Gold standard dialysis procedure may not be so golden for elderly patients

Elderly patients with kidney failure may not gain the same benefits from what's considered the gold standard for accessing the blood for dialysis compared with younger patients, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN). The findings suggest that vascular access procedures should be tailored to individual dialysis patients in the elderly population.

30 jun 2013--The elderly represent the most rapidly growing group of patients on dialysis for kidney failure. Research clearly shows an arteriovenous fistula, which is created by connecting a patient's own vein and artery to form a long-lasting site through which blood can be removed and returned, is the best way to gain access to the blood for dialysis in younger individuals. Other types of access involve the use of a catheter, which does not require needle sticks, and arteriovenous grafts, which is a plastic conduit between an artery and a vein. It's currently unclear which of these is the best type of dialysis access for elderly patients.

To investigate, Ranil DeSilva, MD, Alexander Goldfarb-Rumyantzev, MD, PhD (Beth Israel Deaconess Medical Center), and their colleagues studied information from 2005 to 2008 on more than 115,000 dialysis patients over 66 years of age, 35% of whom were in their 80s and 90s.

Among the major findings over four years:

• The use of catheters was linked with more than a 74% increased risk of death in patients of any age.
• While use of an arteriovenous fistula improved survival compared with use of an arteriovenous graft in patients in their late 60s and 70s, patients in their 80s and 90s experienced similar survival rates with the two procedures.

The findings suggest that in patients who are older than 80 years, placing a graft—which takes a much shorter time to establish and can be placed shortly before starting dialysis—may be a reasonable alternative to a fistula. This is particularly true for those with small veins or when it is uncertain when dialysis may be needed.

"In an era using more standardized quality outcome measures, we must remain cautious about generalizing measures to our growing elderly population. In the case of our study, a strategy that is clearly superior in young individuals requiring hemodialysis for kidney failure does not appear to be the clearly superior strategy for elderly individuals," said Dr. DeSilva. "It appears that the optimal vascular access choice should be tailored to the specific patient in the elderly population," he added.

In an accompanying editorial, Ann O'Hare, MD (University of Washington, Seattle) stressed that "to deliver care that is truly centered on the patient, we may ultimately need to set aside traditional metrics focusing on universal treatment targets… in favor of new ones focusing on the extent to which the process and outcomes of access selection support the goals and preferences of individual patients."

Provided by American Society of Nephrology

Seniors are not just wrinkly adults

Emergency patients over the age of 74 have significantly different and more complex health and social needs than their younger counterparts, even after controlling for illness severity, which has important implications about aging populations and emergency departments of the future. The results of the most extensive international study of the characteristics and outcomes of older emergency patients to be reported to date were published online Tuesday in Annals of Emergency Medicine.

29 jun 2013--"These patients have complex profiles before they come to the ER, and even more complicated needs once they get there," said lead study author Leonard C. Gray, MD, PhD, of the Centre for Research in Geriatric Medicine at the University of Queensland in Brisbane, Australia. "Dependence on others and geriatric illnesses, such as cognitive impairment and mobility problems, affect the majority of older emergency patients across a wide range of nations with different health systems and cultural contexts. They require specialized care to avoid missed diagnoses, pressure ulcers and a range of other potential problems associated with this particular population."

Researchers examined medical records for 2,282 patients older than 74 in 13 different emergency departments in seven countries (Australia, Belgium, Canada, Germany, Iceland, India and Sweden). Functional and cognitive problems increased dramatically after patients arrived at the emergency department.

More than one-third (37 percent) of patients had a recent fall, prior to coming to the emergency department.

Prior to visiting the emergency department, nearly half (46 percent) were dependent on others in one or more activities of daily living; after coming to the emergency department, only 33 percent were completely independent in all activities. In the emergency department, 26 percent displayed symptoms of cognitive impairment, whereas before coming to the ER only 20 percent had cognitive difficulties. Before coming to the ER, 26 percent of older patients could not walk without supervision; after coming to the ER, that number rose to 49 percent.

"Frailty, confusion and dependence on others make these our most fragile emergency patients," said Dr. Gray. "Specialized training in geriatric care and even specialized layout and procedures can help us provide the best assessment and care. The growing prevalence of older patients in ERs around the world suggests a need for careful scrutiny of current clinical practice and design of emergency departments worldwide."

More information: www.annemergmed.com/webfiles/images/journals/ymem/FA-5523.pdf

Provided by American College of Emergency Physicians

Screen all baby boomers for hepatitis C, expert panel says

This generation has highest rate of infection, likely contracted decades ago.

This generation has highest rate of infection, likely contracted decades ago.

27 jun 2013—All adults born between 1945 and 1965—the baby boom generation—should be screened for the hepatitis C virus along with injection-drug users and anyone transfused before 1992, according to new recommendations from the U.S. Preventive Services Task Force.

The guidelines, released Monday, mirror recommendations from the U.S. Centers for Disease Control and Prevention and provide a long-awaited policy from the task force, an independent panel of experts.

"For everyone born between 1945 and 1965 we recommend a one-time screening," said task force member Dr. Kirsten Bibbins-Domingo, an associate professor in residence at the University of California, San Francisco, School of Medicine.

People in this age group account for three-quarters of all hepatitis C cases in the United States, Bibbins-Domingo said. Many contracted the disease decades ago but don't know it.

Hepatitis C—a leading cause of liver damage and liver disease in the United States—is considered a silent killer because it progresses without any indications of illness. More than 30 percent of U.S. patients needing liver transplants have end-stage liver disease related to hepatitis C.

"The challenge is that many people have hepatitis C and don't have signs and symptoms of the disease," Bibbins-Domingo said. "Those people should be identified and consider treatment."

An estimated 3.9 million people are infected with hepatitis C in the United States, the task force said. Unlike other types of hepatitis, there is no vaccine for hepatitis C.

In its 2004 statement, the task force advised against routine screening of adults without symptoms and high risk of infection. It also said it had too little evidence to recommend for or against routine screening for adults with high risk of infection.

It became apparent, however, that two-thirds of infected people weren't getting screened, while treatment was becoming more successful.

"Many people appear to benefit from treatment," Bibbins-Domingo said. "That is what led the task force to conclude that it is beneficial for people to find out they have hepatitis C in order to seek treatment."

Dr. Marc Siegel, an associate professor of medicine at NYU Langone Medical Center in New York City, said he welcomes the new guidelines, which were published June 25 in the Annals of Internal Medicine.

"I am absolutely thrilled that the U.S. Preventive Services Task Force, which has had a head-in-the-sand approach toward screening, has come out for a one-time screening for hepatitis C," Siegel said.

Siegel encourages everyone at risk to get tested.

