New medical advances marking the end of a long reign for 'diet wizards'

French fries and chocolate milkshakes affect people differently. Some are tempted by them, and others are not.

For many years, the long-term success rates for those who attempt to lose excess body weight have hovered around 5-10 percent.
In what other disease condition would we accept these numbers and continue on with the same approach? How does this situation sustain itself?

30 dec 2017--It goes on because the diet industry has generated marketing fodder that obscures scientific evidence, much as the Wizard of Oz hid the truth from Dorothy and her pals. There is a gap between what is true and what sells (remember the chocolate diet?). And, what sells more often dominates the message for consumers, much as the wizard's sound and light production succeeded in misleading the truth-seekers in the Emerald City.
As a result, the public is often directed to attractive, short-cut weight loss options created for the purposes of making money, while scientists and doctors document facts that are steamrolled into the shadows.
We are living in a special time, though – the era of metabolic surgeries and bariatric procedures. As a result of these weight loss procedures, doctors have a much better understanding of the biological underpinnings responsible for the failure to lose weight. These discoveries will upend the current paradigms around weight loss, as soon as we figure out how to pull back the curtain.
As a dual board-certified, interventional obesity medicine specialist, I have witnessed the experience of successful weight loss over and over again – clinically, as part of interventional trials and in my personal life. The road to sustained transformation is not the same in 2018 as it was in 2008, 1998 or 1970. The medical community has identified the barriers to successful weight loss, and we can now address them.
The body fights back
For many years, the diet and fitness industry has supplied folks with an unlimited number of different weight loss programs – seemingly a new solution every month. Most of these programs, on paper, should indeed lead to weight loss. At the same time, the incidence of obesity continues to rise at alarming rates. Why? Because people cannot do the programs.
First, overweight and obese patients do not have the calorie-burning capacity to exercise their way to sustainable weight loss. What's more, the same amount of exercise for an overweight patient is much harder than for those who do not have excess body weight. An obese patient simply cannot exercise enough to lose weight by burning calories.
Second, the body will not let us restrict calories to such a degree that long-term weight loss is realized. The body fights back with survival-based biological responses. When a person limits calories, the body slows baseline metabolism to offset the calorie restriction, because it interprets this situation as a threat to survival. If there is less to eat, we'd better conserve our fat and energy stores so we don't die. At the same time, also in the name of survival, the body sends out surges of hunger hormones that induce food-seeking behavior – creating a real, measurable resistance to this perceived threat of starvation.
Third, the microbiota in our guts are different, such that "a calorie is a calorie" no longer holds true. Different gut microbiota pull different amounts of calories from the same food in different people. So, when our overweight or obese colleague claims that she is sure she could eat the same amount of food as her lean counterpart, and still gain weight – we should believe her.

Strength conditioning builds muscle mass, which can help increase capacity. Credit: Rudd Center for Food Policy and Obesity, CC BY-SA

