Pneumococcal disease, whooping cough, campylobacteriosis most common infectious diseases in older adults

The population is ageing. Data of notifiable infectious diseases among those aged 65 years and older have been analysed by the Norwegian Institute of Public Health. The results show that invasive pneumococcal disease was the most common infectious disease, followed by whooping cough (pertussis) and campylobacteriosis.

28 FEB 2014--Researchers at the Department of Infectious Disease Epidemiology studied data from the Norwegian Surveillance System for Communicable Diseases (MSIS) over the period from 1993 to 2011. Note that less serious infections or infections with lower outbreak potential were excluded.

The data have also been analysed for younger age groups to compare the results of the population aged 65 years and older with the younger population.

Overall, fewer cases with notifiable infectious diseases were reported among the population aged 65 and older compared with the 20-64 year olds. Invasive bacterial diseases and infections with resistant microbes were more frequent in the older population, while food-, water- and blood-borne diseases, sexually transmitted infections, and (non-systemic) vaccine-preventable diseases were more frequent in the younger population.

Most diseases did not change over time, although notification of symptomatic MRSA infections increased from 1 case per 100,000 persons in 1995 (the first year this was notifiable) to 14 per 100,000 in 2011.

The study emphasises the importance of preventing invasive bacterial infections in the population 65 years and older. This can be achieved by increasing the uptake of pneumococcal and influenza vaccine uptake among the over 65 age group, and encouraging them or their caregivers to consult a doctor about symptoms of systemic infection. Good compliance to infection control measures, screening of the at-risk population, and careful use of antibiotics can prevent further increase in antibiotic-resistant infections.

More information: Steens A, Eriksen HM, Blystad H. "What are the most important infectious diseases among those≥ 65 years: a comprehensive analysis on notifiable diseases, Norway, 1993-2011." BMC Infectious Diseases DOI: 10.1186/1471-2334-14-57

Provided by Norwegian Institute of Public Health

'Too much mammography'

Doctors tell many American women that they need a yearly mammogram to screen for breast cancer. Early detection saves lives, women are told. But evidence has been mounting for years that mammograms do not reduce the risk of dying from breast cancer.

25 feb 2014--Last week, the British Medical Journal released a blockbuster long-term study of nearly 90,000 Canadian women. It concluded that yearly mammography screenings for women 40 to 59 do not reduce breast cancer deaths, though they make a diagnosis of breast cancer more likely. That is, the study found that regular mammography leads to more cancers detected but does not lead to fewer women dying of breast cancer.

"We found absolutely no benefit in terms of reduction of deaths from the use of mammography," said study leader Dr. Anthony Miller, an epidemiologist at the University of Toronto's Dalla Lana School of Public Health.

A BMJ editorial bluntly concluded: "Too much mammography."

It won't shock you to know that many people vehemently disagree. The American College of Radiology and the Society of Breast Imaging called the BMJ study "an incredibly misleading analysis" based on a "deeply flawed and widely discredited" previous study. Critics said the Canadian study used outdated equipment and faulty methods that erroneously made mammograms look ineffective.

It's awfully difficult for the public to try to referee this continuing medical debate. What we know: Breast cancer is a fearsome disease. Studies have shown that mammography saves lives. But it also can lead to overdiagnosis, prompting women to undergo unnecessary and potentially harmful treatments. Some tumors are so aggressive that early detection still doesn't save lives. Some cancers progress so slowly that they would never kill.

And remember: The Canadian researchers aren't the first to raise red flags about widespread mammography screenings.

In 2009, the U.S. Preventive Services Task Force set off a firestorm when it recommended most women forgo routine mammograms in their 40s and then test every other year instead of every year. An all-star lineup of doctor's groups and cancer organizations howled that the guidelines would deprive women of a lifesaving test.

One of the panel members on that task force report, Dr. Russell Harris of the University of North Carolina School of Medicine, tells us the latest BMJ study "shows that if mammography makes a difference, it can't be very big. If there were a knock-your-socks-off difference, we would have seen it in this study" because it covers a large number of women over a long time span.

This latest study won't quiet the mammogram controversy. Nor will it dissuade many women from the annual test. In 2010, Americans spent an estimated $7.8 billion for mammography screening, according to a recent study in the Annals of Internal Medicine. The federal government says mammograms are so valuable as a preventive measure that Obamacare requires that they be covered free by insurers.

Many Americans believe that when it comes to screenings, more is always better. More scans, more tests, more detection. That's not necessarily true. Billions of dollars are wasted every year by Americans for unnecessary scans, biopsies and tests. More scans mean more false positive results, which stoke anxiety and prompt even more tests.

Bottom line: What we said in 2009 still holds. Many women know they have a higher than average chance of getting breast cancer, because of family history, a known gene mutation, past exposure to radiation or other risk factors. These women know they have to be vigilant about screening. Others are comfortable with less rigorous monitoring, and the numbers suggest they can afford to relax a little. Some aren't confident where they fall, and many are anxious about that uncertainty. It's not a one-size-fits-all question - it never was - and the conflicting messages within the medical community can be maddening.

Five years later, women have reason to be even more confused and frustrated. All the more reason to follow one simple guideline: The next time your doctor recommends a routine mammogram, ask her why.

©2014 Chicago Tribune 

Heart disease, stroke risk estimator app now available for health care professionals

20 feb 2014—The American College of Cardiology and the American Heart Association have released a mobile and Web-based app for health care professionals to use with their patients in determining 10-year and lifetime risks for developing atherosclerotic cardiovascular disease (ASCVD), the major cause of heart attack and ischemic stroke.

"This tool is meant to facilitate a conversation between the health care provider and the patient about the patient's risk of heart attack and stroke and how best to reduce those risks," said John G. Harold, MD, MACC, president of the American College of Cardiology. "While we hope the app will make the risk assessment guidelines more accessible, it is not a substitute for face-to-face engagement. It is a tool to help health professionals and patients work together as part of a discussion of the patient's medical history and lifestyle."