Screening for hepatitis C involves a simple, inexpensive blood test. Those who test positive usually receive a course of antiviral medication over several months. Most people have no detectable virus following treatment, Bibbins-Domingo said.

"Treatment is effective in preventing the complications of hepatitis C," Bibbins-Domingo said. "Treatments have gotten better, and I suspect treatments will continue to get better."

Many people who test positive for the virus have no signs of active infection. Whether they should be treated should be discussed with their doctor, she said.

Although baby boomers should have a one-time screening, those who continue to be at risk for the infection should be screened more often, Bibbins-Domingo said.

Past or current injection-drug use is the greatest risk for hepatitis C infection. Also at high risk are people with a history of blood transfusions before widespread adoption of screening and infection-control measures in 1992; people who have undergone long-term dialysis treatment; and those with exposure to hepatitis C in health care settings. People with HIV/AIDS, a history of intranasal drug use or tattoos from unregulated or unsafe parlors also are at greater risk than the general population.

This expanded screening may identify millions of Americans who were unaware of their infection, the task force said.

Vitamin D reduces blood pressure and relieves depression in women with diabetes

In women who have type 2 diabetes and show signs of depression, vitamin D supplements significantly lowered blood pressure and improved their moods, according to a pilot study at Loyola University Chicago Niehoff School of Nursing.

26 jun 2013--The study was presented at the American Diabetes Association 73rd Scientific Sessions in Chicago.

"Vitamin D supplementation potentially is an easy and cost-effective therapy, with minimal side effects," said Sue M. Penckofer, PhD, RN, lead author of the study and a professor in the Niehoff School of Nursing. "Larger, randomized controlled trials are needed to determine the impact of vitamin D supplementation on depression and major cardiovascular risk factors among women with Type 2 diabetes."

Penckofer recently received a four-year, $1.49 million grant from the National Institute of Nursing Research at the National Institutes of Health to do such a study. Penckofer and her Loyola co-investigators plan to enroll 180 women who have type 2 diabetes, symptoms of depression and insufficient levels of vitamin D. Women will be randomly assigned to receive either a weekly vitamin D supplementation (50,000 International Units) or a matching weekly placebo for six months. The study is titled "Can the Sunshine Vitamin Improve Mood and Self Management in Women with Diabetes?

About 1 in 10 people in the United States has diabetes, and the incidence is projected to increase to 1 in 4 persons by 2050. Women with type 2 diabetes have worse outcomes than men. The reason may be due to depression, which affects more than 25 percent of women with diabetes. Depression impairs a patient's ability to manage her disease by eating right, exercising, taking medications, etc.

Many Americans do not get enough vitamin D, and people with diabetes are at especially high risk for vitamin D insufficiency or deficiency. Reasons include limited intake of foods high in vitamin D, obesity, lack of sun exposure and genetic variations.

The pilot study included 46 women who were an average age of 55 years, had diabetes an average of 8 years and insufficient blood levels of vitamin D (18 ng/ml). They took a weekly dose (50,000 International Units) of vitamin D. (By comparison, the recommended dietary allowance for women 51 to 70 years is 600 IU per day.)

After six months, their vitamin D blood levels reached sufficient levels (average 38 ng/ml) and their moods improved significantly. For example, in a 20-question depression symptom survey, scores decreased from 26.8 at the beginning of the study (indicating moderate depression) to 12.2 at six months (indicating no depression. (The depression scale ranges from 0 to 60, with higher numbers indicating more symptoms of depression.)

Blood pressure also improved, with the upper number decreasing from 140.4 mm Hg to 132.5 mm Hg. And their weight dropped from an average of 226.1 pounds to 223.6 pounds.

Penckofer is internationally known for her research on vitamin D, diabetes and depression. In October, she will be inducted as a Fellow in the American Academy of Nursing for her scientific contributions in improving the health and quality of life of women with chronic disease. And she recently was appointed as the first nurse researcher to the Chicago Diabetes Center for Translational Research.

Provided by Loyola University Health System

Robo-pets may contribute to quality of life for those with dementia

Professor Glenda Cook with PARO seal.

Professor Glenda Cook with PARO seal.

Robotic animals can help to improve the quality of life for people with dementia, according to new research. A study has found that interacting with a therapeutic robot companion made people with mid- to late-stage dementia less anxious and also had a positive influence on their quality of life.

25 june 2013--The pilot study, a collaboration led by Professor Wendy Moyle from Griffith University, Australia and involving Northumbria University's Professor Glenda Cook and researchers from institutions in Germany, investigated the effect of interacting with PARO – a robotic harp seal – compared with participation in a reading group. The study built on Professor Cook's previous ethnographic work carried out in care homes in North East England.

PARO is fitted with artificial intelligence software and tactile sensors that allow it to respond to touch and sound. It can show emotions such as surprise, happiness and anger, can learn its own name and learns to respond to words that its owner uses frequently.

Eighteen participants, living in a residential aged care facility in Queensland, Australia, took part in activities with PARO for five weeks and also participated in a control reading group activity for the same period. Following both trial periods the impact was assessed, using recognised clinical dementia measurements, for how the activities had influenced the participants' quality of life, tendency to wander, level of apathy, levels of depression and anxiety ratings.

The findings indicated that the robots had a positive, clinically meaningful influence on quality of life, increased levels of pleasure and also reduced displays of anxiety.

Research has already shown that interaction with animals can have a beneficial effect on older adults, increasing their social behaviour and verbal interaction and decreasing feelings of loneliness. However, the presence of animals in residential care home settings can place residents at risk of infection or injury and create additional duties for nursing staff.

This latest study suggests that PARO companions elicit a similar response and could potentially be used in residential settings to help reduce some of the symptoms – such as agitation, aggression, isolation and loneliness – of dementia.

Prof Cook, Professor of Nursing at Northumbria University, said: "Our study provides important preliminary support for the idea that robots may present a supplement to activities currently in use and could enhance the life of older adults as therapeutic companions and, in particular, for those with moderate or severe cognitive impairment.

"There is a need for further research, with a larger sample size, and an argument for investing in interventions such as PARO robots which may reduce dementia-related behaviours that make the provision of care challenging as well as costly due to increased use of staff resources and pharmaceutical treatment."

The researchers of the pilot study have identified the need to undertake a larger trial in order to increase the data available. Future studies will also compare the effect of the robot companions with live animals.

The pilot study, entitled 'Exploring the Effect of Companion Robots on Emotional Expression in Older Adults with Dementia', is published in The Journal of Gerontological Nursing.

