Awareness of memory loss may decline 2-3 years before dementia onset

People who will develop dementia may begin to lose awareness of their memory problems two to three years before the actual onset of the disease, according to a new study published in the August 26, 2015, online issue of Neurology, the medical journal of the American Academy of Neurology. 

30 aug 2015--The study also found that several dementia-related brain changes, or pathologies, are associated with the decline in memory awareness.
"Our findings suggest that unawareness of one's memory problems is an inevitable feature of late-life dementia, driven by a buildup of dementia-related changes in the brain," said study author Robert S. Wilson, PhD, with Rush University Medical Center in Chicago. "Lack of awareness of memory loss is common in dementia, but we haven't known much about how common it is, when it develops or why some people seem more affected than others. "Most studies of memory unawareness in dementia have focused on people who have already been diagnosed. In contrast, this new study began following older adults before they showed signs of dementia."
The analysis included 2,092 participants from three ongoing studies that have each followed older adults for more than 10 years. At the beginning of the study, the participants were an average of 76 years old and showed no signs of memory or cognitive impairments. They were given yearly tests of memory and thinking abilities. Participants were also asked how often they had trouble remembering things, and how they would rate their memory compared to 10 years earlier.
For the 239 people diagnosed with dementia during the study, memory awareness was stable and then began to drop sharply an average of 2.6 years before the onset of dementia. This followed several years of memory decline. "Although there were individual differences in when the unawareness started and how fast it progressed, virtually everyone had a lack of awareness of their memory problems at some point in the disease," Wilson said.
Unexpectedly, memory unawareness began earlier in younger people than in older people. That may be because older people were more likely to expect memory loss as a normal part of aging, the researchers suggest.
The researchers also examined the brains of 385 participants who died during the course of the study, assessing them for seven types of brain changes common to dementia. They found three dementia-related pathologies were associated with the rapid decline in memory awareness: tau proteins or tangles; infarcts, or areas of brain damage; and changes in the protein TDP-43.
As those brain changes build up, affected people lose awareness that their memory is failing.
"This study underscores the importance of family members looking for help from doctors and doctors getting information from friends or family when making decisions about whether a person has dementia, since people may be unable to give reliable reports about the history of their own memory and thinking abilities," Wilson said.


Provided by American Academy of Neurology

Study links physical activity to greater mental flexibility in older adults

Research reveals a new signal of brain health in older adults who regularly engage in moderate to vigorous physical activity Credit: Public domain/Julie McMahon

28 aug 2015--One day soon, doctors may determine how physically active you are simply by imaging your brain. Physically fit people tend to have larger brain volumes and more intact white matter than their less-fit peers. Now a new study reveals that older adults who regularly engage in moderate to vigorous physical activity have more variable brain activity at rest than those who don't. This variability is associated with better cognitive performance, researchers say.
The new findings are reported in the journal PLOS ONE.
"We looked at 100 adults between the ages of 60 and 80, and we used accelerometers to objectively measure their physical activityover a week," said University of Illinois postdoctoral researcher Agnieszka Burzynska, who led the study with Beckman Institute for Advanced Science and Technology director Art Kramer.
The researchers also used functional MRI to observe how blood oxygen levels changed in the brain over time, reflecting each participant's brain activity at rest. And they evaluated the microscopic integrity of each person's white-matter fibers, which carry nerve impulses and interconnect the brain.
"We found that spontaneous brain activity showed more moment-to-moment fluctuations in the more-active adults," said Burzynska, who now is a professor at Colorado State University. "In a previous study, we showed that in some of the same regions of the brain, those people who have higher brain variability also performed better on complex cognitive tasks, especially on intelligence tasks and memory."
The researchers also found that, on average, older adults who were more active had better white-matter structure than their less-active peers.
"Our study, when viewed in the context of previous studies that have examined behavioral variability in cognitive tasks, suggests that more-fit older adults are more flexible, both cognitively and in terms of brain function, than their less-fit peers," Kramer said.

Beckman Institute postdoctoral researcher Agnieszka Burzynska and her colleagues found that older adults who are more active appear to have more mental flexibility than their less-active peers. Burzynska is now a professor at Colorado State University. Credit: L. Brian Stauffer

The new research highlights yet another way to assess brain health in aging, Burzynska said.
"We want to know how the brain relates to the body, and how physical health influences mental and brain health in aging," she said. "Here, instead of a structural measure, we are taking a functional measure of brain health. And we are finding that tracking changes in blood-oxygenation levels over time is useful for predicting cognitive functioning and physical health in aging."
More information: "Physical activity is linked to greater moment-to-moment variability in spontaneous brain activity in older adults" PLOS ONE, journals.plos.org/plosone/article?id=10.1371/journal.pone.0134819

Provided by University of Illinois at Urbana-Champaign

High uric acid levels linked to greater mortality

27 aug 2015—High serum uric acid levels are associated with greater risk of all-cause and cardiovascular mortality, but not cancer mortality, in elderly adults, according to a study published online Aug. 16 in the Journal of the American Geriatrics Society.
Chen-Yi Wu, M.D., Ph.D., from Taipei Veterans General Hospital in Taiwan, and colleagues utilized the Annual Geriatric Health Examination Program (2006 to 2010) to estimate the all-cause, cardiovascular, and cancer mortality risks associated with serum uric acid levels in elderly adults.
The researchers found that men had significantly higher uric acid levels than women (P < 0.001), and mean levels increased with age (P < 0.001). High serum uric acid levels were an independent risk factor for all-cause and cardiovascular mortality, compared to normal levels in men and women, with the strongest association found for cardiovascular mortality. This association with cardiovascular mortality was independent of other cardiovascular risk factors such as hypertension, diabetes mellitus, hyperlipidemia, and glomerular filtration rate levels. Men with levels in the second quartile had the lowest hazard ratios for all-cause and cardiovascular mortality.
"Further studies are warranted to investigate the prognostic implications and potential utility in the monitoring of therapy," the authors write.
More information: Abstract
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Dementia cases to nearly triple by 2050, report says

The number of people with dementia worldwide will nearly triple from 47 million today to 132 million in 2050, a report said Tuesday.

26 aug 2015--Dementia is an umbrella term for degenerative diseases of the brain characterised by a gradual decline in the ability to think and remember.

Accounting for well over half of cases, Alzheimer's is the most common form of dementia.

As the world gets older, the number of people with dementia is set to increase exponentially, notes the World Alzheimer Report 2015, produced by Alzheimer's Disease International.

Today there are 900 million people 60 or older. Over the next 35 years, that age group will grow by 65 percent in rich countries, 185 percent in lower-middle income nations, and 239 percent in poor countries.

In 2015 alone, there will be about 10 million new cases, one every few seconds and nearly 30 percent more than in 2010.

The risk increases dramatically as we age.

Fewer than four out of every 1,000 people aged 60 to 64 are afflicted with some form of what used to be called senility. But from the age of 90, that ratio jumps to 105 for every 1,000 people, more than 10 percent.

The global cost burden of dementia is likewise increasing sharply, having risen by more than 35 percent over the last five years to $818 billion (709 billion euros) in 2015.

Sixty percent of the cost was for medical and institutional care.

"Population ageing alone drives the projected increases," said the report.

More information: www.worldalzreport2015.org 

Study makes major advance toward more effective, long-lasting flu vaccine

The team from The Scripps Research Institute and Janssen Pharmaceutical Companies designed a molecule that mimicked the shape of a key part of the influenza virus, inducing a powerful and broadly effective immune response in animal models. Credit: the Wilson lab, The Scripps Research Institute.