Lots of shame, little understanding
Importantly, the lean population does not feel the same overwhelming urge to eat and quit exercising as obese patients do when exposed to the same weight loss programs, because they start at a different point.
Over time, this situation has led to stigmatizing and prejudicial fat-shaming, based on lack of knowledge. Those who fat-shame most often have never felt the biological backlash present in overweight and obese folks, and so conclude that those who are unable to follow their programs fail because of some inherent weakness or difference, a classic setup for discrimination.
The truth is, the people failing these weight loss attempts fail because they face a formidable entry barrier related to their disadvantaged starting point. The only way an overweight or obese person can be successful with regard to sustainable weight loss, is to directly address the biological entry barrier which has turned so many back.
Removing the barrier
There are three ways to minimize the barrier. The objective is to attenuate the body's response to new calorie restriction and/or exercise, and thereby even up the starting points.
First, surgeries and interventional procedures work for many obese patients. They help by minimizing the biological barrier that would otherwise obstruct patients who try to lose weight. These procedures alter the hormone levels and metabolism changes that make up the entry barrier. They lead to weight loss by directly addressing and changing the biological response responsible for historical failures. This is critical because it allows us to dispense with the antiquated "mind over matter" approach. These are not "willpower implantation" surgeries, they are metabolic surgeries.
Second, medications play a role. The FDA has approved five new drugs that target the body's hormonal resistance. These medications work by directly attenuating the body's survival response. Also, stopping medications often works to minimize the weight loss barrier. Common medications like antihistamines and antidepressants are often significant contributors to weight gain. Obesity medicine physicians can best advise you on which medications or combinations are contributing to weight gain, or inability to lose weight.
Third, increasing exercise capacity, or the maximum amount of exercise a person can sustain, works. Specifically, it changes the body so that the survival response is lessened. A person can increase capacity by attending to recovery, the time in between exercise bouts. Recovery interventions, such as food supplements and sleep, lead to increasing capacity and decreasing resistance from the body by reorganizing the biological signaling mechanisms – a process known as retrograde neuroplasticity.
Lee Kaplan, director of the Harvard Medical School's Massachusetts Weight Center, captured this last point during a recent lecture by saying, "We need to stop thinking about the Twinkie diet and start thinking about physiology. Exercise alters food preferences toward healthy foods … and healthy muscle trains the fat to burn more calories."
The bottom line is, obese and overweight patients are exceedingly unlikely to be successful with weight loss attempts that utilize mainstream diet and exercise products. These products are generated with the intent to sell, and the marketing efforts behind them are comparable to the well-known distractions generated by the Wizard of Oz. The reality is, the body fights against calorie restriction and new exercise. This resistance from the body can be lessened using medical procedures, by new medications or by increasing one's exercise capacity to a critical point.
Remember, do not start or stop medications on your own. Consult with your doctor first.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

Feeling sad? Here's how to beat the holiday blues

The holiday blues might be a common phenomenon, but there's plenty you can do to protect your mental health this time of year.
Even in a tumultuous year like 2017.
"With its combination of natural and human disasters, this year was especially traumatic for many people," said Dr. Richard Catanzaro, chief of psychiatry at Northern Westchester Hospital in Mount Kisco, N.Y.

28 dec 2017--In addition, "social media can make it seem like everyone you know is having the best time of their lives, while what you're really seeing is everyone's 'greatest hits,' " he said in a hospital news release.
"This adds to the pressure many people feel to have a good time during the holidays. If they are not enjoying themselves, they may feel out of step with everyone else," Catanzaro said.
Along with causing and intensifying depression and anxiety, the holiday season can trigger sadness about relatives and friends who are no longer alive, feelings of exhaustion and stress about money, he noted.
What to do? Catanzaro suggests taking preventive steps.

• "Be mindful about how you are feeling," Catanzaro said. "Holidays can trigger sad memories and may always be tinged with sadness if you have lost a loved one. Even if you are not in the mood to be festive, try to engage in other activities, and spend time with friends."
• At family gatherings, avoid politics and other controversial topics that could stir up negative feelings.
• Try to see people in person or talk to them on the phone, rather than using social media.
• Get enough sleep and eat and drink in moderation.
• "Consider volunteering," Catanzaro said. "Doing something for others who are less fortunate will keep things in perspective and give you a sense of purpose."

If you do feel depressed, don't isolate yourself, Catanzaro said. If you're already seeing a therapist, be sure to continue over the holidays—and if you're not seeing a therapist, consider seeking help.
Also, if you know or suspect you have a condition called Seasonal Affective Disorder (SAD)—a form of depression that occurs in the winter months due to less daylight—there are effective treatments such as light therapy, psychotherapy and medications.

More information: The National Alliance on Mental Illness has more on beating the holiday blues.

Cancer screening burdens elderly patients

Elena Altemus is 89 and has dementia. She often forgets her children's names, and sometimes can't recall whether she lives in Maryland or Italy.
Yet Altemus, who entered a nursing home in November, was screened for breast cancer this summer. "If the screening is not too invasive, why not?" said her daughter, Dorothy Altemus. "I want her to have the best quality of life possible."