Provided by Northumbria University

Depression screening in AF Clinics recommended by study

Electrophysiologists (EPs) rate the quality of life of patients with Paroxysmal atrial fibrillation (AF) significantly better than the patients themselves do, with the greatest level of disagreement about mental health. The abstract study, presented at the EHRA EUROPACE meeting, 23 to 26 June, in Athens, Greece, found that patients with paroxysmal AF, even in the absence of significant concomitant cardiac disease, showed signs of depression, sleeping disorders and low levels of physical activity.

24 jun 2013--Since neither rate or rhythm control strategies for AF have been shown to be superior to the other in survival or stroke outcomes, decisions need to be made about which approach is better for each patient's long-term management.

"EPs generally decide whether to take a more or less aggressive treatment approach according to the patient's disease burden. Here, not only physical symptoms need to be taken into consideration, but also the patient's mental health and quality of life in general. If EPs don't know that their patients are suffering from depression they may not be offering them optimum treatments," says Professor Karl Ladwig, the first author of the study. "Good communication between physicians and patients is of paramount importance for adherence to medications and long term prognosis."

In the current study, Ladwig and colleagues set out to assess the degree of congruence between patient and physician assessment of the patients' subjective health status, which, the authors say, provides a good indicator of patient-physician communication and shared understanding. Data for the analysis was taken for patients enrolled in the Angiotensin II Antagonist in Paroxysmal Atrial Fibrillation (ANTIPAF) trial. The ANTIPAF trial, conducted by Professor Andreas Goette within the German Competence NETwork on Atrial Fibrillation (AFNET), examined whether angiotensin II receptor blockers reduced the incidence of paroxysmal AF. The analysis also specifically explored discordance between AF patients and their doctors.

Between February 2004 and September 2008, 334 patients (41% female and 59% male) with paroxysmal AF, without significant concomitant heart disease, and their physicians from 43 participating centres were asked to rate the patients' heath related quality of life (HRQoL). Patients filled in the SF-12 self rating scale in the clinic or home; while physicians complete the SF8 scale after the patient had left the clinic. Physicians had no access to the patient's answer sheets.

Intra-Class Correlations (ICC) were used to assess the consistency or conformity of the measures made by multiple observers, and Bland Altman graphs plotted the strength of concordance for each patient against average ratings for both physicians and patients.

"When one considers the importance placed on quality of life in the AF literature these levels of discordance between physicians and patients are surprisingly large. They underline the need for physician to be trained to recognize depression in patients and for the introduction of systematic screening for depression in all AF clinics," says Ladwig, from the Helmholtz Centre, Munich, Germany.

Future studies should explore whether interventions such as physician training and screening, improve both quality of life and the underlying disease status of patients with AF, he said.

More information: K Ladwig, A Eisenhart-Rothe, T Meinertz,et al. How well do electrophysiologists estimate the degree of quality of life impairment of their patients with paroxysmal atrial fibrillation? Results from the ANTIPAF Trial. FP 175.

Provided by European Society of Cardiology

Dietary supplement linked to increased muscle mass in the elderly

A supplemental beverage used to treat muscle-wasting may help boost muscle mass among the elderly, according to a new study. The results were presented today at The Endocrine Society's 95th Annual Meeting in San Francisco.

23 jun 2013--The supplemental beverage, called Juven, contains three amino acids, including arginine. Amino acids are the building blocks of proteins, and are required for cell growth and repair. The amino acid arginine is especially important because it increases growth-hormone production, which causes the body to produce a critical protein called insulin-like growth factor 1, or IGF-1. This protein promotes growth and development and, as its name suggests, is similar in structure to the hormone insulin.

Previously, studies showed that Juven helped increase muscle mass in patients with AIDS or cancer. These earlier findings led this study's investigators to hypothesize that the increased muscle mass could result from greater blood concentrations of IGF-1. They theorized that these increased protein levels could have the same benefits among the elderly, who also experience decreased muscle mass and strength related to drops in hormone production that occur with aging. In turn, increased muscle strength could potentially improve quality of life among the elderly.

They found that participants who received Juven had significant increases in lean body mass, while those who received placebo did not have any change. In addition, blood concentrations of IGF-1 increased among Juven recipients, but not among the placebo group. The correlation between the improved IGF-1 concentrations and increased lean tissue, however, was not statistically significant.

"The amino acid cocktail of the dietary supplement Juven appears to hold promise for increasing lean body in healthy older adults," said study lead author Amy C. Ellis, PhD, assistant professor at the University of Alabama at Tuscaloosa. "However, more research is needed to determine the cause-and-effect relationship and the mechanisms by which the amino acids in Juven may favorably affect body composition of healthy, older adults."

Study participants were 29 healthy adults between the ages of 65 and 87 years. Each received either Juven® or a placebo drink twice a day, along with their regular daily diet, for six months. At the beginning of the study and again six months later, investigators used a special test to measure lean body mass. At both times, they also assessed participants' blood levels of IGF-1 after fasting.

The National Institutes of Health and the Center for Aging at the University of Alabama-Birmingham funded the study. Abbott Laboratories, the manufacturer of Juven®, provided the dietary supplement and the placebo.

Provided by The Endocrine Society

Americans' vitamin D levels are highest in August, lowest in February, study shows

UC Irvine and Mayo Clinic researchers have found that vitamin D levels in the U.S. population peak in August and bottom out in February. The essential vitamin – necessary for healthy bones – is produced in the skin upon exposure to ultraviolet B rays from the sun.

22 jun 2013--Vitamin D helps bones absorb calcium and can protect against osteoporosis. It's also thought to play a role in seasonal illnesses, such as the flu. Low levels of vitamin D are believed to impair "innate immunity" i.e., the body's first line of defense against pathogens. To further study this link, good estimates of the cyclicality of the vitamin are necessary. Solar exposure – a timely topic since June 21 marks the first day of summer – is the most important way people acquire vitamin D. But certain foods, including egg yolks and oil-rich fish like mackerel, salmon, sardines and herring contain the nutrient. In addition, milk and cereal are often enriched with vitamin D.

"Even with food fortification, vitamin D levels in the population show a high level of seasonality due to the influence of sunlight," said Amy Kasahara, a UC Irvine graduate student in public health and first author on the paper, which appears in the journal PLOS ONE.

"The exact biochemical pathways from UVB rays to vitamin D were discovered in the 1970s," she said. "In this study, we have shown that vitamin D levels lag the solar cycle, peaking in August and troughing in February."

The correlation between the seasons and vitamin D has been known for some time. "What we have been able to do is put a lot more precision on the estimates of vitamin D seasonality," said Andrew Noymer, associate professor of public health and senior author of the article.

"Our analysis, combined with other data, will help contribute to understanding the role of vitamin D in all seasonal diseases, where the simple winter/spring/summer/fall categories are not sufficient."