25 aug 2015--Scientists from The Scripps Research Institute (TSRI) and the Janssen Pharmaceutical Companies of Johnson & Johnson (Janssen) have found a way to induce antibodies to fight a wide range of influenza subtypes—work that could one day eliminate the need for repeated seasonal flu shots.
"This study shows that we're moving in the right direction for a universal flu vaccine," said Ian Wilson, Hansen Professor of Structural Biology and chair of the Department of Integrative Structural and Computational Biology at TSRI.
The study was part of TSRI's long-term collaboration to strengthen research against infectious disease with the former Crucell Vaccine Institute, now known as Janssen Prevention Center and headquartered in Leiden, the Netherlands.
The research was published online ahead of print on August 24 by the journal Science.
The Need for Better Flu Shots
Seasonal flu typically causes more than 200,000 hospitalizations and 36,000 deaths every year in the United States, according to the U.S. Centers for Disease Control and Prevention. While a yearly flu shot provides some protection, subtypes not covered by the vaccine can emerge rapidly. This phenomenon was evident in the 2009 spread of the H1N1 ("swine flu") subtype that killed an estimated 151,700 to 575,400 people worldwide.
In the last decade, several studies from TSRI, Janssen and other institutions have shown that some people are capable of making powerful antibodies that can fight many subtypes of influenza at once by targeting a site on the influenza virusthat does not mutate rapidly. Unfortunately, these "broadly neutralizing antibodies," or bnAbs, are rare.
Still, the tantalizing existence of broadly neutralizing antibodies led Janssen and TRSI to try creating an influenza vaccine specially designed to elicit them.
Researchers zeroed in on a possible target: a protein on the surface of influenza, called hemagglutinin (HA). HA is present on all subtypes of influenza, providing the key viral "machinery" that enables the virus to enter cells. Most importantly, the long "stem" region of HA, which connects the virus to cells, plays such a crucial role that mutations at the site are unlikely to be passed on.
"If the body can make an immune response against the HA stem, it's difficult for the virus to escape," Wilson explained.
Fighting 'Bird Flu' and Other Strains
To create antibodies against the HA stem, the research team looked to influenza's own structure, specifically the universal recognition site of the broadly protective antibody CR9114 in the HA stem (described by Dreyfus et al., Science2012). This vaccine candidate was designed, produced and tested by a team of scientists led by Jaap Goudsmit, head of the Janssen Prevention Center, the paper's first author Antonietta Impagliazzo (responsible for the design) and co-senior author Katarina Radoševi?.
The effort represents the first time scientists have been able to cut off the variable head region of HA, designing features able to stabilize the conformation of the original protein, and at the same time faithfully mimicking the key broadly neutralizing site. The ultimate goal was to use this synthetic version of the HA stem in a vaccine to teach the body to make powerful antibodies against influenza virus, priming it to fight off a variety of flu strains.
The scientists then studied the response of rodent and nonhuman primate models given one of several candidate immunogens. They found that animals given one especially stable immunogen produced antibodies that could bind with HAs in many influenza subtypes, even neutralizing H5N1 viruses ("avian" or "bird" flu).
"This was the proof of principle," said Wilson. "These tests showed that antibodies elicited against one influenza subtype could protect against a different subtype."
Scientists at TSRI studied the structure of the immunogen at every point in the process. Using the imaging techniques of electron microscopy (led by TSRI Associate Professor Andrew Ward and postdoctoral fellow Ryan Hoffman) and x-ray crystallography (led by Wilson and TSRI Staff Scientist Xueyong Zhu), the team showed that the most promising candidate immunogen mimicked the HA stem and that antibodies could bind with the immunogen just as they would with a real virus.
With proof that an immunogen can elicit antibodies against the stem region, Wilson said the next step in this research is to see if the immunogen can do the same in humans.
"While there is more work to be done, the ultimate goal, of course, would be to create a life-long vaccine," Wilson said.
More information: A stable trimeric influenza hemagglutinin stem as a broadly protective immunogen, Science, www.sciencemag.org/lookup/doi/10.1126/science.aac7263

Provided by The Scripps Research Institute

Despite the headlines, dementia epidemic may not actually be getting worse

The future may not be as bleak as we thought.

The notion of a dementia epidemic has been a big concern in ageing societies across the globe for some time. With the extension of life expectancy it seems to be an inevitable disaster – one of the "greatest enemies of humanity", according to UK prime minister David Cameron.

24 aug 2015--Many shocking figures have been published pointing to dramatic increases in dementia prevalence and massive predicted costs and burdens. Yet new evidence seems to suggest otherwise. In a review of dementia occurrence in five studies in the UK, Sweden, Spain and the Netherlands between 2007 and 2013 that used consistent research methods and diagnostic criteria, we found none that supported headlines about dramatic increases in dementia. They report stable or reduced prevalence at specific ages over the past few decades – despite ageing populations.
How to reconcile this relatively optimistic picture with what looks like panic on the part of governments, charities and the mainstream media? One reason is that they fail to recognise the complexity of dementia diagnosis. The main criteria for diagnosing dementia hinge on cognitive decline and an associated deterioration in a person's ability to carry out day-to-day activities. If there are variations in the recognised boundaries of these criteria either in different countries or during different time periods, this can affect occurrence estimates without changing the fundamentals of the dementia syndrome itself.
Over the past few decades, the diagnostic criteria have indeed changed across the world in parallel with public awareness and perceptions. More people are now diagnosed with very early dementia, for example, though it may or may notprogress into more severe forms. The introduction of biomarkers for diagnosis is likely to further expand prevalence by identifying large sections of populations at risk – and is already in its early stages. Such changes will affect different groups of people in different contexts in different ways, but basically we might be counting more people as having dementia due to the use of more inclusive diagnostic criteria.

The future may not be as bleak as we thought. Ocskay Mark

Solution and salvation
Having said that, there might be more than careless use of research evidence at play. The worsening epidemic message also fits well with consumer psychology and the recent history of over-medicalisation: fear, demand for a solution, and salvation. The world is looking for a silver bullet. Since the G8 summit of 2013, the hunt for "a dementia cure or disease-modifying therapy by 2025" has become a global target. We have seen major investment from public and private funding bodies alike, stimulating national and even global collaborations. Current research has focused on drug interventions and clinical trials, as well as relevant biomarkers including novel imaging for assumed brain pathology.
The progress to date has not been promising, but the reality is that healthcare and pharmaceutical companies are looking at large potential profits from future dementia interventions. It makes sense for them to play up the possibility of avoiding conditions associated with ageing, both now and in future. It would be particularly lucrative for them to be able to recommend specific medications for younger people who had been found to have a higher risk of developing dementia later in life. Such treatments could enjoy far wider demand than a specific targeted cure for the smaller group who are already developing the condition.
But if dementia prevalence is indeed stable or even declining, might past policies provide a better answer? Remember we are talking about a generation which experienced substantial post-war investments in education and socialised healthcare, and a partial reduction in social inequalities as a result. If it has worked thus far, the same kind of approach might be the best way forward for the future. Adopting a drug-only approach is likely to lead to widening inequalities of access and problems with affordability, as we learned with HIV/AIDS, cancer and other diseases.
The current dementia prevention advice focuses on what people can do in terms of healthy behaviour and lifestyle: exercise, diet and so forth. Yet our lifestyles and health are considerably influenced by factors in our wider social environment over which we have limited control. For the sake of future populations, this is why responsibility for dementia prevention should be seen as a matter for society and the world as a whole.
More information: "Dementia in western Europe: epidemiological evidence and implications for policy making." DOI: dx.doi.org/10.1016/S1474-4422(15)00092-7

Study: Calcium supplementation does not clog arteries

Heart diagram. Credit: Wikipedia

Contrary to recent reports, consuming calcium supplements is not likely to cause heart problems or heart attacks, according to a study from Purdue University.