The ASCVD Risk Estimator, a mobile and Web version of the Excel-based calculator released with the ACC/AHA Cardiovascular Risk Guideline released in November 2013, uses a patient's age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure-lowering medication use, diabetes status and smoking status to estimate their 10-year and lifetime risk of heart attack and ischemic stroke. The app also helps health care professionals determine whether statin therapy is appropriate, what intensity of statin therapy is needed, how to address safety concerns of statin therapy, and what lifestyle changes should be made.

"We are pleased the risk assessment guidelines are now available in easy to access tools," said Mariell Jessup, MD, president of the American Heart Association. "The guidelines were broadened late last year to include the assessment for risk of stroke as well as heart attack. This app incorporates the stroke risk as well as the new gender- and ethnicity-specific formulas for predicting risk in African-American and white women and men found in the guidelines, and it looks beyond traditional short-term (10-year) risk estimates to predict an individual's lifetime risk of developing heart disease and having a stroke."

The ASCVD Risk Estimator mobile app can be downloaded for free from the iTunes and Google Play app stores. The Web version is available on CardioSource.org and on myamericanheart.org

Provided by American Heart Association

JAMA study shows medication to treat agitation for Alzheimer's disease shows mixed results

The results of a Journal of the American Medical Association study offer a glimmer of hope to families caring for a loved one with Alzheimer's disease. Researchers at the University of Rochester, Johns Hopkins University, and six other academic medical centers found that a high dose of a common antidepressant drug (citalopram) significantly reduced agitation in patients participating in the study. However, given potentially concerning side effects of citalopram, researchers say further investigation is needed to determine whether a smaller dose will be as effective.

19 feb 2014--Agitation can be one of the most heartbreaking symptoms of the disease, and it is one of the most common reasons Alzheimer's patients are moved out of their homes into higher levels of care. Caregivers watch as their loved ones become increasingly short-tempered, physically restless, resistant to help, or even verbally and physically abusive. Treatment options are very limited. Antipsychotics are often prescribed, but these significantly increase a patient's risk of a stroke, heart attack, or death.

Citalopram, sold under the brand names Celexa and Cipramil, is one of the most common antidepressants taken by older adults in America. In this study, published in the February 19 issue of JAMA, 30 milligrams of citalopram were given to 94 patients with agitation.

Another group of 92 patients with these symptoms took a placebo. At the end of the study, 40 percent of patients who took citalopram had "considerable relief" from their agitation symptoms, compared to 26 percent in the placebo group. Researchers obtained these result by comparing the results of two common rating scales (Neurobehavioral Rating Scale NBRS-A and a modified Alzheimer Disease Cooperative Study-Clinical Global Impression of Change mADCS-CGIC), administered by clinicians at the beginning and the end of the study.

In addition, caregivers of patients taking citalopram experienced reduced caregiver distress, further illustrating the clinical relevance of the treatment and its impact.

"It has been a long time since we've had such positive results in a field that has seen a sea of negative study results," says Anton P. Porsteinsson, M.D., the William B. and Sheila Konar Professor at the University of Rochester and lead author of the study.

However, for older adults, the FDA recommends a maximum dose of 20 milligrams of citalopram to avoid risk of QT interval prolongation, a heart rhythm disorder that could eventually lead to death if not successfully treated. Patients in this study were monitored, and researchers confirmed a greater increase in QT interval occurred in the group of patients taking citalopram.

"There are very limited options for the treatment of this tremendously distressing and difficult to treat behavioral disruption. If non-pharmacological intervention is not beneficial, judicious use of citalopram appears to have a role in managing agitation in patients with Alzheimer's disease but generally the dose should not surpass 20 mg daily" says Porsteinsson.

More information: Paper: doi:10.1001/jama.2014.93
Editorial: doi:10.1001/jama.2014.94

Provided by University of Rochester Medical Center

New guidelines double the dose for recommended physical activity in adults

New guidelines on physical activity are a “wake up call” for Australians.

18 feb 2014—New guidelines on physical activity that double the levels previously recommended are a "wake up call" for Australians, the lead author says.

Director of The University of Queensland's Centre for Research on Exercise, Physical Activity and Health (CRExPAH), Professor Wendy Brown, is the lead author of the new guidelines released on Tuesday by the Australian Government Department of Health.

The new Australian physical activity guidelines recommend adults should be completing between 150 and 300 minutes of physical activity per week, twice the amount of the previous government recommendations.

The guidelines draw on research which suggests that while the previous recommendation of 150 minutes per week of moderate activity was sufficient for general health benefits, a higher level is needed to prevent weight gain and some cancers.

Professor Brown said the new guidelines were a wake-up call for Australian adults to be more active.

"In Australia obesity is now contributing more than any other factor to the overall burden of disease," Professor Brown said.

"If we're serious about limiting weight gain Australian adults need to aim for that upper recommendation of 300 minutes per week."

However, for those who are currently inactive, one of the main messages of the new guidelines is that some activity is always better than none.

Professor Brown suggests working towards the recommended range by including a variety of activities.

Professor Brown said muscle-strengthening exercises were also important for general health benefits.

"The guidelines recommend that exercise which involves activities that use either body weight or other weights for resistance should be done on at least two days of the week," she said.

For the first time, the guidelines highlight the risks of sedentary behaviour, recommending that adults break up long periods of sitting as often as possible.

"If the average adult is sitting at their desk for seven hours a day, and in some cases up to 10 hours, this can lead to metabolic changes that affect health," Professor Brown said.

UQ Centre for Research on Exercise, Physical Activity and Health (CRExPAH) researcher Dr Nicola Burton also contributed to the new guidelines.

"It is exciting to see that the mental health benefits of physical activity are being recognised," Dr Burton said.

The new guidelines are for all adults aged 18 to 64 years, irrespective of cultural background, gender or ability.