Researchers measured the level of 25-hydroxyvitamin D in 3.4 million blood samples collected weekly in the U.S. between July 2006 and December 2011.

The study looked at population averages, so people shouldn't make assumptions about their own levels of vitamin D based on the calendar. Healthcare providers can perform individual blood tests to measure vitamin D directly, and supplements are available for those who cannot or do not receive enough exposure to sunlight.

Ravinder J. Singh of the Mayo Clinic co-authored the work.

Provided by University of California, Irvine

Pre-Alzheimer's: Metabolic disorder found in cognitively normal patients

Alzheimer's disease has been linked in many studies to amyloid plaque buildup in the brain, but new research is finding a common thread between amyloid burden and lower energy levels, or metabolism, of neurons in certain areas of the brain associated with Alzheimer's disease—even for people with no sign of cognitive decline. This is a new development in the understanding of Alzheimer's pathology, say neuroscientists unveiling the research at the Society of Nuclear Medicine and Molecular Imaging's 2013 Annual Meeting.

21 jun 2013--"This study shows that there is an association between hypometabolism and amyloid in the brains of normal people," said Val J. Lowe, MD, a professor of radiology at Mayo Clinic Cancer Center based in Rochester, Minn. "Previous studies indicate that hypometabolism of this same pattern is present in patients who have abnormalities of the gene apolipoprotein E, or APOE. The hypothesis is that people who have these genetic abnormalities tend to have hypometabolism and are on the trajectory toward developing Alzheimer's disease. Hypometabolism does appear to be an early harbinger of the disease before dementia sets in."

The research is a part of a longitudinal multi-phase study called the Mayo Clinic Study of Aging, which includes 2,500 patients with 4,000 projected for the next phase. For this imaging study, 617 cognitively normal subjects underwent two separate positron emission tomography (PET) procedures, a molecular imaging technique that visualizes physiological processes in the body. Each subject was imaged with an amyloid-binding radionuclide imaging agent, C-11 Pittsburgh compound B (PiB), produced on-site at the Mayo Clinic. An hour later, all patients were imaged again using the same scanner and a different radionuclide agent, F-18 fluorodeoxyglucose (FDG), which shows up on scans as hot-and-cold spots according to metabolic brain cell activity.

Results were then analyzed via quantitative analysis and reviewed. Researchers found significant hypometabolism in brain regions classically associated with Alzheimer's disease, including the angular gyrus and posterior cingulate. Even the PiB PET scans that were deemed barely positive for amyloid were partnered with FDG PET scans that showed corresponding hypometabolism.

"In general, these findings were group-wide," said Lowe. "We now need to parse the data down to an individual subject level to see what is driving this relationship. As we follow these subjects long term, this relationship will be important because if people have amyloid in their brain and survive without Alzheimer's disease despite amyloid, we want to know why."

Provided by Society of Nuclear Medicine

US doctors' group labels obesity a disease

Advocates say AMA's move will boost resources to fight weight-gain epidemic, but others question decision.

Advocates say AMA's move will boost resources to fight weight-gain epidemic, but others question decision.

20 jun 2013—In an effort to focus greater attention on the weight-gain epidemic plaguing the United States, the American Medical Association has now classified obesity as a disease.

The decision will hopefully pave the way for more attention by doctors on obesity and its dangerous complications, and may even increase insurance coverage for treatments, experts said.

"Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans," AMA board member Dr. Patrice Harris said in a statement Tuesday. "The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity."

One expert thinks the AMA's decision, approved Tuesday at the group's annual meeting, could lead to greater coverage by insurance companies of treatments for obesity.

"We already treat obesity as a chronic illness," said Dr. Esa Matius Davis, an assistant professor of medicine at the University of Pittsburgh. "But this decision will bring more resources into the picture because it will, hopefully, allow for more insurance coverage and that really has been the issue of getting people the help that they need," she said.

Treatments for obesity—including drugs, nutritional counseling and surgery, if needed—often don't get reimbursed by insurance companies, Davis said. That means many patients aren't getting the care they need because they can't afford to pay the out-of-pocket costs, she said.

If insurance covered these services "it would increase referrals and treatment and that would be a huge step in the right direction," Davis said.

Right now, Davis gets insurance coverage for her obese patients by diagnosing them with high blood pressure or high cholesterol or diabetes, or other obesity-related conditions. But, that still leaves many obese patients out in the cold, she said.

The Obesity Society, which calls itself the leading scientific society dedicated to the study of obesity, applauded the AMA's decision. "The passage of a new American Medical Association policy classifying obesity as a disease reinforces the science behind obesity prevention and treatment," Theodore Kyle, advocacy chair, said in a statement.

"This vital recognition of obesity as a disease can help to ensure more resources are dedicated to needed research, prevention and treatment; encourage health care professionals to recognize obesity treatment as a needed and respected vocation; and, reduce the stigma and discrimination experienced by the millions affected," he said.

Kyle said the AMA has now joined a number of organizations that have previously made this classification, including the U.S. National Institutes of Health, the Social Security Administration, and the Centers for Medicare and Medicaid Services.

Not everyone thinks the AMA's decision was the right one, however. In fact, the move was opposed by many in the doctors' group, including a committee that had been charged with exploring the issue. It had voted not to recognize obesity as a disease.

One of the objections to labeling obesity as a disease hinges on the way obesity is determined, using the so-called body mass index—a ratio of weight to height—that some health experts think is inexact.

That's not the only objection.

"I have never liked the idea of characterizing obesity as a disease, because disease occurs when the body is malfunctioning," said Dr. David Katz, director of the Yale University Prevention Research Center. "Turning surplus calories into a fat reserve is not malfunction, it is normal physiology."

Katz said obesity is largely a societal problem caused by too much food and too little physical activity. While obesity certainly needs to be treated, the aspects of culture that have led to the obesity epidemic need to be changed, he said.

"Obesity is rampant in the modern world not because of changes in our bodies, but because of changes in the modern world. We are drowning in excess calories and labor-saving technologies," he said.

He thinks obesity treatments deserve insurance coverage.

During the past 20 years, there has been a dramatic increase in obesity in the United States, with more than one-third of adults (35.7 percent) and approximately 17 percent (or 12.5 million) of children and teens considered obese, according to the U.S. Centers for Disease Control and Prevention.

Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death.

In 2008, medical costs associated with obesity were estimated at $147 billion; the medical costs for people who are obese were $1,429 higher than those of normal weight, the CDC said.

Blacks have the highest age-adjusted rates of obesity—49.5 percent—followed by Mexican Americans (40.4 percent), all Hispanics (39 percent) and whites (34 percent).

Among children and teens, the obesity prevalence since 1980 has almost tripled. There are significant racial and ethnic disparities in obesity rates among children. Hispanic boys are significantly more likely to be obese than white boys, and black girls are significantly more likely to be obese than white girls, the CDC said.