23 AUG 2015--"Our study found that consuming a high-calcium diet, which is defined as not exceeding 2,000 milligrams of calcium a day, is not a risk factor for heart attacks," said Connie Weaver, distinguished professor and head of the Department of Nutrition Science. "The recent concern that calcium supplements were a risk factor led people to stop supplementing their diets. This is a great concern because supplementation is essential to fill a void to meet the daily recommended amount of calcium for strong bones."
"We're already at epidemic levels for osteoporosis as one in two women older than 50 will get a fracture in her lifetime, and 20 percent of hip fractures occur in men," said Weaver, who is an expert in mineral bioavailability, calcium metabolism, botanicals and bone health.
The research is published online in the Journal of the American Heart Association. The project was funded by Pharmavite LLC, the Dairy Research Institute, Dairy Australia, Fonterra Cooperative Group Limited, Kraft Foods Inc., Nestle and grants from the National Institutes of Health. Weaver serves on the scientific advisory board for Pharmative LLC. Collaborators included Scott Radcliff, Meryl Wastney, Bill van Alstine and George Jackson from Purdue; Mike Sturek from the Indiana University School of Medicine; and Sean Newcomer from California State University.
"It had been reported that there is a 30 percent higher chance of heart attack from consuming calcium supplements," Weaver said. "In 2011, 22 percent of the population consumed calcium supplements, and that decreased in 2012 to 17 percent. The research supporting such a risk has been based on self-reports or from correlations or secondary analysis rather than primary causes. And this would be too hard to study in humans in such a way to control their diet and identify concerns prior to having a heart attack."
In Weaver's study, three groups of pigs were fed a normal diet, a high-calcium diet from supplements or a high-calcium diet from dairy products over a six-month period. The high-calcium diets were equivalent to 2,000 milligrams of calcium consumed one time each day. Neither high-calcium group had an increase of calcium in the arteries.
"The speculation was that calcium deposited in the soft tissue of the arteries and that a big dose of calcium from a supplement would cause it to precipitate in the blood," Weaver said.
The researchers determined this by using the calcium 41 technology, an isotope measure to trace calcium deposits through accelerator mass spectrometry. It can measure atomic quantities and determine whether any of the calcium 41 is deposited in the arteries' soft tissue. The researchers also used CT imaging and ultrasounds, as well as other biological measures.
"There is no cause for concern, and for every serving of low-fat dairy you miss, take 300 milligrams of calcium to get what you need for bone health," she says.
More information: "Effect of High‐Calcium Diet on Coronary Artery Disease in Ossabaw Miniature Swine With Metabolic Syndrome." J Am Heart Assoc. 2015;4:e001620, originally published August 13, 2015, DOI: 10.1161/JAHA.114.001620

Provided by Purdue University

The biological origins of sexual orientation and gender identity

Credit: Jean Manuel Duvivier

Male? Female? The distinction is not always clear. Exploring the scientific evidence for the biological origins of sexual orientation and gender identity must continue to both enhance patient care and fight discrimination.

