to do differently and they are very positive about how useful it's been for them to go through the exercise."

In her study of home-based elders, Dr Mansvelt got insight into the lives of older New Zealanders. Many had multiple impairments and very few used computers or had internet access. Social isolation was a problem for some, with a number expressing a desire to leave their homes but a reluctance to ask for assistance for other than essential trips like doctor's appointments.

"They talked about the adaptations they'd made and the things they were able to do with pride, and many demonstrated considerable resilience in the face of significant challenges," Dr Mansvelt says. "However I noted a number of people who were struggling financially, and others who didn't want to burden their families or friends, and I think there are additional challenges for those who live in rural areas. Social isolation and services to rural communities is a real issue that needs more research."

Both academics stress the need for voluntary, government, and commercial organisations to consider the impact of societal and organisational changes on older people. Many changes – like new technologies or larger stores – can improve the experiences of customers, but it is important to make accommodations for those who have limited access to, or challenges in negotiating, these technologies or spaces, says Professor Zorn.

"For older people to feel connected and feel like they matter, they need flexibility," Dr Mansvelt says. "We need to recognise they may be mobile in different ways and enable the normality of doing things differently."

Provided by Massey University

Fewer friends, lower self-esteem can lead to distorted perceptions of life challenges

Being with friends can make climbing a hill feel less daunting.

18 sept 2012—People who have fewer social resources, such as friends and family, literally see challenging objects and events in a more exaggerated way than do people who feel emotionally supported, according to research by Kent Harber, associate professor of psychology at Rutgers-Newark.

"Those with fewer friends, with lower self-esteem and with less opportunity to disclose their emotions tend to visually amplify threats," Harber said. "Their perceptions are exaggerated, and disturbing things appear higher, closer, of greater duration or more intense than they actually are."

According to Harber's thesis – a theory known as the Resources and Perception Model (RPM) – psychosocial resources can prevent this amplification, leading to more accurate perception. In a study published in the The Journal of Experimental Social Psychology, Harber and colleagues from the University of Virginia enlisted passersby who were alone or with a friend and asked them to estimate the angle of a steep hill on the U.Va campus. "Those with friends saw the hill as less steep, and the longer they knew their friend or the closer they felt toward their friend the less steep the hill appeared to them," Harber said.

His latest study, published in the journal Emotion, tested whether the resource of self-worth affected distance perception to a live tarantula. Subjects were first asked to recall one of the following: a personal success, a neutral chore or a personal failure. Next, they used a reel to pull a clear plastic cart toward their face and estimate how far away it was from them. For some people, the cart contained a harmless cat toy; but for others it contained a live tarantula.

"As expected, feeling good, neutral or bad about oneself had no effect on distance to the cat toy but did affect distance to the tarantula," Harber said. "Those who felt bad about themselves saw the tarantula as looming closer than it was; those who felt good about themselves were strikingly accurate."  

Another study tested how high a ledge appeared depending on one's frame of mind. Researchers brought subjects to the fifth floor of a building and estimate how high up they were. One group could put their hands the railing, while the other was prevented in doing so by paper handcuffs. For those who could hold onto the rail, self-esteem had no effect on height perception.

"They were all pretty accurate in their height estimates," Harber said. But self-esteem did matter for the subjects who couldn't hold the railing; the hand-cuffed subjects with high esteem did as well as did subjects who could hold the handrail.

"Those with high levels of self-worth could 'get a grip' internally," Harber said.  But handcuffed subjects who lacked self-esteem "had neither an external nor an internal resource. They saw the distance to floor as much greater than did all other subjects,"  Harber said.

Why would our mind's eye play these tricks on us?  According to Harber,  the distortions can be useful.  "When we lack resources, the potential costs of engaging with hazards are greater and we need to adjust our behavior accordingly.  Our psyches might be nudging us toward caution by exaggerating the visual aspect of challenging things, when our resources are low."   

But for people who chronically lack resources, there may be a serious downside.  "Those who are isolated, who often lack self-worth, or who are in other ways bereft of resources might live in a more threatening world where mole hills look like mountains." 

The remedy, suggests Harber, is not to be super-popular or in a perpetually happy mood (in fact, mood has little influence on his studies).  Rather, it's about having a sufficient number of good friends and a core level of self-acceptance.  "It's not about seeing the world through rose-colored glasses," Harber says. "It's about having the resources to see things clearly, as they are."