Provided by University of Queensland

Loneliness is a major health risk for older adults

University of Chicago psychologist John Cacioppo will speak at a seminar on "The Science of Resilient Aging" at the 2014 annual meeting of the American Association for the Advancement of Science. Credit: Robert Kozloff/University of Chicago

17 feb 2014--Feeling extreme loneliness can increase an older person's chances of premature death by 14 percent, according to research by John Cacioppo, professor of psychology at the University of Chicago.

Cacioppo and his colleagues' work shows that the impact of loneliness on premature death is nearly as strong as the impact of disadvantaged socioeconomic status, which they found increases the chances of dying early by 19 percent. A 2010 meta-analysis showed that loneliness has twice the impact on early death as does obesity, he said.

Cacioppo, the Tiffany & Margaret Blake Distinguished Service Professor in Psychology at the University, joined other scholars at a seminar on "The Science of Resilient Aging" Feb. 16 at the American Association for the Advancement of Science Annual meeting in Chicago.

The researchers looked at dramatic differences in the rate of decline in physical and mental health as people age. Cacioppo and colleagues have examined the role of satisfying relationships on older people to develop their resilience, the ability to bounce back after adversity and grow from stresses in life.

The consequences to health are dramatic, as feeling isolated from others can disrupt sleep, elevate blood pressure, increase morning rises in the stress hormone cortisol, alter gene expression in immune cells, and increase depression and lower overall subjective well-being, Cacioppo pointed out in a talk, "Rewarding Social Connections Promote Successful Aging."

Cacioppo, one of the nation's leading experts on loneliness, said older people can avoid the consequences of loneliness by staying in touch with former co-workers, taking part in family traditions, and sharing good times with family and friends – all of which gives older adults a chance to connect others about whom they care and who care about them.

"Retiring to Florida to live in a warmer climate among strangers isn't necessarily a good idea if it means you are disconnected from the people who mean the most to you," said Cacioppo. Population changes make understanding the role of loneliness and health all the more important, he explained.

"We are experiencing a silver tsunami demographically. The baby boomers are reaching retirement age. Each day between 2011 and 2030, an average of 10,000 people will turn 65," he said. "People have to think about how to protect themselves from depression, low subjective well-being and early mortality."

Although some people are happy to be alone, most people thrive from social situations in which they provide mutual support and develop strong rapport. Evolution encouraged people to work together to survive and accordingly most people enjoy companionship over being alone.

Research by Cacioppo and his colleagues has identified three core dimensions to healthy relationships —intimate connectedness, which comes from having someone in your life you feel affirms who you are; relational connectedness, which comes from having face-to-face contacts that are mutually rewarding; and collective connectedness, which comes from feeling that you're part of a group or collective beyond individual existence.

It is not solitude or physical isolation itself, but rather the subjective sense of isolation that Cacioppo's work shows to be so profoundly disruptive. Older people living alone are not necessary lonely if they remain socially engaged and enjoy the company of those around them. Some aspects of aging, such as blindness and loss of hearing, however, place people at a special risk for becoming isolated and lonely, he said. —William Harms

Provided by University of Chicago

Two parents with Alzheimer's disease? Disease may show up decades early on brain scans

People who are dementia-free but have two parents with Alzheimer's disease may show signs of the disease on brain scans decades before symptoms appear, according to a new study published in the February 12, 2014, online issue of Neurology, the medical journal of the American Academy of Neurology.

16 feb 2014--"Studies show that by the time people come in for a diagnosis, there may be a large amount of irreversible brain damage already present," said study author Lisa Mosconi, PhD, with the New York University School of Medicine in New York. "This is why it is ideal that we find signs of the disease in high-risk people before symptoms occur."

For the study, 52 people between the ages of 32 and 72 and free of dementia underwent several kinds of brain scans, including Positron Emission Tomography (PET) and Magnetic Resonance Imaging (MRI) scans. PET scans measure the amount of brain plaques as well as overall brain activity, such as brain metabolism. MRI scans look at brain structure and possible reductions in brain volume. Participants were split into four groups of 13 people: those with a mother with Alzheimer's disease, a father, both parents, or no family history of the disease.

People with both parents who had Alzheimer's disease showed more severe abnormalities in brain volume, metabolism and five to 10 percent increased brain plaques in certain brain regions compared to the other three groups.

"Our study also suggests that there might be genes that predispose individuals to develop brain Alzheimer's pathology as a function of whether one parent or both parents have the disease," Mosconi said. "We do not yet know which genes, if any, are responsible for these early changes, and we hope that our study will be helpful to future genetic investigations."

People whose mother had Alzheimer's disease showed a greater level of the Alzheimer's disease biomarkers in the brain than people whose father had the disease, which is consistent with previous studies showing that people whose mothers had the disease were more likely to develop it than those with fathers with the disease, Mosconi said. She noted the small sample size of the study.

More information: Abstract 

Understanding the basic biology of bipolar disorder

Brain regions (cropped)

15 feb 2014—Scientists know there is a strong genetic component to bipolar disorder, but they have had an extremely difficult time identifying the genes that cause it. So, in an effort to better understand the illness's genetic causes, researchers at UCLA tried a new approach.

Instead of only using a standard clinical interview to determine whether individuals met the criteria for a clinical diagnosis of bipolar disorder, the researchers combined the results from brain imaging, cognitive testing, and an array of temperament and behavior measures. Using the new method, UCLA investigators—working with collaborators from UC San Francisco, Colombia's University of Antioquia and the University of Costa Rica—identified about 50 brain and behavioral measures that are both under strong genetic control and associated with bipolar disorder. Their discoveries could be a major step toward identifying the specific genes that contribute to the illness.

The results are published in the Feb. 12 edition of the journal JAMA Psychiatry.

A severe mental illness that affects about 1 to 2 percent of the population, bipolar disorder causes unusual shifts in mood and energy, and it interferes with the ability to carry out everyday tasks. Those with the disorder can experience tremendous highs and extreme lows—to the point of not wanting to get out of bed when they're feeling down. The genetic causes of bipolar disorder are highly complex and likely involve many different genes, said Carrie Bearden, a senior author of the study and an associate professor of psychiatry and psychology at the UCLA Semel Institute for Neuroscience and Human Behavior. 