22 aug 2015--"It's not just black or white" is an adage heard so often that it borders on cliché. It underscores life's complexities; wherever a gray area exists between two opposing endpoints, it asks us to consider the diverse realities and experiences that make life both more interesting yet harder to comprehend. But that gray area brings with it a certain unease. We are most comfortable when we can neatly categorize our environment. It helps make the world seem more manageable, more familiar.
When it comes to sex and gender, that "gray area" remains murky and mysterious—often undiscussed and even taboo. Pitted against familiar "black-or-white" stereotypes of what it means to be male or female, masculine or feminine, society struggles to accept what lies in between. At UCLA, however, and elsewhere in the small but growing field of sex and gender biology, science is shedding light on this unfamiliar terrain.
People often are unaware of the biological complexity of sex and gender, says Eric Vilain, MD (RES '98, FEL '99), PhD, director of the Center for Gender-Based Biology at UCLA, where he studies the genetics of sexual development and sex differences. "People tend to define sex in a binary way—either wholly male or wholly female—based on physical appearance or by which sex chromosomes an individual carries. But while sex and gender may seem dichotomous, there are in reality many intermediates."
Dr. Vilain says that understanding this complexity is critical, as misperceptions affect the health and civil liberties of those who fall outside perceived societal norms. "Society has categorical views on what should define sex and gender, but the biological reality is just not there to support that," he says.
Even at the most basic physical level, Dr. Vilain explains, there is a spectrum between male and female that often goes unrecognized and risks being obscured by stigma. Among his many lines of research, Dr. Vilain studies differences and disorders of sex development (DSDs), an umbrella term that encompasses genetic variation and developmental differences of "intersex" individuals—those whose physical characteristics are not completely male or female but somewhere in between. This includes genetic variations in the complement of sex chromosomes—for example, a mix of XX (female) and XY (male) sex chromosomes in the same body, or an extra or missing sex chromosome (XXY, Klinefelter syndrome, for example, or monosomy X, Turner syndrome). DSDs also include variations in the development of the genitals or the gonads. Individuals can be born with both testicular and ovarian gonadal tissue or with ambiguous genitalia—female genitalia that is enlarged enough to resemble a male penis or exceptionally small male genitalia.
Conditions that affect hormone levels also fall into this category. Examples include androgen insensitivity syndrome, which impairs the male body's ability to recognize male hormones, and congenital adrenal hyperplasia (CAH), which causes females to produce unusually high levels of male hormones.
A number of genetic factors have been associated with DSDs, and, in recent years, whole-exome sequencing—analysis of the parts of the genetic code that control protein-coding regions of the human genome—has made it possible to diagnose the genetics at play in many intersex cases.
A growing body of research also is showing how biology influences gender expression, sexual orientation and gender identity—characteristics that can also fall outside of strict, socially defined categories. "Toy-preference tests," a popular gauge of gender expression, have long shown that boys and girls will typically gravitate to toys that are stereotypically associated with their gender (cars and guns for boys, for instance, or plush toys for girls).
While one might argue that this could be the by-product of a child's environment—parental influence at play, or an internalization of societal norms—Melissa Hines, PhD, a former UCLA researcher and current professor of psychology at the University of Cambridge, in England, has shown otherwise. In 2008, she demonstrated that monkeys given the toy-preference test exhibit the same sex-based toy preferences as humans—absent societal influence. Dr. Hines later found that girls with CAH tended to prefer masculine toys compared to their non-CAH sisters, suggesting that hormones heavily influence gender expression.
Sexual orientation (whether one tends to be attracted to men or women) has also been shown to have biological roots. Twin studies and genetic linkage studies have shown both hereditary patterns in homosexuality (attraction to one's own sex), as well as genetic associations with specific parts of the genome.
And while gender identity—the sense one has of oneself as being either male or female—has been harder to pinpoint from a biological standpoint, efforts to understand what role biology may play are ongoing.
In the 1960s and '70s, UCLA psychiatrists Richard Green, MD, JD, and the late Robert Stoller, MD, conducted groundbreaking research on the early expression of significant cross-gender behavior in males, then termed "gender-identity disorder" and now known as "gender dysphoria," a condition where one identifies with the gender that doesn't match the sex assigned at birth. The researchers studied boys whose cross-gender behaviors matched those retrospectively reported by adult males seeking sex-change hormones and surgery. They tracked the youths over some 15 years, gaining a better understanding of the course of early cross-gender behaviors. Most of the boys matured into homosexual, not transgender/ transsexual, young adults.
Today, cross-gender childhood behaviors that distinguish later transgender/transsexual from homosexual adults remain a research puzzle. Dr. Vilain says that most promising approaches to understanding the development of gender identity include genetics and the study of the environment, including epigenomics—combining the effects of environmental factors on gene expression. His lab recently found a connection between hormone exposure early in life and long-termsexual development. In their study, female mice exposed to high levels of testosterone at birth later exhibited more masculinized gene-expression patterns. Dr. Vilain's team is looking at the location of these epigenomic changes for clues about which regions of the genome may be influencing gender expression and possibly gender identity.
Squeamishness about sexual biology and adherence to long-held gender stereotypes have masked just how diverse sex and gender are across the population. The Intersex Society of North America estimates that as many as one in every 100 people is born intersex, and a 2011 study by the Williams Institute at the UCLA School of Law reported that approximately 9-million Americans identified as lesbian, gay, bisexual or transgender (LGBT).
Despite the prevalence of this variance, we remain uncomfortable with the subject. That discomfort feeds an ignorance that affects patient health.
Doctors, patients and caregivers alike need to be aware of the implications of a condition and willing to discuss the patient's needs. These may be medical. For instance, fertility issues often accompany DSDs, and some of these conditions carry a higher risk of diseases such as breast, ovarian or testicular cancers. Hesitance to discuss the issues could put patients at physical risk or add to the psychological burden of being part of an often-persecuted minority.
Clinical psychiatrist Vernon Rosario, MD (RES '00, FEL '02), PhD, counsels intersex patients and their families at the Clark-Morrison Children's Urological Center at UCLA. He says that the accessibility of information and studies about these conditions are helping clinicians and patients and their families make informed choices. For instance, he has witnessed an increasing willingness to accept the ambiguity that accompanies DSDs; parents are less likely to impose a gender on their child, opting to wait several years until their son or daughter expresses a clearer gender behavior. As recently as the 1980s and early 1990s, it was not uncommon to assign a sex at birth and to surgically alter the child to physically conform.
Dr. Rosario, whose PhD is in the history of science, suggests it also is important to put intersex and LGBT health in cultural and historical context; he advises clinicians to be aware of the ethnic, religious and cultural values that patients and families bring with them to the clinic.
"I try to stress to patients that the gender norms they are dealing with are societal constructs and are not something that were determined scientifically. We have these categories, but practitioners need to help patients and parents recognize that everything doesn't have to all fit together in one particular way that we conventionally call 'normal.' There's a lot of diversity, and that's okay," he says.
This is all the more important because pressure to conform comes with a psychological cost—one that the healthcare community has struggled to address. Those who fall outside of sex and gender norms face stigma, hostility and outright violence. Many endure bullying and rejection that can lead to psychological scars or even suicide. A 2014 study from the Williams Institute and the American Foundation for Suicide Prevention found that 41 percent of transgender individuals and 10-to-20 percent of gays and lesbians have attempted suicide. That risk jumps dramatically for those who have faced violence, familial rejection or homelessness.
Suicide attempts also increase among transgender individuals who have been turned away by medical professionals—a surprisingly common experience, experts say, and one that often is noted on LGBT advocacy websites. "I think more times than not, health providers shy away from seeing transgender individuals because they don't want to offend them, or they don't really understand what all the issues are," says Gail Wyatt, PhD, clinical psychologist and director of the UCLA Sexual Health Program.
It is essential, she says, for clinicians to maintain an open dialogue with transgender patients, to maintain trust and not inadvertently compound the rejection and denial they often face. "Health professionals should encourage the individuals to talk freely about their life as one sex, as well as the process of transitioning to a different sex or gender. A lot of people have never asked these questions," she says. (In 2014, UCLA Health was recognized as one of the "Leaders in LGBT Healthcare Equality" by the Human Rights Campaign Foundation, which is the educational arm of the country's largest lesbian, gay, bisexual and transgender civil rights organization.)
Dr. Wyatt says that health professionals should also be aware of transgender-specific issues they might not encounter regularly in their clinic. She and colleagues from Planned Parenthood in New York City recently adapted an intervention program originally designed for abused, HIV-positive women, called "Healing Our Women," for use with transgender women. The process brought important issues to light about the needs of transgender patients. A session on preventive care, for instance, had to be adapted to address a spectrum of male and female physical characteristics. Since many transgender patients do not follow through with sex-reassignment surgery, either by choice or because of financial or procedural barriers, the individuals in the program represented various stages of transition. Transgender individuals needed to be educated about both male and female anatomy, including tips on sex-specific hygiene and self-exams for breast and testicular cancer. Such topics can be neglected when doctor or patient is hesitant to discuss the transition.
"This is something we need to do more about in the training phase of health professionals' careers so that they are better equipped to care for transgender men and women," Dr. Wyatt says.
When patients are alienated by health professionals, they are denied basic access to care. This not only happens at the doctor-patient level, but also often is systemic. Many insurance carriers won't cover sex-reassignment surgery. Health professionals lack training about LGBT issues. And in some places, patients are steered toward controversial "treatments" like sex- or gender-conforming surgeries or conversion therapies.
Ironically, one way for LGBT populations to be assured access to care would be to fit neatly into another category—a "suspect class." Legally speaking, if a population is defined by inborn and immutable characteristics (as with women or African-Americans), they can be deemed a "suspect class," with special protections against unfair discrimination.
U.S. courts have thus far skirted the issue, but legal actions over the past half-century have still resulted in civil rights gains. As early as the 1970s, Dr. Green's pioneering work on gender identity—he has edited or authored several books, including Transsexualism and Sex Reassignment (Johns Hopkins Press, 1969), The "Sissy Boy Syndrome" and the Development of Homosexuality (Yale University Press, 1987) and Sexual Science and the Law (Harvard University Press, 1992)—made him a sought-after expert in civil rights cases, including job-discrimination lawsuits and child-custody battles involving lesbian mothers. He later earned a law degree to help lead such cases, where he argued that sexual orientation should be protected against discrimination under the U.S. Constitution.
"The arguments we used were based on a growing body of evidence pointing to sexual orientation as innate and immutable, as well as evidence that efforts to change sexual orientation were rarely successful," he explains in a telephone conversation from London, England, where he now lives and teaches.
Dr. Green says that scientific evidence on the biological origins of sexual orientation and gender identity, like that which is being amassed at UCLA, will continue to be critical in fighting discrimination, both legally and socially. "When I started my career, homosexuality was considered a mental illness by American psychiatry and a crime in many U.S. states. Now," Dr. Green says, "the conversation is, 'Which state will become the next to allow same-sex marriage?'"

Provided by University of California, Los Angeles

Nine factors you can control may be key to Alzheimer's risk

Healthy lifestyle important but no guarantee against most common form of dementia, researchers find.