Obesity and overweight are labels for ranges of weight that are greater than what are considered healthy for a given height.

For adults, obesity and overweight are determined by using weight and height to calculate your body mass index, or BMI. An adult with a BMI between 25 and 29.9 is considered overweight, while someone with a BMI of 30 or higher is considered obese.

Someone who is 5 feet, 9 inches tall and weighs between 125 pounds and 168 pounds has a BMI between 18.5 and 24.9, which is considered healthy. That same person who weighs between 169 and 202 pounds has a BMI between 25.0 and 29.9, which is considered overweight. And if he or she weighs more than 203 pounds, they have a BMI of 30 or higher—considered obese.

Timing of calcium and vitamin D supplementation may affect how bone adapts to exercise

Taking calcium and vitamin D before exercise may influence how bones adapt to exercise, according to a new study. The results will be presented on Tuesday at The Endocrine Society's 95th Annual Meeting in San Francisco.

19  jun 2013--"The timing of calcium supplementation, and not just the amount of supplementation, may be an important factor in how the skeleton adapts to exercise training," said study lead author Vanessa D. Sherk, PhD, postdoctoral research fellow at the University of Colorado Anschutz Medical Campus. "Further research, however, is needed to determine whether the timing of calcium supplementation affects the skeletal adaptations to exercise training."

Previous research has shown that a year of intense training is associated with substantial decreases in bone mineral density among competitive road cyclists. Experts believe that this kind of exercise-induced bone loss could be related to the loss of calcium during exercise. As blood calcium levels drop, the parathyroid gland produces excess parathyroid hormone, which can mobilize calcium from the skeleton.

In this study, investigators found that an exercise-induced decrease in blood calcium occurred whether calcium supplements were taken before or after exercising. Pre-exercise supplementation, however, resulted in less of a decrease. Although not statistically significant, parathyroid hormone levels increased slightly less among cyclists who took calcium before exercising.

"These findings are relevant to individuals who engage in vigorous exercise and may lose a substantial amount of calcium through sweating," Sherk said. "Taking calcium before exercise may help keep blood levels more stable during exercise, compared to taking the supplement afterwards, but we do not yet know the long-term effects of this on bone density."

The timing of calcium supplementation did not cause a difference in blood levels of a compound that is a biological indicator of bone loss. Both the before- and after-exercise groups exhibited 50-percent increases in the level of this compound, called CTX, for collagen type-1 C-telopeptide.

Study participants included 52 men aged 18 to 45 years. Investigators randomly assigned participants to take 1,000 milligrams of calcium and 1,000 international units of vitamin D either 30 minutes before or one hour after exercise. The exercise comprised a simulated 35-kilometer time trial, and participants wore skin patches to absorb sweat.

Investigators measured blood levels of calcium and parathyroid hormone before and immediately after exercise. They also measured CTX before and 30 minutes after exercise. They used pre- and post-body weight, adjusted for fluid intake, combined with the calcium measured in the sweat from the skin patches, to estimate the amount of calcium lost through the skin during exercise.

Provided by The Endocrine Society

Elderly benefit from using implantable defibrillators

This infographic from the article outlines the elderly may benefit from implantable cardioverter defibrillators as much as younger people. Credit: American Heart Association journal Circulation; D. Lee

This infographic from the article outlines the elderly may benefit from implantable cardioverter defibrillators as much as younger people. Credit: American Heart Association journal Circulation; D. Lee

The elderly may benefit from implantable cardioverter defibrillators as much as younger people, according to new research in the American Heart Association journal Circulation.

18 jun 2013--An implantable cardioverter defibrillator (ICD) is a small battery-powered device placed under the skin of the chest which delivers electrical impulses to restore a normal heartbeat if it detects a dangerous abnormal rhythm.

Overall health—not age alone—should determine how well patients will do after getting an ICD and help guide decisions about who should receive one, researchers said.

"Whether elderly patients benefit from the devices has been controversial and research on the topic is lacking," said Douglas S. Lee, M.D., Ph.D., lead author and scientist at the Institute for Clinical Evaluative Sciences and cardiologist at the Peter Munk Cardiac Centre in Toronto, Ontario, Canada. "The issue is important as the population ages and the number of elderly people living with heart disease grows."

Researchers studied 5,399 patients who had ICDs implanted because of poor heart function due to a prior heart attack or heart failure, or after being resuscitated from cardiac arrest.

"Older patients were just as likely to experience an appropriate electrical shock from the device to treat a life-threatening heart rhythm. However, older patients experienced more non-cardiac and cardiovascular hospitalizations and higher associated rates of death overall," said Lee, who is also associate professor of medicine at the University of Toronto.

Other study findings include:

• Among those who received an ICD with heart failure or after heart attack, 38.5 percent were 70 years or older and 7 percent were 80 years or older.
• Among those who received an ICD after surviving a cardiac arrest, 42.5 percent were 70 years or older and 10.9 percent were in their 80s.
• Older age correlated with increased risk of death after ICD implantation in both groups. For example, among those undergoing ICD implantation for prevention of cardiac arrest, 2 in every 100 patients ages 18-49 died whereas 10 in 100 died among those 80 years and older.
• Use of the devices was equally effective among younger and older patients in restoring heart rhythm after a serious life-threatening rhythm disorder occurred. Across all age groups, ICDs more often delivered appropriate electrical shocks when implanted after cardiac arrest than when used to prevent the first cardiac arrest.

Provided by American Heart Association

Commonly-prescribed drugs may influence the onset and progression of Alzheimer's disease

Multiple drug classes commonly prescribed for common medical conditions are capable of influencing the onset and progression of Alzheimer's disease, according to researchers at The Mount Sinai Medical Center. The findings are published online in the journal PLoS One.

17 jun 2013--Led by Giulio Maria Pasinetti, MD, PhD, the Saunders Family Chair and Professor in Neurology at Mount Sinai, a research team used a computer algorithm to screen 1,600 commercially-available medications to assess their impact on the brain accumulation of beta-amyloid, a protein abnormally accumulated in the brain of Alzheimer's disease and implicated in neurodegeneration. They found that currently-available medications prescribed for conditions such as hypertension, depression, and insomnia were found to either to block or to enhance the accumulation of beta-amyloid, the component of amyloid plaques.

"This line of investigation will soon lead to the identification of common medications that might potentially trigger conditions associated with the prevention, or conversely the onset, of Alzheimer's disease," said Dr. Pasinetti. "They may be a novel reference for physicians to consider when prescribing the most appropriate drug, particularly in subjects at high risk for Alzheimer's disease."