Bipolar disorder and brain regions

"The field of psychiatric genetics has long struggled to find an effective approach to begin dissecting the genetic basis of bipolar disorder," Bearden said. "This is an innovative approach to identifying genetically influenced brain and behavioral measures that are more closely tied to the underlying biology of bipolar disorder than the clinical symptoms alone are."

The researchers assessed 738 adults, 181 of whom have severe bipolar disorder. They used high-resolution 3-D images of the brain, questionnaires evaluating temperament and personality traits of individuals diagnosed with bipolar disorder and their non-bipolar relatives, and an extensive battery of cognitive tests assessing long-term memory, attention, inhibitory control and other neurocognitive abilities. 

Approximately 50 of these measures showed strong evidence of being influenced by genetics. Particularly interesting was the discovery that the thickness of the gray matter in the brain's temporal and prefrontal regions—the structures that are critical for language and for higher-order cognitive functions like self-control and problem-solving—were the most promising candidate traits for genetic mapping, based on both their strong genetic basis and association with the disease.

"These findings are really just the first step in getting us a little closer to the roots of bipolar disorder," Bearden said. "What was really exciting about this project was that we were able to collect the most extensive set of traits associated with bipolar disorder ever assessed within any study sample. These data will be a really valuable resource for the field."

The individuals assessed in this study are members of large families living in Costa Rica's central valley and Antioquia, Colombia. The families were founded by European and native Amerindian populations about 400 years ago and have a very high incidence of bipolar disorder. The groups were chosen because they have remained fairly isolated since their founding and their genetics are therefore simpler for scientists to study than those of general populations. 

The fact that the findings aligned so closely with those of previous, smaller studies in other populations was surprising even to the scientists, given the subjects' unique genetic background and living environments. 

"This suggests that even if the specific genetic variants we identify may be unique to this population, the biological pathways they disrupt are likely to also influence disease risk in other populations," Bearden said.

The researchers' next step is to use the genomic data they collected from the families—including full genome sequences and gene expression data— to begin identifying the specific genes that contribute to risk for bipolar disorder. The researchers also plan to extend their investigation into the children and teens in these families. They hypothesize that many of the bipolar-related brain and behavioral differences found in adults with bipolar disorder had their origins in adolescent neurodevelopment.

Provided by University of California, Los Angeles

Dark chocolate, red wine will keep your honey heart-healthy this Valentine's Day

Forget the oysters and the champagne this Valentine's Day. If you want to keep your true love's heart beating strong, the real foods of love are dark chocolate and red wine, said Loyola University Health System preventive heart specialist Sara Sirna, MD.

14 feb 2014--"Red wine and dark chocolate taste great and have heart-healthy components," said Dr. Sirna, who also is a professor of Medicine at Loyola University Chicago Stritch School of Medicine. "We can help fight heart disease and aging and perhaps even boost our romance for the evening by choosing our foods wisely."

Red wine contains resveratrol, which has been found to lower blood sugar and LDL, or "bad" cholesterol. It also is a source of catechins, which can help improve HDL, or "good" cholesterol, and polyphenols, which may prevent the formation of toxic plaque that leads to Alzheimer's disease. Dr. Sirna warns that you should drink in moderation by consuming no more than one 5 oz. glass for women and two 5 oz. glasses for men.

Dark chocolate with a cocoa content of 70 percent or higher is rich in flavonoids, which help prevent the plaque buildup in the arteries. It also boosts the immune system and contains cancer-fighting enzymes.

Other items that top the list of heart-healthy foods include:

Nuts – The heart-health benefits of nuts have been documented in several large studies, including the Nurses' Health Study and the Iowa Women's Health Study. The FDA reports that eating a diet that includes 1 oz. of nuts daily can reduce your risk of heart disease.

Fish – Consider a Valentine's meal with fish that is high in omega-3 fatty acids, which reduce your risk of dying from a heart attack. Salmon and tuna are excellent sources. Canned salmon also contains soft bones, which give an added boost of calcium intake.

Flaxseed – Choose either brown or golden yellow and have them ground for a good source of omega-3 fatty acids, fiber and antioxidants.

Oatmeal – Cooked for a breakfast porridge or used in breads or desserts, oatmeal is a good source of soluble fiber, niacin, folate and potassium.

Black or kidney beans – These beans are a good source of niacin, folate, magnesium, omega-3 fatty acids, calcium and soluble fiber.

Walnuts and almonds – Both walnuts and almonds contain omega-3 fatty acids, vitamin E, magnesium, fiber and heart-favorable mono- and polyunsaturated fats.

Berries – Blueberries, cranberries, raspberries and strawberries are a good source of beta carotene, lutein, polyphenols, vitamin C, folate, potassium and fiber.

Provided by Loyola University Health System

Supplements and behavioural therapy make safe headway with Parkinson's

“People with PD take up to five medications just to manage their PD; adding antidepressants can be very dangerous…it would be much safer to offer a non-pharmacological alternative,” Dr Troeung says. Credit: Kat N.L.M.

13 feb 2014--In light of the high degree of psychiatric and cognitive symptoms present in Parkinson's disease (PD) sufferers, researchers have reviewed the efficacy of various therapies used to treat depression and anxiety in PD patients.

Curtin University School of Psychology and Speech Pathology lead researcher Dr Lakkhina Troeung says depression affects up to 75 per cent of PD sufferers while anxiety is experienced by 30-40 per cent of patients.

"Studies from all over the world have shown that depression and anxiety are consistently rated by patients as more detrimental to well-being than motor symptoms, even in the most advanced stage of illness where motor symptoms have fully progressed," she says.

"But despite this, the main focus of treatment and research in PD remains on motor symptoms.

"Our aim was to integrate all the available scientific information on the treatment of depression and anxiety in PD, in order to guide clinical care."

From the 29 randomised controlled trials uncovered after a comprehensive literature search, nine randomised placebo-controlled trials were eligible for analysis.