21 aug 2015—Up to two-thirds of Alzheimer's cases worldwide may stem from any of nine conditions that often result from lifestyle choices, a broad research review suggests.
Those include obesity (specifically, high body mass index, an indication of obesity, in midlife); carotid artery disease, in which plaque buildup narrows major neck arteries and slows blood supply to the brain; high blood pressure; depression; being frail; being poorly educated; having high levels of a naturally occurring amino acid known as homocysteine; and (specifically among those of Asian descent) being a smoker and/or having either type 2 diabetes.
The implication: Taking steps to minimize or eliminate such conditions might reduce the long-term risk for developing Alzheimer's, a brain disorder that affects memory and thinking. It is the most common form of dementia among seniors.
"The current evidence from our study showed that individuals would benefit from [addressing] the related potentially modifiable risk factors," said study lead author Dr. Jin-Tai Yu, an associate specialist in neurology at the University of California, San Francisco, and senior editor of the Journal of Alzheimer's Disease.
But Yu cautioned that "what is what is seen here is an association rather than a direct cause-and-effect relationship between any one factor and Alzheimer's risk." And that, he said, means it's impossible to determine exactly how much protection against Alzheimer's would be gained by the elimination of any one condition.
Yu and his colleagues discuss their findings in the Aug. 20 online issue of the Journal of Neurology, Neurosurgery & Psychiatry.
In all, investigators reviewed the findings of 323 studies completed between 1968 and 2014. Collectively, the studies involved more than 5,000 patients and looked at 93 conditions with the potential to affect Alzheimer's risk.
The team set out to determine which factors appeared to offer some protection against developing Alzheimer's.
On that score, the strongest evidence suggested that coffee, vitamins C and E, folate, NSAIDS (anti-inflammation drugs), statins (cholesterol-lowering drugs), blood pressure medications, and estrogen supplementation all appeared to reduce Alzheimer's risk.
Patients battling several serious health conditions also seemed to see their risk fall, including those with arthritis, heart disease, metabolic syndrome and/or cancer.
Those who were light or moderate drinkers of alcohol similarly saw their Alzheimer's risk dip, alongside current smokers (apart from those of Asian descent), those struggling with stress, and seniors with high body mass index.
By contrast, a complex statistical analysis enabled the research team to zero in on the nine factors that appeared to elevate Alzheimer's risk among 66 percent of those who ultimately get the disease.
But Dr. Anton Porsteinsson, a professor of psychiatry and director of the Alzheimer's Disease Care, Research and Education Program at the University of Rochester School of Medicine in Rochester, N.Y., suggested that to his mind, "there's not a lot of surprise here."
"It's an interesting paper," he said. "And certainly this review validates a number of individual studies that have previously shown an association between Alzheimer's and the factors they're identifying." But it doesn't improve understanding of the causes, he added.
The take-away, Porsteinsson said, is that a healthy lifestyle matters. Paying attention to blood pressure and cholesterol levels as well as exercise are all beneficial, and the other factors studied may make a difference, he added, but it doesn't mean there is a simple way to reduce Alzheimer's risk. Large clinical trials have looked at behavior modifications that might help, but those kind of simple interventions have failed.
"So reducing risk is probably not going to happen by just taking a pill or a food supplement or a single medication," he added. "That kind of a shortcut answer just doesn't have a lot of support."
More information: There's more on preventing Alzheimer's at U.S. National Institute on Aging.

Baby boomers reeling in the years

People in their 60s are the group most likely to feel younger than their age. Credit: Thinkstock

It's long been said that you're as old as you feel. Now a group of researchers is looking at how the concept of "subjective" age might be used to manage the wellbeing of the baby boomer generation.

20/08/2015--The researchers, from Australia and the US, have developed a model for measuring age that takes into account social, mental and biological factors, not only how many birthdays have passed.
Individuals, potentially with the help of their GPs, may one day be able to measure themselves against this subjective age index.
If it reveals weakness in any of the three key elements – you may be more socially isolated than the average 60-year-old, say – steps could be taken to improve that area of your life. The aim is to "time bend" to achieve a lower subjective age than your birth certificate shows.
"We see this as becoming a great aid in healthcare, as a diagnostic tool that can assist a move away from reparative medicine to rejuvenative medicine," says Dr Bruce Perrott, a senior lecturer in marketing with the Business School at the University of Technology Sydney (UTS).
"Within the next three decades, Australia, like other Western countries, will experience a lift in the numbers of people in older age brackets," Dr Perrott says. "Many healthcare systems will strain to keep up. Insights into subjective age have the potential to help us improve quality of life for an ageing population and ease that burden."
As specialists in the science of consumer behaviour, Dr Perrott and researchers from the University of Massachusetts Amherst are interested in how people's values affect their decisions, including their choices about how they manage ageing.
"One value among baby boomers is that they want to be forever young, and they'll do absolutely everything they can to stay young," says Professor Charles Schewe of the University of Massachusetts.
"One of the things they can do is keep their mind thinking that they are younger. So the question for us, as marketers, as healthcare providers, is how can we provide mechanisms for them to get to that end?"
Studies have shown that lowering your subjective age improves quality of life, reducing health issues and even adding to lifespan, the researchers say. "In one longitudinal study, it was shown to add 7.5 years to life," Professor Schewe says.
The chief executive of the Council on the Ageing NSW, Ian Day, says his 90-year-old father regularly used the line that the only thing wrong with his retirement village was the number of old people there.
"It's that concept of, 'my body may say I'm 75 but I'm going to keep trying to behave like I'm 25'. It's when you finally say, 'I'm going to start acting like a 75-year-old' that you really start to age," Day says.
The research team, which includes Professor George Milne and doctoral students David Agogo and Fatima Hajjat of Massachusetts, broke down the factors of subjective age into how old you feel, how old you look, and how "old" your interests are.
They then developed an extensive questionnaire that asks things such as how often you walk briskly for 20 minutes, how often you carry out physical tasks you believe others your age cannot do (biological factors), how often you forget appointments, how often you wonder whether you've used a word correctly (mental factors), how often you speak to more than one person at a social gathering, and how often you introduce or connect people (social factors).
This subjective ageing index has been tested in the US and Dr Perrott plans to replicate it in Australia. Among the findings so far are:

• Only about 1 per cent of people feel their actual age
• The average person feels about 13.5 years younger than their chronological age
• People aged in their 60s are the group most likely to feel younger than their actual age.

Dr Perrott is particularly interested in the concept of "self-balancing" behaviour, the theory being that older people who lose something – such as a degree of manual dexterity – will compensate in another area, by doing something else that makes them feel younger.
"It's been observed – though not empirically proven – that people considered by others to be ageing successfully tend to take up as many activities as they give up," he says.
Dr Perrott hopes that, as well as potentially providing a diagnostic tool, the research will inspire policymakers to create programs that encourage healthy lifestyles at each of the critical life stages.
Day says the research underlines the fact that there is great diversity among older people, including how "old" different people of the same age feel. "They are regularly bunched together as a homogenous group but they definitely are not."

Provided by University of Technology, Sydney

USPSTF draft recommendation urges against COPD screening

The U.S. Preventive Services Task Force (USPSTF) has found no net benefit for chronic obstructive pulmonary disease (COPD) screening in asymptomatic adults and consequently recommends against screening. These findings form the basis of a draft recommendation statement published online Aug. 17 by the USPSTF.