27 dec 2017--But a growing number of geriatricians, cancer specialists and health-system analysts say there are many reasons. Such testing in the nation's oldest patients is highly unlikely to detect lethal disease, hugely expensive and more likely to harm than help since any follow-up testing and treatment is often invasive.
And yet such screening is widespread in the United States, the result of medical culture, aggressive awareness campaigns and financial incentives to doctors.
By looking for cancer in people who are unlikely to benefit, "we find something that wasn't going to hurt the patient, and then we hurt the patient," said Dr. Sei Lee, an associate professor of geriatrics at the University of California-San Francisco.
Nearly 1 in 5 women with severe cognitive impairment—including older patients like Elena Altemus—are still get regular mammograms, according to the American Journal of Public Health—even though they're not recommended for people with a limited life expectancy. And 55 percent of older men with a high risk of death over the next decade still get PSA tests for prostate cancer, according to a 2014 study in JAMA Internal Medicine.
Among people in their 70s and 80s, cancer screenings often detect slow-growing tumors that are unlikely to cause problems in patients' lifetimes. Such patients often die of something else long before their cancers would ever have become a threat, said Dr. Deborah Korenstein, chief of general internal medicine at New York's Memorial Sloan Kettering Cancer Center. Prostate cancers, in particular, are often harmless.
Patients with dementia, for example, rarely live longer than a few years.
"It generally takes about 10 years to see benefit from cancer screening, at least in terms of a mortality benefit," Korenstein said.
Enthusiasm for cancer screenings runs high among patients and doctors, both of whom tend to overestimate the benefits but underappreciate the risks, medical research shows.
In some cases, women are being screened for tumors in organs they no longer have. In a study of women over 30, nearly two-thirds who had undergone a hysterectomy got at least one cervical cancer screening, including one-third who had been screened in the past year, according to a 2014 study in JAMA Internal Medicine.
Even some patients with terminal cancer continue to be screened for other malignancies.
Nine percent of women with advanced cancer—including tumors of the lung, colon or pancreas—received mammograms and 6 percent received cervical cancer screening, according to a 2010 study of Medicare recipients over age 65. Among men on Medicare with incurable cancer, 15 percent were screened for prostate cancer.
Although screenings can extend and improve lives for healthy, younger adults, they tend to inflict more harm than good in people who are old and frail, Korenstein said. Testing can lead to anxiety, invasive follow-up procedures and harsh treatments.
"In patients well into their 80s, with other chronic conditions, it's highly unlikely that they will receive any benefit from screening, and more likely that the harms will outweigh the benefits," said Dr. Cary Gross, a professor at the Yale School of Medicine.
By screening patients near the end of life, doctors often detect tumors that don't need to be found and treated. Researchers estimate that up to two-thirds of prostate cancers are overdiagnosed, as are a third of breast tumors.
"Overdiagnosis is serious," Gross said. "It's a tremendous harm that screening has imposed. ... It's something we're only beginning to reckon with."
A variety of medical specialties—from the American College of Surgeons to the Society of General Internal Medicine—have advised doctors against screening patients with limited time to live.. For example, the American Cancer Society recommends prostate and breast cancer screenings only in patients expected to live 10 years or more.
In November, a coalition of patient advocates, employers and others included prostate screenings in men over age 75 in its list of the top five "low-value" medical procedures. Dr. A. Mark Fendrick, co-director of the coalition, referred to the five procedures as "no-brainers," arguing that health plans should consider refusing to pay for them.
Prostate cancer screening in men over 75 cost Medicare at least $145 million a year, according to a 2014 study in the journal Cancer. Mammograms in this age group cost the federal health plan for seniors more than $410 million a year, according to a 2013 study in JAMA Internal Medicine.
And while cancer screenings generally aren't expensive—a mammogram averages about $100—they can begin a series of follow-up tests and treatments that add to the total cost of care.
Most spending on unnecessary medical care stems not from rare, big-ticket items, such as heart surgeries, but cheaper services that are performed much too often, according to an October study in Health Affairs.
Many older patients expect to continue getting screened, said Dr. Mara Schonberg, an associate professor at Harvard Medical School and Boston's Beth Israel Deaconess Medical Center.
"It's jarring for someone who's been told every year to get screened and then at age 75 you tell them to stop," she said.

Experts say these two things are the secret to living a longer life

Costa Rica’s Nicoya Peninsula is home to the second-largest community of centenarians in the world. 