These trials involved both pharmacological (antidepressants) and non-pharmacological treatments including Omega-3 fatty acid supplementation and cognitive behavioural therapy (CBT).

Dr Troeung's analysis calculated the pooled effect size (the strength of an outcome from an experimental intervention) of antidepressant therapies for the treatment of depression in PD; the first meta-analysis to do so.

"Our review showed the pooled effect of antidepressants in PD, while statistically non-significant, was large, suggesting they are beneficial," she says.

In terms of non-pharmacological treatments, both Omega-3 supplementation and CBT had significant effects on depression, and CBT showed an additional secondary effect on anxiety.

The CBT trial also resulted in the largest reduction in depression over all other treatments.

"This is really promising," she says.

"People with PD take up to five medications just to manage their PD; adding antidepressants can be very dangerous…it would be much safer to offer a non-pharmacological alternative."

Dr Troeung stresses that the limited research available makes it difficult to make any substantive conclusions but says "…the overall message [from our review] is that any treatment, pharmacological or non-pharmacological, is better than no treatment."

"In all of the trials, those who were treated demonstrated better outcomes than placebo, no matter how small the difference."

Dr Troeung highlights the need for more clinical trials on antidepressants to determine their efficacy in PD, as well as further research on non-pharmacological treatments as safer alternatives.

More information: "A meta-analysis of randomised placebo-controlled treatment trials for depression and anxiety in Parkinson's disease." Troeung L, Egan SJ, Gasson N. PLoS One. 2013 Nov 13;8(11):e79510. DOI: 10.1371/journal.pone.0079510. eCollection 2013.

Provided by Science Network WA

One-quarter of diagnostic catheterizations for suspected coronary artery disease are unnecessary

A quarter of all patients undergoing diagnostic catheterizations for coronary artery disease in New York were rated as inappropriate for the procedure because they were relatively healthy, a new study finds.

12 feb 2014—One-quarter of patients undergoing diagnostic catheterizations (DC) for suspected coronary artery disease in New York were rated as inappropriate for the procedure primarily because they were relatively healthy, a recent study finds.

In the study published in January's Circulation: Cardiovascular Interventions, University at Albany School of Public Health and New York State Department of Health researcher Edward Hannan examined New York's Cardiac Diagnostic Catheterization Database to identify patients undergoing DC for coronary artery disease between 2010 and 2011.

Patients were rated using appropriateness criteria developed by professional societies as appropriate, uncertain, and inappropriate for DC. The relationships between various patient characteristics and the appropriateness ratings were examined, along with the relationships between hospital-level inappropriateness for DC and other hospital-level variables (hospital DC volume and percutaneous coronary intervention inappropriateness).

Of the 8,986 patients who were rated, 35.3 percent were rated as appropriate, 39.8 percent as uncertain, and 24.9 percent as inappropriate for DC. Of the 2,240 patients rated as inappropriate, 56.7 percent were asymptomatic, had no previous stress test, or had low or intermediate coronary artery disease risk. An even 36 percent had a previous stress test with low-risk findings and no symptoms, and 7.3 percent were symptomatic, had no previous stress test, or had low pretest probability. 

Further, the study found that while one-quarter of patients undergoing DC for suspected coronary artery disease were rated as inappropriate for the procedure, approximately two-thirds of those inappropriate patients had no previous stress test, and approximately 90 percent of the inappropriate patients with no previous stress test were asymptomatic with low or intermediate global risk scores, i.e. the majority of those rated as inappropriate for DC procedures were comparatively healthy.

At the hospital level, the inappropriateness of DC procedures rate ranged from a maximum of 48.8 percent to a minimum of 8.6 percent. The researchers suggest that since a wide range of inappropriateness rates exists across hospitals, hospitals with very high rates could learn best practices DC protocols from hospitals with the lowest rates.

More information: "Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State." Edward L. Hannan, Zaza Samadashvili, Kimberly Cozzens, Gary Walford, David R. Holmes, Jr, Alice K. Jacobs, Nicholas J. Stamato, Ferdinand J. Venditti, Samin Sharma, and Spencer B. King III. Circ Cardiovasc Interv. 2014; CIRCINTERVENTIONS.113.000741. published online before print January 28 2014, DOI: 10.1161/CIRCINTERVENTIONS.113.000741

Provided by University at Albany

Study examines aging in a super-diverse society

Cultural sensitivity should be a vital component in all future services for older people, experts at the University of Birmingham, will say today.

11 feb 2014--As the Care Bill 2013/14 reaches its final stages in the House of Lords, a Birmingham Policy Commission report urges policy makers to "recognise and accommodate super-diversity" when planning services for an ageing population.Professor Steve Field, Chief Inspector of General Practice for the Care Quality Commission, headed the Commission entitled Healthy Ageing in the 21st Century: The best is yet to come.

He said: "This is the first time we have looked at ageing in a super diverse society. Birmingham is a multicultural city. Its 'super-diverse' population provided an ideal opportunity to explore the implications of ageing for ethnically diverse people from across the world."

The report, being launched today in the House of Commons, found that some communities and faith groups drew on the huge contribution older people make to society and that "sharing this good practice presents a real opportunity for communities of all kinds".

It also noted that the Equalities Act 2010 could prove more influential in safeguarding the rights of older people than the Human Rights Act 1998.

Among its recommendations, the report calls for:

• A new statutory post of Commissioner for Older People in England
• The Human Rights of older people to be at the heart of health and social care policy
• Research Councils to gain a better understanding of ageing in a super-diverse society
• More effort to give older people a louder voice when planning any kind of service for an ageing population, not just those related to health and social care

The report also found that health inequalities in younger life must be evened out if the poor are to age as well as the better off.