19 aug 2015--Janelle M. Guirguis-Blake, M.D., from the Kaiser Permanente Center for Health Research in Portland, Ore., and colleagues conducted a systematic review to update USPSTF recommendations on screening for COPD.
The researchers found no evidence that COPD screening with questionnaires or spirometry improves health outcomes in asymptomatic individuals. There was no indication that COPD screening before symptom development affected treatment decisions, altered the course of disease, or improved patient outcomes. There was inadequate evidence on the harms of screening; the cost associated with screening asymptomatic individuals may be large, given the lack of benefit of early detection and treatment. These findings form the basis of a draft recommendation statement which will be available for comment until Sept. 14.
"The Task Force found that there is no evidence that screening for COPD in adults without symptoms results in improved health outcomes," Task Force member William Phillips, M.D., M.P.H., said in a statement. "The most important step you can take to prevent COPD is to avoid smoking. People who smoke should talk with their doctors about ways to quit."
More information: Evidence Review
Draft Recommendation Statement
Comment on Recommendation

Study reveals benefits of clinical medication reviews for improving medication management

Structured and collaborative medication reviews performed by pharmacists and general practitioners are beneficial in improving the quality use of medicines, according to a groundbreaking new review published by Monash University.

18 aug 2015--Researchers from the Faculty of Pharmacy and Pharmaceutical Sciences' Centre for Medicine Use and Safety found that clinical medication reviews (CMRs) resulted in identification of medication-related problems, improved medication adherence and reduced hospitalisations.
Published in respected pharmaceutical research journal Research in Social and Administrative Pharmacy, the comprehensive review titled 'Clinical medication review in Australia: a systematic review' demonstrated the value of medication review models that incorporate inter-professional collaboration.
The Pharmaceutical Society of Australia (PSA) highlighted the importance of the research in a recent announcement, with National President Joe Demarte saying, "This review is landmark in that it provides an overview of the research to date and describes the clinical, humanistic, economic and qualitative benefits of medication reviews." Australia's Chief Medical Officer Professor Chris Baggoley AO also highlighted the research as part of his keynote address at the recent PSA 15 conference in Sydney.
The research team was led by Associate Professor Simon Bell and also included Ms Natali Jokanovic, Dr Edwin Tan, Professor Carl Kirkpatrick, Professor Michael Dooley, and Ms Denise van den Bosch.
"Our research showed that clinical medication reviews are capable of improving the quality use of medicines in older Australians. This is an important finding because up to 30 per cent of unplanned hospital admissions among people aged 75 years and older are medicines related," said Associate Professor Bell.
The review identified a lack of awareness of CMRs among eligible non-recipients, including people from indigenous and linguistically diverse communities, recipients of palliative care, people with poor medication adherence and those in rural and remote areas. Addressing these "access gaps" represents an opportunity to further improve the current model for CMRs in Australia, according to the review.
This was the first systematic review of CMR research undertaken in Australia.
More information: "Clinical medication review in Australia: A systematic review." DOI: dx.doi.org/10.1016/j.sapharm.2015.06.007

Provided by Monash University

Exercise-induced hormone irisin is not a 'myth'

Credit: Peter Griffin/Public Domain

Irisin, a hormone linked to the positive benefits of exercise, was recently questioned to exist in humans. Two recent studies pointed to possible flaws in the methods used to identify irisin, with commercially available antibodies. In Cell Metabolism on August 13, the Harvard scientists who discovered irisin address this contentious issue by showing that human irisin circulates in the blood at nanogram levels and increases during exercise.

17 aug 2015--Senior study author Bruce Spiegelman of Dana-Farber Cancer Institute and Harvard Medical School says that the confusion over irisin comes down to disagreement over how irisin protein is made in skeletal muscle cells and the detection limits of protocols. He and co-author Steven Gygi turned to state-of-the-art quantitative mass spectrometry techniques to show that the human hormone uses a rare signal ATA (start codon) to initiate its production (translation) rather than the usual ATG.
The use of the ATA, rather than the more common ATG, had led some investigators to conclude that the human gene was a pseudogene—a gene that serves no function. But alternative start codons account for a few of all genes and are usually an indication of complex regulation. The authors show that human irisin is similar to the mouse hormone and that it circulates in the range previously reported. Although irisin circulates at low levels (nanograms), this range is comparable to that observed for other important biological hormones such as insulin. Furthermore, the investigators developed a protocol, that does not rely on antibodies, to precisely measure how much irisin increases in people after exercise.
"The data are compelling and clearly demonstrate the existence of irisin in circulation," says endocrinologist Francesco Celi of the Virginia Commonwealth University Medical Center, who was not involved with the study. "Importantly, the authors provide a precise and reproducible protocol to measure irisin." He adds that further studies are necessary to fully understand how the hormone works in humans, specifically how it relates to brown and beige fat tissue and energy use.
Irisin's discovery in 2012 was exciting because scientists had potentially found one reason why exercise keeps us healthy. When irisin levels were increased in mice, their blood and metabolism improved. Results from human studies are still mixed as to what kinds of exercise raise irisin, but data suggest that high-intensity training protocols are particularly effective. The protocol described in the Cell Metabolism paper is likely to help such studies, as it is the most precise way to measure the hormone to date.
The authors point out one caveat in their methods—that some irisin is lost during sample preparation, and therefore the amount of irisin detected is, if anything, a slight underestimation. The technology is also expensive and requires specificmass spectrometry instruments. However, future refinement of this work should lead to more scalable protocols."Spiegelman and colleagues have unequivocally shown that the "mythical" irisin peptide is produced as a result of exercise," says chemical physiologist John Yates of The Scripps Research Institute, also not affiliated with the work. "This data should settle the controversy surrounding the existence of irisin and its increase in blood as a function of exercise."
More information: Cell Metabolism, Jedrychowski et al.: "Detection and Quantitation of Circulating Human Irisin by Tandem Mass Spectrometry" dx.doi.org/10.1016/j.cmet.2015.08.001

Provided by Cell Press

New, rapid dementia screening tool rivals 'gold standard' clinical evaluations

15 aug 2015--Determining whether or not an individual has dementia and to what degree is a long and laborious process that can take an experienced professional such as a clinician about four to five hours to administer, interpret and score the test results. A leading neuroscientist at Florida Atlantic University has developed a way for a layperson to do this in three to five minutes with results that are comparable to the "gold standard" dementia tests used by clinicians today.

The "Quick Dementia Rating System" (QDRS), which uses an evidence-based methodology, validly and reliably differentiates individuals with and without dementia. When dementia is present, it accurately stages the condition to determine if it is very mild, mild, moderate or severe. QDRS has applications for use in clinical practice, to pre-qualify patients in clinical trials, prevention studies, community surveys and biomarker research.

James E. Galvin, M.D., M.P.H., is one of the most prominent neuroscientists in the country and a professor of clinical biomedical science in the Charles E. Schmidt College of Medicine and a professor in the Christine E. Lynn College of Nursing at Florida Atlantic University, and the QDRS is his brainchild. He recently published an article on his findings in Alzheimer's & Dementia, the journal of the Alzheimer's Association. Galvin has developed a number of dementia screening tools including the AD8, a brief informant interview to translate research findings to community settings that is used worldwide to detect dementia in diverse populations.

"After extensive testing and evaluation of the Quick Dementia Rating System, we have found it to be as effective as the gold standard used today to screen for the five stages of dementia," said Galvin. "This new tool gives you a lot of power to see the same results as a full screening in a fraction of the time it takes for a complete screening."

The QDRS is a 10-item questionnaire that can be completed by a caregiver, friend or family member, and is brief enough to be printed on one page or viewed as a single screenshot, maximizing its clinical utility. Scores range from 0 to 30 with higher scores representing greater cognitive impairment. The questionnaire covers: 1) memory and recall; 2) orientation; 3) decision-making and problem-solving abilities; 4) activities outside the home; 5) function at home and hobbies; 6) toileting and personal hygiene; 7) behavior and personality changes; 8) language and communication abilities; 9) mood; and 10) attention and concentration.