"Blue zones" are areas of the world where people live considerably longer lives. On these territories we can find octogenarians, nonagenarians and many centenarians, and even some supercentenarians (people who have reached the age of 110).
These regions were named "blue zones" after the Belgian demographer Michel Poulain and the Italian doctor Gianni Pes discovered a population with such features in the region of Barbaglia (Sardinia, Italy), and they marked out the area with blue ink

26 dec 2017--A demographic study carried out at the beginning of this century showed that one out of 196 people who were born between 1880 and 1990 reached the age of 100 years old.
Later on, the American researcher Dan Buettner embarked on a project aimed at identifying other areas with high longevity rates. He found four additional regions. These were also named "blue zones": Okinawa (Japan), Icaria (Greece), Loma Linda (California) and Nicoya Peninsula (Costa Rica). In all these territories there is a high proportion of long-lived people, and each area is characterised by specific features which relate to that condition.
In the region of Barbaglia, located in the Sardinian mountain area, there is the world's largest concentration of centenarians. Okinawa Island is inhabited by the oldest women on Earth. Icaria – an island which is located in the Aegean Sea – has the long-lived population with the lowest senile dementia levels. Loma Linda is home to a community of Seventh-day Adventists whose life expectancy is 10 years over the average lifespan in the United States. And in Nicoya we can find the second-largest community of centenarians in the world.
What is the secret behind this great longevity; the mystery of the blue zones, where so many centenarians live?
A team composed of several specialists (doctors, anthropologists, demographers, nutritionists, epidemiologists) – and led by Dan Buettner himself – travelled many times to the different blue zones. They identified the following nine general longevity factors, which are related to diet and lifestyle:

1. intense and regular physical activity in the performance of daily duties. The concept of a sedentary lifestyle is unknown to the people living in these regions
2. having an "ikigai" – a Japanese word (Okinawa) which is used to define our own "reasons for being" or, more precisely, the reasons why we wake up every morning
3. reduction of stress, a factor which is closely linked to almost all ageing-related diseases. Stress reduction means interrupting the normal pace of our daily lives in order to allow time for other activities which are part of normal social habits. For example, taking a nap in Mediterranean societies, praying in the case of Adventists, the tea ceremony of women in Okinawa, and so on.
4. "Hara hachi bu" – a Confucian teaching that means we should not continue to eat until we are full, but only until 80% of our eating capacity
5. prioritising a diet that is rich in plant-based products. Meat, fish and dairy products may be consumed, but in lower amounts
6. a moderate consumption of alcoholic beverages, which confirms the belief that moderate drinkers live longer lives than nondrinkers
7. engaging in social groups that promote healthy habits
8. engaging in religious communities with common religious practices
9. building and maintaining solid relationships between family members: parents, siblings, grandparents and others.

To sum up, the above nine longevity factors could be synthesised in just two.
Firstly, maintaining a healthy lifestyle – which implies regular intensity exercise, including routines to "break" from daily stress, and including mainly plant-based products in our diets, eating without filling up and not drinking excessively.
Secondly, integrating in groups that promote and support those "good practices": family, religious communities, social groups, and so on – all of which must have their own "ikigai", that is, their own "reason to live". There is a personal "ikigai", but there is also a collective "ikigai" that sets the goals for each community as well as the challenges to overcome in order to achieve them.
Living this way means living better and longer. Longevity may be determined by genetics, but it is also something that can be trained, as can be seen in the example of the inhabitants of the blue zones.
Rafael Puyol, Director of the Observatory of Demography and Generational Diversity, IE Business School

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

What psychiatrists have to say about holiday blues

Holiday parties, fun though they may be, can also bring conflict. 

This time of the year brings a lot of changes to the usual day-to-day life of hundreds of millions of people: The weather is colder, trees are naked, snowy days become plentiful and friendly critters are less visible around the neighborhood. Especially in the Western Hemisphere, this time of the year is also linked to a lot of joyous celebrations and traditions. Most children and many adults have been excited for this time of the year to come for months, and they love the aura of celebrations, with their gatherings, gifts, cookies, emails and cards.