More information: doi: 10.1037/a0023995

Provided by Rutgers University

Biggest European health study identifies key priorities in 26 cities

Researchers have announced the results of the largest ever health and lifestyle survey of cities and conurbations across Europe – including five British urban centres.

17 sept 2012--The research examined and compared the health, life expectancy and lifestyles of the populations of 26 European cities (the Euro-26) and found major differences, not only between cities, but within individual urban areas too.

The pan-European study, led in the UK by the Universities of Manchester and Liverpool, identified key priority areas for each city studied that the researchers hope policymakers will address.

In England's Greater Manchester and Merseyside, for example, depression and anxiety were identified as problem areas, along with cancer and respiratory disease – both of which were higher in these conurbations than the Euro-26 average. Obesity among Manchester and Liverpool's populations was also higher than the average of those cities studied, as was heavy drinking among the population's youth and binge drinking among adults.

It wasn't all bad news for Manchester though: Mancunians ate considerably more fruit and vegetables than the average Euro-26 city; they had more green spaces to enjoy, and ate breakfast more frequently than their European counterparts. Liverpudlians smoked less than the European average but had a lower-than-average perception of their own wellbeing.

Birmingham, Cardiff and Glasgow were the other British cities analysed. Death from respiratory disease in Birmingham was substantially higher than the Euro-26 average, although the incidence of male cancers was significantly lower. Heavy drinking and smoking among young Brummies was also well below the Euro-26 average.

In Cardiff, male cancers and deaths among women from circulatory diseases were much lower than in the other European cities studied, but depression and anxiety among adults in the Welsh capital, as well as binge drinking, were higher than the Euro-26 average. Mortality from cancers and respiratory diseases were seen as key concerns in Scotland's largest conurbation, but drinking and smoking among young Glaswegians was on par with the Euro-26 average.

The study, known as the European Urban Health Indicator System (EURO-URHIS 2) project and co-funded through the European Union's Seventh Framework Programme, provides an in-depth health and lifestyle analysis, as well as key policy recommendations, for each of the 26 European cities and beyond.

The 26 cities and conurbations are: Amsterdam, Birmingham, Bistrita, Bordeaux, Bratislava, Cardiff, Craiova, Glasgow, Greater Manchester, Iasi, Kaunas, Koln, Kosice, Liepaja, Ljubljana, Maribor, Merseyside, Montpellier, Oberhausen, Oslo, Riga, Siauliai, Skopje, Tetova, Tromso and Utrecht. (A link to the findings for all cities is provided in the notes below.)

Project coordinator Dr Arpana Verma, from The University of Manchester, said: "The gap between the rich and poor living in urban areas across the world is widening. The urban poor are now worse off than the rural poor. Health inequalities are a greater issue than ever before and it's becoming increasingly important for policymakers to take the valuable information that we have to offer and translate into policies that can help improve our health.

"The European Urban Health Conference highlights these disparities and demonstrated effective tools that policymakers can use to improve health for all. Comparison within cities and between cities is becoming an area of interest to researchers, policymakers and the populations they serve. We will shortly launch our website with our preliminary results, including the differences we have seen. By highlighting these differences, we can learn from each other to make our cities healthier, and empower the citizens of Europe."

Dr Erik van Ameijden, from Utrecht Municipal Health Service, Netherlands, said: "The monitoring of health information is vital to bring about evidence-based health gain in urban populations. With the help of our partners, my team in Utrecht has been able to analyse and present data in easy-to-use profiles, as well as demonstrate the key differences seen between cities and countries.

"We are proud to launch our health profiles for 26 cities across Europe where we describe differences in the health status of our urban citizens. These differences may be explained by the variation in social, demographic and economic conditions both within and between cities. We are concerned that the European north/south divide in health outcomes previously reported at national and regional level is happening in our cities."

Dr Christopher Birt, from the University of Liverpool, said: "Networks and public health advocacy is vital if we are to make our urban areas work for our populations in the future. Policy makers and researchers need to work together, with the best evidence, to reduce inequalities and improve health."

Dr Daniel Pope, also from the University of Liverpool, said "The results of our research show that policy makers are keen to use and learn about the tools we have created such as the profiles, healthy life expectancy and future trends, tools to help prioritise policies, urban health impact assessment and screening tools."