More information: A copy of the full report can be found here: www.birmingham.ac.uk/research/impact/policy-commissions/healthy-ageing/index.aspx

Provided by University of Birmingham

Experts increasingly contemplate end of smoking

In this April 29, 1964 file photo, etiquette expert Cathy Bauby shows how puffing a cigarette like a steam engine shows that one is behind the "Jet Age" and doesn't care how one looks, during a demonstration in New York. Fifty years on, health officials have begun to predict the end of cigarette smoking in America. A confluence of changes has recently prompted public health leaders to start throwing around phrases like "endgame" and "tobacco-free generation." Now, they talk about the slowly-declining adult smoking rate dropping to 10 percent in the next decade and to 5 percent or lower by 2050. (AP Photo/Dan Grossi)

10 feb 2014--U.S. health officials have begun to predict the end of cigarette smoking in America.

They have long wished for a cigarette-free America, but shied away from calling for smoking rates to fall to zero or near zero by any particular year. The power of tobacco companies and popularity of their products made such a goal seem like a pipe dream.

But a confluence of changes has recently prompted public health leaders to start throwing around phrases like "endgame" and "tobacco-free generation." Now, they talk about the slowly-declining adult smoking rate dropping to 10 percent in the next decade and to 5 percent or lower by 2050.

Acting U.S. Surgeon General Boris Lushniak last month released a 980-page report on smoking that pushed for stepped-up tobacco-control measures. His news conference was an unusually animated showing of anti-smoking bravado, with Lushniak nearly yelling, repeatedly, "Enough is enough!"

"I can't accept that we're just allowing these numbers to trickle down," he said, in a recent interview with the AP. "We believe we have the public health tools to get us to the zero level."

This is not the first time a U.S. health official has spoken so boldly. In 1984, Surgeon General C. Everett Koop called for a "smoke-free society" by the year 2000. However, Koop—a bold talker on many issues—didn't offer specifics on how to achieve such a goal.

"What's different today is that we have policies and programs that have been proven to drive down tobacco use," said Matthew Myers, president of the Campaign for Tobacco-Free Kids. "We couldn't say that in 1984."

Among the things that have changed:

—Cigarette taxes have increased, making smokes more expensive. Though prices vary from state to state, on average a pack of cigarettes that would have sold for about $1.75 20 years ago would cost more than triple that now.

—Laws banning smoking in restaurants, bars and workplaces have popped up all over America. Airline flights have long been off-limits for smoking.

—Polls show that cigarette smoking is no longer considered normal behavior, and is now less popular among teens than marijuana.

—Federal officials are increasingly aggressive about anti-smoking advertising. The Food and Drug Administration launched a new youth tobacco prevention campaign last week. At about the same time, the Centers for Disease Control and Prevention debuted a third, $60-million round of its successful anti-tobacco ad campaign—this one featuring poignant, deathbed images of a woman featured in earlier ads.

—Tobacco companies, once considered impervious to legal attack, have suffered some huge defeats in court. Perhaps the biggest was the 1998 settlement of a case brought by more than 40 states demanding compensation for the costs of treating smoking-related illnesses. Big Tobacco agreed to pay about $200 billion and curtail marketing of cigarettes to youths.

—Retailing of cigarettes is changing, too. CVS Caremark, the second-largest U.S. pharmacy chain, announced last week it will stop selling tobacco products at its more than 7,600 drugstores. The company said it made the decision in a bid to focus more on providing health care, but medical and public health leaders predicted pressure will increase on companies like Walgreen Co. and Wal-Mart Stores Inc. to follow suit.

In this April 8, 2003 file photo, David Ozanich of Brooklyn smokes outside the Live Bait bar in New York after a city-wide ban on smoking in bars and restaurants went into effect. Laws banning smoking in restaurants, bars and workplaces have been implemented in places across the country. (AP Photo/Diane Bondareff, File)

"I do think, in another few years, that pharmacies selling cigarettes will look as anachronistic" as old cigarette ads featuring physician endorsements look today, said CDC Director Dr. Tom Frieden.

These developments have made many in public health dream bigger. It's caused Myers' organization and others to recently tout the goal of bringing the adult smoking rate down to 10 percent by 2024, from the current 18 percent. That would mean dropping it at twice the speed it declined over the last 10 years.

In this Oct. 16, 1937 file photo, Alfred Gwynne Vanderbilt lights the cigarette of Eleanor Young at the opening of the Sert Room of the Waldorf Astoria in New York. (AP Photo)

The bigger goal is to reduce U.S. smoking-related deaths to fewer than 10,000, from the current level of 480,000. But even if smoking rates dropped to zero immediately, it would take decades to see that benefit, since smoking-triggered cancers can take decades to develop.

But while some experts and advocates are swinging for the fences, others are more pessimistic. They say the key to reaching such goals is not simply more taxes and more local smoking bans, but action by the U.S. Food and Drug Administration to regulate smoking.

In this Jan. 11, 1937 file photo, Eugene O'Neil, playwright and winner of the Nobel Prize, holds a book and a cigarette in his hospital bed in Oakland, Calif. during his first interview since being stricken with appendicitis. (AP Photo/RJF)

A 2009 U.S. law gave the FDA the authority to regulate tobacco products. The law barred the FDA from outright blocking the sale of cigarettes, but the agency was free to take such pivotal steps as prohibiting the use of appealing menthol flavoring in cigarettes and requiring cigarette makers to ratchet down the amount of addictive nicotine in each smoke.

But nearly five years after gaining power over cigarettes, FDA has yet to even propose such regulations. Agency officials say they're working on it.

This undated photo provided by RKO shows dancer-actor Fred Astaire for the 1935 film musical "Top Hat" with a cigarette in his mouth. (AP Photo/RKO)

A spokesman for Altria Group Inc., the maker of Marlboro, said the company supports FDA exercising its regulatory authority over tobacco products. But as a whole, the industry has tended to fight regulation. Some of America's largest tobacco companies—though not Altria—sued to stop FDA-proposed graphic warning labels on cigarette packs. A federal court blocked the ads.

"The industry makes money as long as they can delay regulation," said Kenneth Warner, a University of Michigan public health professor who is a leading authority on smoking and health.