To validate the screening protocol, Dr. Pasinetti and his colleagues administered these drugs in mice that were genetically engineered to develop the hallmark amyloid plaques associated with Alzheimer's disease. After six months of treatment with blood pressure medicines, amyloid plaques and neurodegeneration were significantly reduced in the mice. One such medicine was Carvedilol, now under clinical investigation in Alzheimer 's disease with the intent to slow down memory deterioration.

"In recent years, amyloid plaques have become one of the main focal points in the search to understand and to treat Alzheimer's disease," said Dr. Pasinetti. "Thus, identifying novel drug treatments that prevent harmful beta-amyloid generation will help in the development of treatments for Alzheimer's disease. For example, one very exciting finding of our study is that Carvedilol, already approved for treatment of hypertension, may immediately become a promising drug for the treatment of Alzheimer's as well."

The authors discuss the limitations of the research, noting that studies must be immediately verified in human-safety studies that examine the effects of the drugs independent of the original indication. Dr. Pasinetti hopes these findings will lead to multiple clinical trials in the future to identify preventive drugs, which will need to be prescribed at tolerable dosages.

"If we can repurpose drugs currently used for different indications, such as lowering blood pressure, this could have dramatic implications for this population," said Dr. Pasinetti.

Provided by The Mount Sinai Hospital

Depression in postmenopausal women may increase diabetes and cardiovascular disease risk

Postmenopausal women who use antidepressant medication or suffer from depression might be more likely to have a higher body mass index (BMI), larger waist circumference and inflammation—all associated with increased risk for diabetes and cardiovascular disease, according to a study led by University of Massachusetts Medical School investigator Yunsheng Ma, PhD, MD, MPH, and published in the June 13 issue of the American Journal of Public Health.

16 jun 2013--The UMass Medical School study investigated whether elevated depressive symptoms and antidepressant use are associated with biomarkers for glucose dysregulation and inflammation, BMI and waist circumference. The three main findings indicate that both elevated depressive symptoms and antidepressant use are each significantly associated with higher BMI and waist circumference; elevated depressive symptoms are associated with increased levels of insulin and insulin resistance; and antidepressant use is associated with increased C-reactive protein (CRP) levels, a marker of inflammation, which increases the risk of type-2 diabetes and cardiovascular disease.

"It may be prudent to monitor post-menopausal women who have elevated depression symptoms or are taking antidepressant medication to prevent diabetes and cardiovascular disease," said Dr. Ma, associate professor of medicine, who with UMMS colleagues analyzed data from the landmark Women's Health Initiative (WHI).

Postmenopausal women were recruited into the WHI from 1993 to 1998, and data for this analysis were collected at regular intervals through 2005. Using data from 1,953 women who completed all relevant WHI assessments, the study found that elevated depressive symptoms were found to be significantly associated with increased insulin levels and measures of insulin resistance. Significantly, throughout the entire 7.6 years on average that women were enrolled in the WHI, those who had elevated depressive symptoms or were using antidepressants had higher average BMI and waist circumference than did women not using antidepressants or without depressive symptoms among 71,809 women. However, the associations were stronger for waist circumference.

Analysis of data from 2,242 women showed that both elevated depressive symptoms and antidepressant use was associated with higher CRP levels, a marker of inflammation.

"Identifying these markers in women is important for diabetes prevention because they can be monitored for possible action before progression to full-blown diabetes," said Ma.

Few studies have examined the association of BMI, waist circumference and biomarkers of glucose dysregulation and inflammation with depression, antidepressant medication use, or both. The UMMS study included a large, racially and ethnically diverse sample of post-menopausal women. Because the analysis was epidemiological, it could not determine a causal relationship, so further study is needed to confirm the results through clinical trials.

"Given that diabetes and cardiovascular disease can be effectively prevented or delayed in high-risk individuals with lifestyle modifications or pharmacological interventions, our findings indicate the prudence of monitoring BMI, waist circumference, along with established biomarkers for diabetes and cardiovascular risk including serum glucose, insulin resistance, and CRP among women with elevated depression symptoms, or who are taking antidepressant medication, to prevent diabetes and cardiovascular disease," adds Simin Liu, MD, MS, MPH, ScD, professor of epidemiology and medicine at Brown University, a WHI investigator and study coauthor. "Further intervention trial is needed to confirm our findings and identify the specific patterns of change associated with diabetic and cardiovascular disease risk markers and individual antidepressants and depression."

Provided by University of Massachusetts Medical School

Volunteering reduces risk of hypertension in older adults, research shows

It turns out that helping others can also help you protect yourself from high blood pressure.

14 jun 2013--New research from Carnegie Mellon University shows that older adults who volunteer for at least 200 hours per year decrease their risk of hypertension, or high blood pressure, by 40 percent. The study, published by theAmerican Psychological Association's Psychology and Aging journal, suggests that volunteer work may be an effective non-pharmaceutical option to help prevent the condition. Hypertension affects an estimated 65 million Americans and is a major contributor to cardiovascular disease, the leading cause of death in the U.S.

"Everyday, we are learning more about how negative lifestyle factors like poor diet and lack of exercise increase hypertension risk," said Rodlescia S. Sneed, a Ph.D. candidate in psychology in CMU's Dietrich College of Humanities and Social Sciences and lead author of the study. "Here, we wanted to determine if a positive lifestyle factor like volunteer work could actually reduce disease risk. And, the results give older adults an example of something that they can actively do to remain healthy and age successfully."

For the study, Sneed and Carnegie Mellon's Sheldon Cohen studied 1,164 adults between the ages of 51 and 91 from across the U.S. The participants were interviewed twice, in 2006 and 2010, and all had normal blood pressurelevels at the first interview. Volunteerism, various social and psychological factors, and blood pressure were measured each time.

The results showed that those who reported at least 200 hours of volunteer work during the initial interview were 40 percent less likely to develop hypertension than those who did not volunteer when evaluated four years later. The specific type of volunteer activity was not a factor—only the amount of time spent volunteering led to increased protection from hypertension.

"As people get older, social transitions like retirement, bereavement and the departure of children from the home often leave older adults with fewer natural opportunities for social interaction," Sneed said. "Participating in volunteer activities may provide older adults with social connections that they might not have otherwise. There is strong evidence that having good social connections promotes healthy aging and reduces risk for a number of negative health outcomes."

More information: www.psy.cmu.edu/people/sneed.html

Provided by Carnegie Mellon University

Home palliative care services double people's chances of dying at home and reduce symptoms

13 jun 2013—A new Cochrane review led by King's College London has found that providing home palliative care doubles the odds that someone with a terminal illness can die at home if they want to, and leads to better control of their symptoms.