24 dec 2017--Alas, there are also millions who have to deal with darker emotions as the world literally darkens around them.
The holiday blues – that feeling of being in a lower or more anxious mood amid the significant change in our environment and the multitude of stressors that the holidays can bring – is a phenomenon that is yet to be researched thoroughly. However, as academic psychiatrists and neuroscience researchers, we have seen how several factors contribute to this experience.
Why feel blue in the red and green season?
There are many reasons to feel stressed or even downright overwhelmed during this time of year, in addition to the expectations set around us.
Memories of holidays past, either fond or sad, can create a sense of loss this time of year. We may find ourselves missing people who are no longer with us, and carrying on the same traditions without them can be a strong reminder of their absence.
The sense of burden or obligation, both socially or financially, can be significant. We can get caught up in the commercial aspects of gift giving, wanting to find that perfect item for family and friends. Many set their sights on special gifts, and we often can feel stretched thin trying to find a balance between making our loved ones happy and keeping our bank accounts from being in the black.
It's also a time for gathering with those close to us, which can stir up many emotions, both good and bad. Some may find themselves away from or without close connections and end up isolated and withdrawn, further disconnected from others. On the other hand, many people find themselves feeling overwhelmed by the combination of potlucks and Secret Santas stacking up through multiple invitations, be it at school, work, or from friends and family – leaving us with the difficult position of not wanting to disappoint others, while not getting totally depleted by all the constant socializing.
Great expectations
People often feel disappointed when reality does not meet expectations. The larger the mismatch, the worse the negative feelings. One of us (Arash) often finds himself telling his patients: Childhood fairy tales can set an unrealistic bar in our minds about life. I wish we were told more real stories, taking the bad with the good, as we would get hurt less when faced with difficult realities of life, and learn how to especially appreciate our good fortunes.
These days viewers are showered with Christmas and New Year's Eve movies, almost all of which sound and feel like fairy tales. People get married, get rich, fall in love or reconnect with their loved ones. Even unhappy events within "A Christmas Carol" conclude with a happy ending. These all, besides exposure to only happy moments and beautiful gifts (courtesy of Santa), dazzling Christmas decorations, and picturesque family scenes on social media, often set an unrealistic expectation for how this time of the year "should" feel.
Reality is different, though, and at its best is not always as colorful. There may be disagreements about hows, wheres, whats and whos of the celebration, and not all family members, friends and relatives get along well at parties. And as we feel lonelier, we may find ourselves spending more time immersed in TV and social media, leading to more exposure to unrealistic views of the holidays and feeling all the worse about our situation.
When is blue a red flag?
While many experience the more transient "holiday blues" this time of year, it is important not to miss more serious conditions like seasonal mood changes, which in its most severe case leads to clinical depression, including Seasonal Affective Disorder. SAD consists of episodes of depression or a worsening of existing depression during the late fall and early winter. The person may feel depressed and hopeless, or they may find it difficult to focus, sleep, or be motivated – they can even feel suicidal. As our emotions can color our thoughts and memories, a depressed person may remember more negative memories, have a more negative perception and interpretation of the events, and feel upset about the holidays.
In such cases, the sadness is "coincident" with the holidays and not caused solely by its circumstances. It is important to seek professional help with SAD, as we have effective treatments available, such as medications and light therapy.
What to do to minimize the blues?

• Set realistic expectations: One readily available strategy is simply reframing the beliefs we have about what the holidays "should" be like. Not all parties will go perfectly. Some decorations may break, or kids may wake up grumpy or not be exhilarated by their gifts – but it doesn't have to stop us from enjoying all the good moments.
• Set firm boundaries: Too many invitations to social events? Too many financial demands? Set clear limits about what you are able and willing to do, whether that means declining some social events and setting your own limit on spending this year, focusing more on meaningful experiences over expense. This can be spending time with loved ones or getting creative with homemade gifts.
• Feeling alone? There are many ways to steer clear of isolating this time of year. Reaching out to friends, volunteering at animal shelters, local charities or attending community meetups or religious events can be a great way to stay connected while also bringing happiness to ourselves and others.
• Making new memories: Starting a new tradition, either solo or with loved ones, can help create fond new memories of the holidays, no longer overshadowed by the past.
• Take care of yourself: It's important to remember the value of self-care, including eating and drinking in moderation (as alcohol can worsen a depressed mood), exercising (even a short walk), and treating yourself this holiday season by doing something you enjoy.