Professor Arnoud Verhoeff, from the Amsterdam Municipal Health Service, Netherlands, and chair of the local organising committee, added: "We enjoyed welcoming our esteemed speakers, guests and delegates to what proved to be the most popular venue for urban health researchers, policy makers and lay people to mix and share ideas. The main outputs of the conference will be the launch of the results of EURO-URHIS 2 and a new website which will offer a resource for all people interested in urban health."

More information: The key findings for each individual city involved in the research can be accessed here: www.urhis.eu/index… 25&Itemid=73

Provided by University of Manchester

Symptoms of alcohol abuse, not dependence, may better reflect family risk for alcohol use disorders

Individuals with alcohol use disorders (AUDs) vary widely in their age of onset of use, patterns of drinking, and symptom profiles. AUDs are often 'divided' into two categories: alcohol abuse (AA) and alcohol dependence (AD), with AA perceived as a milder syndrome that might develop into AD over time. A recent study of the clinical features of AUDs, with a focus on family liability, has found that – contrary to expectations – AA symptoms better reflect familial risk for AUDs than AD symptoms.

16 sept 2012--Results will be published in the December 2012 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"We decided to look at the clinical features of AA and AD as they correspond to familial liability to AUDs because familial risk of illness has been long used as a major validator of diagnostic approaches in psychiatry," explained Kenneth S. Kendler, professor of psychiatry at the Virginia Commonwealth University School of Medicine and corresponding author for the study. "For example, in the Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III) criteria, it was assumed the AA and AD represent distinct syndromes. Since then, results have accumulated to suggest that these two categories are very highly correlated and may in fact jointly represent one underlying dimension of risk.

The researchers examined clinical features of AUDs among 1,120 twins from the Virginia Twin Study of Psychiatric and Substance Use Disorders who met Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for lifetime AUDs. Analysis focused on whether clinical features of AUDs, including individual DSM-IV criteria for AD and AA, predicted risk for AUDs in cotwins and/or parents.

Results indicate that individual DSM-IV criteria for AA and AD differ meaningfully in the degree to which they reflect the individual's familial/genetic liability to AUDs. Importantly, and contrary to expectations, the familial/genetic risk to AUDs was better reflected by symptoms of alcoholabuse and negative psychosocial consequences of AUDs than by early age at onset of drinking, or symptoms of tolerance and withdrawal.

"Symptoms of alcohol abuse do a better job of reflecting the familial risk for AUDs than symptoms of dependence," said Kendler. "This is not what we expected. Clearly the symptoms of alcohol abuse may have more validity than they are commonly given credit for."

The most consistent single predictor of familial risk was AUD-associated legal problems, the researchers noted, one of the negative psychosocial consequences of AUDs, which is the one criterion slated for removal in the impending DSM-5.

"This removal is slated to occur largely through the influence of the International Classification of Diseases 11th Revision (ICD-11) which is used worldwide and is itself slated for revision by 2015," explained Kendler. "The DSM-5 authors are concerned that legal standards differ so widely across the world that it would be problematic to use any criteria reflecting legal practices."

Provided by Alcoholism: Clinical & Experimental Research

Mortality from CVD in Brazil has increased 3.5 times more than in other developing countries

Despite Brazil's successful prevention campaigns which have contributed to a reduction in risk factors such as smoking, cardiovascular disease (CVD) remains the first cause of death in the country, at 32%. Tobacco consumption and decrease of salt in local diets are some of the risk factors that will be discussed at the 67th Annual Congress of the Brazilian Society of Cardiology (1) which takes place in Recife, Brazil from 14 to 17 September 2012. This meeting is the largest cardiology conference in Latin America. The Brazilian Society of Cardiology is an affiliated society of the European Society of Cardiology since 2009 and has around 13,000 members.

15 sept 2012--Brazil's fast development has brought many positive changes to people's lives, but the move from a rural to an urban society has introduced changes in eating and exercise patterns resulting in growing obesity, diabetes and dyslipidaemia in the 185 million population.Cardiovascular mortality in Brazil has increased 3.5 times more than in other developing countries (2) making prevention of CVD an urgent issue. The recently updated European Guidelines on CVD Prevention (3), will be part of the one-day educational session (4) presented in Recife by senior faculty of the ESC together with representatives of the host society. These Guidelines have been reformatted to help disseminate the information from to where it is needed: health professionals working in the field, politicians and the general public.