In this undated image from video provided by Resound Marketing in August 2013, Jenny McCarthy uses a blu eCig in a television advertisement. Electronic cigarettes have often been described as a less dangerous alternative to regular cigarettes. But there are few studies exploring exactly what chemicals are in them, and whether they are harmful. Some experts believe that at a time when cigarette smoking has finally become passe in popular culture, e-cigarettes may re-glamorize puffing away in public places. (AP Photo/Resound Marketing)

Warner and Michigan colleague David Mendez estimate that, barring any major new tobacco control victories, the adult smoking rate will drop from its current 18 percent only to about 12 percent by 2050. If health officials do make huge strides, the rate could drop as low as 6 percent, they think.

But Lushniak said zero. Will that ever happen?

Some experts doubt it. As long as cigarettes and other combustible tobacco products are legal, it's likely some people will smoke them.

In this Thursday, April 21, 2011 file photo, Queens District Attorney Richard Brown, left, joins state and federal officials in the Queens borough of New York to announce a crackdown on cigarette smugglers and tax evaders behind a display of cartons of confiscated cigarettes. Cigarette taxes have increased around the country. Though prices vary from state to state, on average a pack of cigarettes that would have sold for under $1.75 20 years ago would cost about $6 now. (AP Photo/Frank Franklin II)

"It's hard to do a ban on cigarettes because you're taking something away from people they have and are using. Once you have something, you hold tight," said Richard Daynard, a Northeastern University law professor who focuses on tobacco issues.

Better, he said, to bar people from having a product in the first place. He is intrigued by legal efforts in Singapore and a handful of other countries to ban sales of tobacco to anyone born after a certain year—2000, say. That would be constitutional, he said. The question is: Would American culture accept it?

In this Saturday, March 2, 2013 file photo, John Connelly, left, inhales marijuana vapor just after midnight, with the help of bar worker Jenae DeCampo, right, in the upstairs lounge area of Stonegate, a pizza-and-rum bar in Tacoma, Wash. Owner Jeff Call charges patrons a small fee to become a member of the private second-floor club, which prohibits smoking marijuana, but does permit "vaporizing," a method that involves heating the marijuana without burning it. Washington and Colorado became the first states to pass legislation legalizing marijuana use for adults over 21. Polls show that cigarette smoking is no longer considered normal behavior, and is now less popular among teens than marijuana. (AP Photo/Ted S. Warren)

Probably not, said Ruth Malone, editor-in-chief of the scientific journal Tobacco Control.

"In our culture, we tend to think we have a right to things even if they're terrible for us," she said.

A growing number of experts believe the most promising option is to get people to switch voluntarily to something else, like electronic cigarettes.

In this Wednesday, May 20, 1998 file photo, Olympic gold medalist Tara Lipinski, right, stands with school children in an anti-tobacco rally on Capitol Hill in Washington. The rally was sponsored by the Campaign for Tobacco-Free Kids. (AP Photo/Dennis Cook)

Electronic cigarettes are battery-powered devices that provide users with aerosol puffs that typically contain nicotine, and sometimes flavorings like fruit, mint or chocolate. They've often been described as a less dangerous alternative to regular cigarettes. But there are few studies exploring exactly what chemicals are in them, and in what concentrations, and whether those levels are harmful.

In this Thursday, April 14, 1994 file photo, the heads of the nation's largest cigarette companies are sworn in before a hearing of a House Energy subcommittee which was holding hearings on the contents of cigarettes on Capitol Hill in Washington. More than 40 states brought lawsuits demanding compensation for the costs of treating smoking-related illnesses. Big Tobacco settled in 1998 by agreeing to pay about $200 billion and curtail marketing of cigarettes to youths. From left are Robert Sprinkle III, executive vice president for Research American Tobacco Co.; Donald Johnston, American Tobacco; Thomas Sandefur Jr., Brown and Williamson Tobacco Corp.; Edward Horrigan Jr., Liggett Group Inc.; Andrews Tisch, Lorillard Tobacco Co.; Joseph Taddeo, U.S. Tobacco Co.; James Johnston, RJ Reynolds; and William Campbell, Phillip Morris USA. (AP Photo/John Duricka)

They're controversial: Some experts believe that at a time when cigarette smoking has finally become passe in popular culture, e-cigarettes may re-glamorize puffing away in public places. Cigarette sales could surge.

"It could go in either direction," said John Seffrin, the American Cancer Society's chief executive officer.

In this Monday, Nov. 30, 1987 file photo, U.S. Surgeon General C. Everett Koop sits with elementary school students at P.S. III in the Manhattan borough of New York to warn them of the dangers of smoking. In 1984, Koop called for a "smoke-free society" by the year 2000. (AP Photo/Richard Drew)

But if the FDA can ratchet down nicotine in conventional cigarettes to levels below what's in e-cigarettes, perhaps everyone who clings to smoking will switch to the higher-nicotine new products. That could achieve the end of smoking, at least of combustible, carcinogen-filled cigarettes—or so the thinking goes.

In this Thursday, May 14, 1998 file photo, Minnesota Attorney General Hubert Humphrey III holds an internal RJR document stating that tobacco causes lung cancer, while testifying on Capitol Hill in Washington before the Democratic Tobacco Task Force. (AP Photo/Khue Bui)

In the past, "the country really wasn't ready" to walk away from cigarettes," Daynard said. "I think the country's ready now."

This image provided by the New York Public Library shows one of the cigarette advertisements from 1920s through the 1950s included in an 2008 exhibit at the library. The ad featuring a baby reads, "Gee, Dad, you always get the best of everything... even Marlboro!" (AP Photo/New York Public Library)

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This image provided by the New York Public Library shows one of the cigarette advertisements from 1920s through the 1950s included in an 2008 exhibit at the library. The ad which features a man dressed as a doctor holding a pack of Lucky Strike cigarettes reads, "20,679 physicians say 'LUCKIES are less irritating'" (AP Photo/New York Public Library)

Rapid recovery on exercise ECG may obviate need for more tests

9 feb 2014—Additional testing for ischemic heart disease is less likely to yield benefit in those with rapid recovery of electrocardiographic (ECG) changes on the exercise treadmill test (ETT), according to research published online Feb. 5 in the Journal of the American College of Cardiology.