The total score is derived by summing up the 10 fields and each area has five possible answers increasing in severity of symptoms. The 10 areas capture the prominent symptoms of mild cognitive impairment, Alzheimer's disease, and non-Alzheimer's neurocognitive disorders including Lewy Body Dementia, frontotemporal degeneration, vascular dementia, chronic traumatic encephalopathy and depression.

A total of 267 individuals with various forms of dementia from Alzheimer's disease to Lewy Body Dementia participated in the study, which included 32 healthy controls. Study participants also included their spouses/significant others, adult children, relatives, friends and paid caregivers who completed the QDRS.

"Most patients never receive an evaluation by a neurologist, geriatric psychiatrist, or geriatrician skilled in dementia diagnoses and staging. Early detection will be important to enable future interventions at the earliest stages when they are likely to be most effective," said Galvin. "The QDRS has the potential to provide a clearer, more accurate staging for those patients who are unable to see these more specialized clinicians and get them the treatment, referrals and community services they so desperately need."

The Quick Dementia Rating System is copyrighted and permission to use this tool is required. QDRS is available at no cost to clinicians, researchers and not-for-profit organizations.

Galvin is working to improve clinical detection by combining biomarkers including high density EEG, functional and structural MRI, PET scans and CSF biomarkers to characterize and differentiate Lewy Body Dementia from healthy aging and other neurodegenerative diseases. He led efforts to develop a number of dementia screening tools in addition to the QDRS and AD8, and has done cross-cultural validation of dementia screening methods in comparison with Gold Standard clinical evaluations and biomarker assays. His team also developed sophisticated statistical models to explore transition points in clinical, cognitive, functional, behavioral and biological markers of disease in healthy aging, mild cognitive impairment, Alzheimer's disease and Parkinson's disease.

Provided by Florida Atlantic University

Low-fat diet results in more fat loss than low-carb diet in humans

Artistic depiction of a study investigating whether low-fat or low-carb diets lead to more fat burning and fat loss. 

14 aug 2015--A study from the US National Institutes of Health presents some of the most precise human data yet on whether cutting carbs or fat has the most benefits for losing body fat. In a paper published August 13 in Cell Metabolism, the researchers show how, contrary to popular claims, restricting dietary fat can lead to greater body fat loss than carb restriction, even though a low-carb diet reduces insulin and increases fat burning.

Since 2003, Kevin Hall, PhD—a physicist turned metabolism researcher at the National Institute of Diabetes and Digestive and Kidney Diseases—has been using data from dozens of controlled feeding studies conducted over decades of nutrition research to build mathematical models of how different nutrients affect human metabolism and body weight.

He noticed that despite claims about carbohydrate versus fat restriction for weight loss, nobody had ever measured what would happen if carbs were selectively cut from the diet while fat remained at a baseline or vice versa. His model simulations showed that only the carb-restricted diet would lead to changes in the amount of fat burned by the body, whereas the reduced-fat diet would lead to greater overall body fat loss, but he needed the human data to back it up.

"A lot of people have very strong opinions about what matters for weight loss, and the physiological data upon which those beliefs are based are sometimes lacking," Hall says. "I wanted to rigorously test the theory that carbohydrate restriction is particularly effective for losing body fat since this idea has been influencing many people's decisions about their diets."

Studying the effects of diet on weight loss is often confounded by the difficulty in measuring what people actually eat—participants may not adhere to meal plans, misjudge amounts, or are not truthful in follow-up surveys. To counter this, Hall and colleagues confined 19 consenting adults with obesity to a metabolic ward for a pair of 2-week periods, over the course of which every morsel of food eaten was closely monitored and controlled.

To keep the variables simple, the two observation periods were like two sides of a balance scale: during the first period, 30% of baseline calories were cut through carb restriction alone, while fat intake remained the same. During the second period the conditions were reversed. Each day, the researchers measured how much fat each participant ate and burned and used this information to calculate the rate of body fat loss.

At the end of the two dieting periods, the mathematical model proved to be correct. Body fat lost with dietary fat restriction was greater compared with carbohydrate restriction, even though more fat was burned with the low-carb diet. However, over prolonged periods the model predicted that the body acts to minimize body fat differences between diets that are equal in calories but varying widely in their ratio of carbohydrate to fat.

"There is one set of beliefs that says all calories are exactly equal when it comes to body fat loss and there's another that says carbohydrate calories are particularly fattening, so cutting those should lead to more fat loss," Hall says. "Our results showed that, actually, not all calories are created equal when it comes to body fat loss, but over the long term, it's pretty close."

Hall does caution against making sweeping conclusions about how to diet from this study. The study's purpose was to explore the physiology of how equal calorie reductions of fat versus carbs affect the human body. The research is limited by its sample size; only 19 people could be enrolled due to the expense of such research and the restrictiveness of the carefully controlled protocol. However, this study clearly reaches statistical significance. In addition,, the menu that the participants followed does not emulate normal dieting and does not account for what diet would be easier to eat over extended periods.

"We are trying to do very careful studies in humans to better understand the underlying physiology that will one day be able to help generate better recommendations about day-to-day dieting," Hall says. "But there is currently a gap between our understanding of the physiology and our ability to make effective diet recommendations for lasting weight loss."

Hall recommends that for now, the best diet is the one that you can stick to. His lab will next investigate how reduced-carbohydrate and reduced-fat diets affect the brain's reward circuitry, as well as its response to food stimuli. He hopes these results might inform why people respond differently to different diets.

More information: Cell Metabolism, Hall et al.: "Calorie for calorie, dietary fat restriction results in more body fat loss than carbohydrate restriction in people with obesity" dx.doi.org/10.1016/j.cmet.2015.07.021 

Provided by Cell Press

High-dose vitamin D supplementation not associated with benefits for postmenopausal women

High-dose vitamin D supplementation in postmenopausal women was not associated with beneficial effects on bone mineral density, muscle function, muscle mass or falls, according to the results of a randomized clinical trial published online byJAMA Internal Medicine.

12 aug 2015--Low levels of vitamin D contribute to osteoporosis because of decreased total fractional calcium absorption (TFCA) and nearly half of postmenopausal women sustain an osteoporotic fracture. However, experts disagree on the optimal vitamin D level for skeletal health. Some experts contend that optimal serum 25-hydroxyvitamin D levels are 30 ng/mL or greater, while the Institute of Medicine recommends levels of 20 ng/mL or greater, according to study background.

Karen E. Hansen, M.D., M.S., of the University of Wisconsin School of Medicine and Public Health, Madison, and colleagues compared the effects of placebo, low-dose cholecalciferol (a form of vitamin D) and high-dose cholecalciferol on one-year changes on total TFCA, bone mineral density, sit-to-stand tests and muscle mass in 230 postmenopausal women (75 or younger) with vitamin D insufficiency.

Trial participants were divided into three groups: daily white and twice monthly yellow placebo, daily 800 IU vitamin D3 (low dose) and twice monthly yellow placebo, and daily white placebo and twice monthly 50,000 IU vitamin D3 (high dose). The high-dose regimen vitamin D regimen achieved and maintained 25-hydroxyvitamin D levels at greater than or equal to 30 ng/mL.