"Most of CVD related deaths could be prevented through the widespread adoption of simple interventions such as smoking cessation, improved diets and increased exercise. Evidence that CVD is caused by modifiable risk factors, comes from clinical trials and observational community studies," says Professor Panos Vardas, President of the ESC who is leading the European delegation to Brazil. "We will be promoting these and other ESC Guidelines in Brazil. Our agenda (4) also includes highlights from ESC Congress 2012 with the latest information in diagnosing and treating cardiovascular disease as well as "Meet the expert" sessions where ESC faculty will explain recent Clinical Trials that will impact practice."

In recent years, the Brazilian Society of Cardiology has also sought greater international collaboration. Jadelson Pinheiro de Andrade, President of the Brazilian Society of Cardiology said "We think this will be our most international congress ever. We are happy to welcome the ESC sessions once again. Exchanges with our European colleagues are stimulating and we are hoping to collaborate on projects concerning registries and surveys in the future."

The ESC's GSA Committee was established to meet demand for ESC science and knowledge outside of Europe, to build closer ties with international cardiology organisations, and to extend the ESC mission beyond its traditional borders.

"International collaboration is a key objective of the ESC. There are worrying and significant disparities in the way CVD is diagnosed and treated, both in developed and developing countries. We will only be able to fulfill our mission of reducing the burden of CVD by joining forces across frontiers, exchanging experiences and promoting education and research in the cardiovascular field.," concluded Prof Vardas.

More information:

References

(1) congresso.cardiol.… gramacao.asp

(2) eurheartj.oxfordjo… 13/1541.full and www.who.int/chp/ch… a/brazil.pdf

(3) www.escardio.org/g… x?hit=TLinks

(4) www.escardio.org/c… welcome.aspx

Antidepressants, sleeping pills and anxiety drugs may increase driving risk

Drugs prescribed to treat anxiety, depression and insomnia may increase patients' risk of being involved in motor vehicle accidents, according to a recent study, published in the British Journal of Clinical Pharmacology. Based on the findings, the researchers suggested doctors should consider advising patients not to drive while taking these drugs.

14 sept 2012--Psychotropic drugs affect the way the brain functions and can impair a driver's ability to control their vehicle. Research on the links between psychotropic medication and driving accidents has focused on benzodiazepines, which have been used to treat anxiety and insomnia. Perhaps the best known of these drugs is diazepam. Newer Z-drugs, used to treat insomnia, have received less attention, as have antidepressants and antipsychotics.

To understand the effects of a wider spectrum of psychotropic drugs on driving accidents, the authors compared drug use in two groups of people identified using medical records from the Taiwanese national health insurance programme. The first group included 5,183 people involved in motor vehicle accidents. The second group included 31,093 people, matched for age, gender and the year of vehicle accidents, who had no record of being involved in motor vehicle accidents. In general, those involved in accidents were more likely to have been taking psychotropic drugs, whether they had been taking them for one month, one week or one day.

The results suggest that the increased risk associated with benzodiazepines is mirrored in both Z-drugs and antidepressants. However, antipsychotics were not associated with an increased risk of motor vehicle accidents, even among those taking higher doses.

"Our findings underscore that people taking these psychotropic drugs should pay increased attention to their driving performance in order to prevent motor vehicle accidents," said lead researcher, Hui-Ju Tsai, who is based at the National Health Research Institutes in Zhunan, Taiwan. "Doctors and pharmacists should choose safer treatments, provide their patients with accurate information and consider advising them not to drive while taking certain psychotropic medications."

The research strengthens the findings of previous reports that have assessed the risk associated with individual psychotropic drugs. It also provides more evidence on the link between dose and driving performance, showing that higher doses are associated with a higher risk of an accident. "Our data demonstrated significant dose effects for antidepressants, benzodiazepine and Z-drugs," said Tsai. "This suggests that taking a higher dosage poses a greater danger to those intending to drive."

The authors recommend that patients do not stop taking their medication, but if concerned should consult their doctor.

More information: Chia-Ming Chang, Erin Chia-Hsuan Wu, Chuan-Yu Chen, Kuan-Yi Wu, Hsin-Yi Liang, Yeuk-Lun Chau, Chi-Shin Wu, Keh-Ming Lin, Hui-Ju Tsai; Psychotropic Drugs and Risk of Motor Vehicle Accidents: a Population-based Case-Control Study; British Journal of Clinical Pharmacology; DOI: 10.1111/j.1365-2125.2012.04410.x

Provided by Wiley