Mitalee P. Christman, of Harvard Medical School in Boston, and colleagues analyzed data from 3,345 consecutive patients without known coronary artery disease who were referred for clinical ETT at a large medical center. The researchers sought to estimate the frequency and results of downstream testing following ETT.

The researchers found that, following ETT, 9.0 percent underwent noninvasive imaging and 2.3 percent were referred directly to invasive angiography. Rapid recovery of ECG changes during ETT was associated with excellent prognosis and low yield of downstream testing. Typical angina, despite negative ETT, was associated with worse prognosis and higher yield of downstream testing. Predictors of negative downstream tests included younger age, female gender, higher metabolic equivalents of task achieved, and rapid recovery of ECG changes.

"These data provide important feedback; at the margins, the exercise ECG remains a useful initial strategy for the risk stratification of individuals suspected of ischemic heart disease," write the authors of an accompanying editorial.

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Endocrine Society calls for large-scale studies to evaluate testosterone therapy risks

According to a statement issued today by the Endocrine Society, the risks and benefits of testosterone therapy for older men with declining levels of the hormone need to be fully evaluated.

08 feb 2014--The statement comes in response to recent studies that have raised concerns about the safety of testosterone therapy in older men with a history of heart disease. Two retrospective analyses and one randomized trial supported by the Veterans Health Care System, and the National Institutes of Health found a higher rate of cardiovascular events in men who received testosterone and had preexisting heart problems. The U.S. Food and Drug Administration has announced it plans to evaluate the safety of testosterone therapy.

Testosterone is approved for the treatment of hypogonadism due to known diseases of the testes, pituitary and hypothalamus. Although the use of testosterone therapy is increasing, the treatment has not been approved for the treatment of age-related symptoms or the age-related decline of testosterone levels.

Important safety data are expected from the NIA's ongoing randomized trial examining testosterone in about 800 older men with unequivocally low testosterone levels and accompanying symptoms, including sexual and physical dysfunction. The trial's structure and careful monitoring of cardiovascular events will help provide important safety information.

The Society calls for the development of more large-scale randomized controlled trials to determine the true risks and benefits of testosterone therapy in older men.

In the statement, the Society recommends that middle-aged and older men who are considering testosterone supplementation for age-related declines should be informed of the potential cardiovascular risks. The Society also believes that it may be prudent not to administer testosterone therapy to men who have had a cardiovascular event (such as myocardial infarction, stroke or acute coronary syndrome) in the preceding six months.

In cases where men are being treated for hypogonadism as a result of known diseases of the testes, pituitary and hypothalamus, however, patients should consult their health care providers before making any changes to their medication regimen. The Society believes testosterone is generally safe and beneficial when used to treat young, hypogonadal men with these conditions. The Society's Clinical Practice Guideline on testosterone therapy in this population is available at http://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical%20Practice%20Guidelines/FINAL-Androgens-in-Men-Standalone.pdf.

Provided by The Endocrine Society

Study supports 3-D MRI heart imaging to improve treatment of atrial fibrillation

A University of Utah-led study for treatment of patients with atrial fibrillation (A-fib) provides strong clinical evidence for the use of 3-D MRI to individualize disease management and improve outcomes.

07 feb 2014--Results of the Delayed-Enhancement MRI Determinant of Successful Radio-frequency Catheter Ablation of Atrial Fibrillation (DECAFF) study will be published Wednesday in the Journal of the American Medical Association.

Atrial fibrillation is a common arrhythmia, or an irregular heartbeat, which is a major cause of stroke, heart failure and death. For treatment, doctors have mostly relied on drugs, or more recently, on catheter ablation. Despite those two treatment options, outcomes remain mediocre mainly due to poor patient selection, says Nassir F. Marrouche, M.D., founder of the U's interdisciplinary Comprehensive Arrhythmia Research & Management Center (CARMA) and associate professor of internal medicine at the University's School of Medicine. "We've been treating A-fib based on patients' symptoms, duration of arrhythmia and associated comorbidities. Instead we should be integrating the diseased, fibrotic heart tissue itself into our management plan."

"Every cardiologist in the world knows that A-fib and atrial tissue disease are intertwined. But, until recently, we have been lacking noninvasive tools to define this relationship," he says. "We at CARMA have developed a significant breakthrough in the way A-fib is managed."

The DECAFF study built on innovative work from CARMA, which invented the technology enabling heart tissue imaging with MRI. With these images, physicians can assess the extent of the disease using a novel staging system similar to the ones developed for cancer. "This is a major step for individualizing arrhythmia management."

Conducted in partnership with 15 major medical centers across the United States, Europe, and Australia, Marrouche's landmark study demonstrated that the amount of atrial injury can effectively predict whether patients were likely to benefit from A-fib catheter ablation procedure. Using the enhanced MRI and the Utah Staging System, the hearts of 329 patients were scanned and staged on a scale of 1-4 before undergoing ablation and procedure outcomes were assessed at follow-up.

What Marrouche and his worldwide study partners found reflected early published findings from CARMA at the U of U: that those with less extensive fibrotic tissue had a greater chance of responding to ablative treatment.

According to the data, patients with less than 10 percent left atrial wall fibrosis (Utah Stage 1) showed good outcomes with ablation therapy while those with greater than 30 percent fibrosis (Stage 4) experienced significantly higher failure rates.

Marrouche believes the study findings will encourage a shift in the way physicians treat patients with atrial fibrillation, specifically by integrating MRI into their A-fib management protocols.

"MRI scanning of heart tissue is more and more becoming a screening test to predict people at risk for arrhythmias and its associated complications like stroke and heart failure," he says. He also believes atrial disease-causing arrhythmias should be screened for just like cancers and other common diseases.

Provided by University of Utah Health Sciences