Based on this evidence the researchers are calling for the development of specialist home palliative care services to be included in national healthcare strategies, to ensure people who wish to die at home receive the best possible care. Researchers also say that providing palliative care at home could reduce avoidable and often expensive hospital admissions.

Previous studies show that most people with a terminal illness would prefer to die at home if possible. However, often multiple severe symptoms such as pain, breathlessness, nausea, fatigue, or a lack of home support means that they are admitted to hospital as their disease progresses. Earlier research from the Cicely Saunders Institute at King's found that people with diseases such as advanced cancer, respiratory failure and late stageneurological diseases, can suffer as many as 12-14 different symptoms that need treatment and care.

In this new study, funded by Cicely Saunders International and the Calouste Gulbenkian Foundation, King's researchers analysed and combined studies from across the globe that compared home palliative care services with usual care, such as that from general practitioners, district nurses and hospital outpatients. The research team at the Cicely Saunders Institute collaborated in this work with colleagues at the King's Centre for the Economics of Mental and Physical Health and at the geriatrics unit of the Princess Grace Hospital Centre in Monaco. The review gathered information about over 37,500 patients who suffered from terminal illnesses including cancer, heart failure, respiratory diseases and neurological conditions, such as multiple sclerosis. In addition information and views from over 4,000 family caregivers were analysed.

The results showed that expert home palliative care teams improved the odds of dying at home by 2.21 – i.e. more than double. This result was highly significant and so is not likely to have occurred by chance. In addition, home palliative care services improved symptom control and reduced the burden of symptoms for patients. These palliative care teams were working from hospices, home care services and hospitals, and comprised doctors, nurses, and other professionals specially trained in delivering palliative care to ensure that they have the right expertise, skills and experience.

Dr Barbara Gomes from King's, who led the study, said: 'These are important findings as they show for the first time clear and reliable evidence of benefits that justify the provision of home palliative care to allow more people to die at home and to reduce patients' symptoms. Home palliative care is key to narrowing the gap between where people wish to die and where they actually die, which we know exists in many countries. The research shows these services work. Their development must therefore be central in national strategies to improve the care people receive towards the end of their life."

Professor Irene J Higginson, Director of the Cicely Saunders Institute at King's, added: 'With the number of deaths in England and Wales expected to increase by 17 percent by 2030, we need to find ways of improving palliative care for our ageing population.

'This review shows the need to provide specialist, dedicated home palliative care services to provide an additional layer of individualised support for people reaching the end of life, and their families. Specialist care teams should work with existing services, and people with progressive and far advanced illness or their families should be able to ask for these services, which should be made available where they are lacking. The goal is to control symptoms, improve quality of life and support individual patients and families where they want to be cared for at the end of life.

'As well as providing better care for patients, this approach could minimise unwanted and often expensive hospital admissions, reducing the burden on the NHS.'

More information: onlinelibrary.wile… ub2/abstract

Provided by King's College London

Genetic research clarifies link between hypertension and vitamin D deficiency

Low levels of vitamin D can trigger hypertension, according to the world's largest study to examine the causal association between the two. Although observational studies have already shown this link, a large-scale genetic study was necessary before the cause and effect could be proven, the annual conference of the European Society of Human Genetics (ESHG) will hear today (Tuesday).

11 jun 2013--Dr. Vimal Karani S, from the Institute of Child Health, University College London, London, UK, will tell the meeting that data from the D-CarDia collaboration, involving 35 studies, over 155,000 individuals, and numerous centres in Europe and North America, showed that those with high concentrations of 25-hydroxyvitamin D (25(OH)D) had reduced blood pressure and therefore a reduced risk of hypertension. "We knew from earlier observational studies that low 25(OH)D concentrations were likely to be associated with increases in blood pressure and hypertension, but correlation is not causality", he says. "Additionally, randomised controlled trials of vitamin D supplementation in humans have produced inconsistent effects on cardiovascular outcomes. The whole picture was somewhat confused, and we decided to try to figure it out once and for all."

The researchers used genetic variants known as single nucleotide polymorphisms, or SNPs, as proxy markers to reflect individual's vitamin D status in order to test for a causal association with blood pressure and hypertension. When the results were analysed, they found a significant link; for every 10% increase in 25(OH)D concentrations, there was a 8.1% decrease in the risk of developing hypertension.

"Even with the likely presence of unobserved confounding factors", Dr. Karani S will say, "the approach we followed, known as Mendelian randomisation, allows us to draw conclusions about causality because the genetic influence on disease is not affected by confounding. To put it in simple terms, by using this approach we can determine the cause and effect and be pretty sure that we've come to the right conclusion on the subject."

Low vitamin D status is common throughout the western world, the researchers say, and hence these data have important public health implications. The best-known manifestation of vitamin D deficiency is the childhood bone disease rickets, where long bones are weakened by the deficiency and start to bend. Recently, however, Vitamin D has been implicated in a number of other non-skeletal-related conditions, but studies involving supplementation have given conflicting results.

"Our study strongly suggests that some cases of cardiovascular disease could be prevented through vitamin D supplements or food fortification", says Dr. Karani S. "Our new data provide further support for the important non-skeletal effects of vitamin D. We now intend to continue this work by examining the causal relationship between vitamin D status and other cardiovascular disease-related outcomes such as lipid-related phenotypes, for example, cholesterol, inflammatory markers such as C-reactive protein, and type 2 diabetes and markers of glucose metabolism. We believe that we still have a lot to find out about the effect of Vitamin D deficiency on health, and we now know that we have the tools to do so."

Provided by European Society of Human Genetics

Recurrent pneumonia not common, lung expert says

Pneumonia is one of the most common of lung infections among the elderly but concerns of underlying conditions arise when it recurs, a leading South African pulmonologist said Sunday.

10 jun 2013--Nelson Mandela was admitted Saturday in a "serious but stable" condition for a recurrent lung infection.

It is his fourth hospital stay since December and his third for lung infection. The Nobel peace prize laureate, who turns 95 next month, was in April hospitalised for 10 days for pneumonia treatment. Officials have not specified if the latest infection afflicting Mandela is pneumonia.

Of the different types of lung infections, "pneumonia is the most serious and the most common in elderly patients," said professor Guy Richards, director of critical care at Johannesburg's Charlotte Maxeke Academic Hospital.

But when it recurs, it means there would be other underlying conditions.

"It's very unusual to get the common pneumonia occurring recurrently unless there's a specific reason for it.

"And those sorts of things are that if your lung has been damaged previously, for example if you had tuberculosis, then often those damaged areas will be colonized with bacteria which are able to cause recurrent infections," he told AFP.

Acute pneumonia can damage other organs of the body such as the kidneys or affect blood pressure, he said.