Results indicate that calcium absorption increased 1 percent in the high-dose group but decreased 2 percent in the low-dose group and 1.3 percent in the placebo group. The small increase in the high-dose group did not translate into beneficial effects because authors found no difference between the three study groups for changes in spine, average total-hip, average femoral neck or total-body bone mineral density, trabecular bone score, muscle mass or sit-to-stand tests. There also were no differences between the groups for numbers of falls, number of fallers, physical activity or functional status.

The authors note few African-American women participated in the study, which limits its ability to detect differential responses to cholecalciferol based on race. The study results also cannot be used to guide cholecalciferol therapy for young adults, men, or women older than 75, according to the authors. They point out individuals only participated for one year and perhaps longer exposure to high-dose cholecalciferol might yield greater effects on bone mineral density.

"Study results do not justify the common and frequently touted practice of administering high-dose cholecalciferol to older adults to maintain serum 25(OH)D [25-hydroxyvitamin D] levels of 30 ng/mL or greater," the study concludes.

More information: JAMA Intern Med. Published online August 3, 2015. DOI: 10.1001/jamainternmed.2015.3874 

Provided by The JAMA Network Journals

The five things you didn't know about teaching empathy

The Drexel College of Medicine teaches empathy to its students to help doctors and patients better connect for more efficient care.

11 aug 2015--Though it seems like they may obscure a patient's medical issues at times, emotions can actually be the key to unlocking more about a person's condition.

At Drexel's College of Medicine, understanding and reading those emotions is a point of focus. Medical students take part in empathy training during their first year. In their second year, that training is reinforced. 

By the time they hit their third year, students take part in a webcam-based simulation developed at the College that uses actors portraying patients to test what the students have learned and determine how well they apply it.

That technology, created by Dennis Novack, MD, professor of medicine and associate dean of Medical Education, Christof Daetwyler, associate professor of Family, Community and Preventive Medicine, and Gregory McGee, web developer in the College of Medicine, was recently licensed by DecisionSim under the name CommSim. It will be used to train doctors across the country, potentially including the United States Department of Veteran Affairs.

But how do you actually train someone to be empathetic? Novack talked with DrexelNow about what you need to know.

You have to be careful about mixing empathy and sympathy.

"There are several definitions of empathy in the medical literature, but the most common is 'the ability to put yourself in somebody else's shoes,'" Novack said. "It's to have a, more or less, objective experience of what it must be like to be this person going through an illness. It's understanding."

Sympathy, in the meantime, is to "feel with," Novack said. It's a more subjective experience.

"If your friend's mother dies, you go over to their house and cry with them. You're feeling similar emotions," he said. "Sympathy is quite different, in that regard."

The training provided at the College of Medicine is about giving medical students the skills to understand what a person is going through.

When a doctor blurs the lines between empathy and sympathy, Novack said studies have shown that they order extra or unnecessary testing and procedures.

"The patient-physician relationship relies on boundaries," he said. "If a patient tells you something tragic, you don't want them to look up and see you crying."

Empathy is a skill-based quality.

"People have a different capacity for empathy going into medical school," Novack said. "People are just wired differently."

Brain scans show that some people simply have fewer brain cells designed for empathetic qualities, according to Novack.

So the training aims to develop listening skills that can be applied to demonstrating empathy.

They include skills like reflection, which means being able to comment or ask about a patients emotions; legitimization, which can be indicating recognition and normalizing  an emotional reaction ("most people would feel as you do in this situation"); partnership or support, which could be as simple as saying you'll do your best to work with them; and summarization, an accurate retelling and checking what a person has told you.

Personal biases need to be recognized and overcome.

"We're human beings. We're social animals. We all have judgments," Novack said. "You meet someone and 30 seconds later you have a judgment." 

The training at the College of Medicine encourages students to reflect on their own lives and also those of their parents and grandparents to trace back any biased attitudes or feelings they might have and where they originated.

Being aware of these biases or attitudes is crucial to overcoming them and seeing the world the way a patient might.

"If you don't seek the patients' perspective, you can get judgmental and that will get in your way when you're caring for a person."

Empathy is about being present in a situation, but that can be hard for a doctor.

Doctors whip back and forth from the mundane to the horrific, seeing the best moments of people's lives to the absolute worst.

"You go from death to the birth of a baby," Novack said.

As such, it's important to teach medical students to do their best to be present in each situation.

"You have to free yourself up. You can't completely do it but you can rely on the skills we're teaching you, even if you're not feeling it," Novack said. "If you can just get a glimmer of what that person is feeling, that will help them, even when you're not completely present."

Sharpening empathy skills can boost a doctor's overall performance.

"If you're not empathic, you're not going to get very far," Novack said. "Patients who feel understood are more willing to reveal important information and worries to their physicians."

The more information a doctor has, the easier it is to diagnose a condition and the more efficiently it can be treated.

"I remember seeing an interaction where the doctor was being completely clinical, didn't say one empathic thing but he listened very well and, if you watched this interaction, you would've said, 'That's not an empathic doctor,'" Novack said. "And then, at the end, he said, 'I think I know what's going on with you now.' And he said to this woman what he thought the emotional experience was. And she started to cry and said, 'Yes, that's exactly what I'm going through.'"

Two minutes of empathy was all it took to ensure the patient's trust.and form an agreement with a difficult diagnostic and therapeutic plan.

"If you can get to that moment where you accurately relate their experience back to them, that sets up a relationship where patients are now ready to listen to you and your recommendations," Novack said.

Provided by Drexel University

Many seniors overestimate their mobility

Many seniors who visit emergency departments require more assistance with physical tasks than they think they do, which may lead to hospital readmission later on. The results of the study were published online Friday in Annals of Emergency Medicine.

10 aug 2015--"Ensuring that older adults discharged from the emergency department are able to safely function in their home environment is important because those who are unable to function safely at home are at risk for falls and return ER visits," said lead study author Timothy Platts-Mills, MD, MSc, of the University of North Carolina Chapel Hill in Chapel Hill, N.C. "Accurately determining the ability of these patients to care for themselves at home is critical for emergency physicians as they make decisions about whether to discharge patients home or elsewhere. A patient who reports they can walk with an assistive device but actually requires human assistance to walk is likely to be bed-bound or to fall if they go home alone."

Overall, only 77 percent of patients in the study accurately assessed their ability to perform tasks. Of patients who said they could perform the assigned tasks without assistance, 12 percent required some assistance or were unwilling to complete the tasks. Of those who said they could perform the task with a cane or walker, 48 percent required either human assistance or were unable to perform the task. Of those who said they could perform the task with human assistance, 24 percent were unable to perform the task even with someone helping them.

The tasks assigned were getting out of bed, walking 10 feet and returning to bed. Twenty million people aged 65 and older visit emergency departments every year, and that number is expected to grow as the Baby Boomers continue to age.

"Emergency physicians are experts in deciding who can go home and who needs to come in the hospital," said Dr. Platts-Mills. "But we are not perfect and sometimes we make decisions based on patient statements about abilities, rather than direct assessments. Our results suggest that patient statements are sometimes inaccurate, and, particularly for older adults who need some assistance, directly observing the patient's ambulation can be informative. Of course being able to move around isn't the only determinant of whether an older adult can be safely sent home, but it is a critical piece of information and it's good to get it right."

More information: "Self-Reported vs. Performance-Based Assessments of a Simple Mobility Task Among Older Adults in the Emergency Department", www.annemergmed.com/article/S0196-0644(15)00584-3/fulltext 

Provided by American College of Emergency Physicians