"If you have severe pneumonia, your body mounts an immune response to that pneumonia. We then sometimes have an overwhelming immune response which can result in multiple organ disfunction," said Richards.

"So for example they might present not only with a chest infection but then they might develop kidney failure, or they might develop failure of the heamodynamic system, their blood pressure might go down."

Treatment, under normal circumstances last just days, but in serious cases where hospitalisation is required, it can last several weeks.

"The majority of patients with pneumonia don't need to be admitted but those that are admitted would generally remain for three to four days. If they develop multiple organ failure and they are in ICU (intensive care unit) and they are on a ventilator, then we are talking weeks."

While he disease can affect people of all ages, it common among the elderly.

"Pneumonia was in fact known for many years as an 'old man's friend'. In other words it was the final illness that often took him away," said Richards.

Doctors differ on prostate screening

Prostate screening tests detect prostate cancer early, but questions about whether the tests do more harm than good have made them one of the most hotly debated areas of medicine.

9 jun 2013--Some doctors and researchers believe testing for PSA, which stands for prostate-specific antigen, leads to unnecessary, costly and even harmful medical procedures because so many early diagnoses are slow-growing cancers that don't require immediate treatment. But men typically demand care once they hear the "C" word.

Those on the other side say PSA screening remains a valuable tool for detecting cancer early and saving lives.

Last month, The American Urological Association reversed course and no longer recommends routine screening for men 40 to 54 years old, who face an average risk of getting prostate cancer. It said testing should be considered primarily for those 55 to 69. Even then, a PSA testshould not be automatic. Men should talk to their doctors about the benefits and risks and "proceed based on their personal values and preferences," the association recommended.

The urology group's announcement followed the 2011 recommendation by the United States Preventive Services Task Force, arguing against routine screening in healthy men because it often leads to unnecessary biopsies and surgery as well as life-altering complications such as impotence and incontinence.

A problem with screening is that PSA levels can be high, indicating cancer, even when a man doesn't have it. Another issue is that if a biopsy detects cancer, it is often very slow-growing and, as cancers go, relatively benign.

In other words, a PSA test was taking healthy men and turning them into cancer patients who underwent radiation therapy, surgery and other invasive procedures for something that would never cause death or even lead to any symptoms.

But even seemingly benign cancer can turn serious. And some men want to turn back any risk of cancer immediately.

Four years ago, Michael LeBlanc, 62, didn't even think about waiting to treat cancer detected in his prostate. Whether the cancer was slow-growing or more aggressive was a moot point, he said.

"Although it's slow growing, what says tomorrow it won't change?" said LeBlanc. "It's like calling 911 and you say there is a man who broke into the house but he looks like such a nice guy, I don't think he's going to hurt us right away. A home invasion in a home invasion. Cancer is cancer. You don't dilly dally with that." LeBlanc of Canton underwent robotic surgery to remove his prostate. He said an analysis indicated the cancer "had consumed my prostate." Exercise, he said, helped him make a full recovery.

Dr. Otis Brawley, chief medical officer for The American Cancer Society, has long called for more caution with prostate cancer screening, speaking against mass screenings such as the ones offered by health companies at shopping malls.

Many patients, he said, don't fully realize the potential complications associated with PSA testing.

"My whole campaign has not been one that men should not be screened," he said. "Let the man know the pluses and minuses, and what we know about the disease and the screening of the disease and then let the man decide," Brawley said.

That decision, he said, should be based on weighing the benefits versus potential harm of screening. Research of men 55 to 69 suggests PSA screening may prevent one death from prostate cancer for every 1,000 men screened at two-to-four year intervals over a 10-year-period, according to The American Urological Association. At the same time, many men who get the screening will be harmed because of treatments that can lead to health complications. Even a biopsy poses a risk of infection, for example.

Doctors may recommend "active surveillance" for men with low-risk prostate cancer tumors, in which the tumor is regularly monitored rather than treated. But getting patients to watch and wait is a difficult.

"Part of it is a reaction to cancer. The 1970s Nixon War on Cancer and there's this concept that all cancer is bad," said Dr. Martin Sanda, chairman of the Department of Urology at Emory University School of Medicine and director of the Prostate Cancer Center in Emory's Winship Cancer Institute. "But now we are pushing the envelope. Many of these (cancers) can be watched." Over a 5-to-10-year period, about a third of men whose cancers are considered low risk turn worse and require treatment, according to Sanda.

Sanda said a patient's decision about whether to monitor the low-risk cancer or undergo treatment often depends on how the information is presented. The key, he said, is explaining that the biopsies not only detect aggressive cancers that need immediate treatment but also pick up cancers that are "quasi cancer" and safe to watch rather than treat immediately.

But not all doctors are entirely comfortable with the concept of simply waiting and watching.

"These so-called quasi cancers may not be a problem at all. And there's also the possibility these quasi cancers can spread," said Dr. Marc Harrigan, a primary care physician at Piedmont Hospital. "You've got to put yourself in the shoes of the patient: 'Do I want something inside of me?' I mean, how comfortable would I be as a patient knowing there is a cancer inside of me that can grow at any time?" Harrigan said his patients are predominantly African-Americans who face a higher risk for prostate cancer. They tend to opt for screening before 50. But Harrigan reviews the pros and cons of testing for any patient 40 and up. And then he lets the patient decide whether or not to get the PSA test.

"Who am I to tell patients you really shouldn't be tested until 50?" said Harrigan.

Sanda remains an advocate of screening - which includes not only the PSA blood test but also the digital rectal exam. He sees firsthand what can happen when prostate cancer is not caught in the early stages.

"I see patients every month who are in their late 40s and early 50s and their cancer is too far along and we can't do anything to treat them," he said.

Sanda is also studying a new, more sophisticated blood test that could change the way men are screened. Studies indicate The Prostate Health Index or phi, is more precise than the PSA and better distinguishes an aggressive cancer from a low-risk cancer. It's one of several tests being studied across the country with the same goal: to have more accurate information, prevent unnecessary biopsies and treatments and the anxiety that often accompanies them, while saving lives from a disease expected to kill almost 30,000 men this year alone.

—-

Other than skin cancer, prostate cancer is the most common cancer in American men. The American Cancer Society's estimates for prostate cancer in the United States for 2013 are:

-About 238,590 new cases of prostate cancer will be diagnosed

-About 29,720 men will die of prostate cancer

-Prostate cancer can be a serious disease, but most men diagnosed with prostate cancer do not die from it. In fact, more than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today.

-About 1 man in 6 will be diagnosed with prostate cancer during his lifetime.

-Prostate cancer occurs mainly in older men. Nearly two thirds are diagnosed in men age 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 67.

©2013 The Atlanta Journal-Constitution (Atlanta, Ga.)