While the holiday blues are most often temporary, it's important to identify when things have crossed over into clinical depression, which is more severe and longer lasting. It also impairs daily functioning. For these symptoms it is often helpful and necessary to seek professional help. This can consist of counseling or use of medications, or both, to help treat symptoms.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

Laser shoes prevent 'freezing' in Parkinson patients

Figure1: laser shoes.

Freezing of gait, an absence of forward progression of the feet despite the intention to walk, is a debilitating symptom of Parkinson's disease. Laser shoes that project a line on the floor to the rhythm of the footsteps help trigger the person to walk. The shoes benefit the wearer significantly, according to research by the University of Twente and Radboud university medical center, which will be published on December 20 in Neurology, the scientific journal of the American Academy of Neurology.

23 dec 2017--Walking problems are common and very disabling in Parkinson's disease. In particular, freezing of gait is a severe symptom which generally develops in more advanced stages. It can last seconds to minutes and is generally triggered by the stress of an unfamiliar environment or when medication wears off. Because the foot remains glued to the floor but the upper body continues moving forward, it can cause the person to lose her balance and fall.

Lines on the floor

Parkinson patient experience a unique phenomenon. By consciously looking at objects on the floor, such as the lines from a zebra crossing ('visual cues'), and stepping over them, they are able to overcome their blockages during walking. This activates other circuits in the brain, hereby releasing the blockages and allowing the person to continue walking. This is why patients often make use of floor tiles at home. With the laser shoes, these useful cues can be continuously applied in everyday life, to walk better and safer. The principle behind the laser shoes is simple: upon foot contact, the left shoe projects a line on the floor in front of the right foot. The patient steps over or towards the line, which activates the laser on the right shoe, and so on (see videos below the text).

Beneficial effect

The present research study shows a beneficial effect in a large group of patients. The number of 'freezing' episodes was reduced by 46% with the use of the shoes. The duration of these episodes was also divided by two. Both effects were strongest in patients while they had not taken their medication yet. This is typically when patients experience the most problems with walking. But an improvement was also seen after the patients had been taking their medication.
"Our tests were administered in a controlled lab setting with and without medication," says researcher Murielle Ferraye. " Further research in their everyday environment is necessary. We plan on testing this using laser shoes that in the meantime came on the market."

Activating the laser

Of the nineteen patients who tested the shoes, the majority would be happy to use them. The patients did not seem to mind that the laser was activated for each single step.  "Ideally, the laser should only be activated once the blockage is detected, but we're not quite there yet," says Ferraye. "Freezing is a very complex phenomenon."
Murielle Ferraye, who developed the laser shoes, conducted her study at the Donders Institute at Radboud university medical center and the MIRA Institute for Biomedical Technology and Technological Medicine at the University of Twente.


Provided by Radboud University

USPSTF reviews use of ECG for preventing A-fib, CVD events

The U.S. Preventive Services Task Force (USPSTF) has found that the current evidence is inadequate to assess the benefits and harms of screening with electrocardiogram (ECG) for atrial fibrillation (AF) in older adults; and for low-risk adults, screening with resting or exercise ECG is not recommended for preventing cardiovascular disease (CVD) events. These findings form the basis of two draft recommendation statements published online Dec. 19 by the USPSTF.

21 dec 2017--Researchers from the USPSTF reviewed the evidence on screening for and the treatment of nonvalvular AF among adults aged 65 years and older. The evidence was inadequate to assess whether screening with ECG identified older adults with previously undiagnosed AF more effectively than usual care. The Task Force found adequate evidence that screening is associated with small-to-moderate harms. Based on these findings, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of AF screening with ECG (I statement).
USPSTF researchers also examined the evidence on screening asymptomatic adults for CVD risk using resting or exercise ECG. The evidence was inadequate to examine whether incremental information offered by resting or exercise ECG can reduce CVD events. However, the Task Force found adequate evidence that screening can lead to small or moderate harms. Based on these findings, the USPSTF concludes that the potential harms of screening are equivalent to or exceed the potential benefits among asymptomatic adults at low risk for CVD events (D recommendation).
The two draft recommendation statements have been posted for public comment. Comments can be submitted through Jan. 22, 2018.

More information:

Evidence Review - A-FIB
Draft Recommendation Statement - A-FIB
Comment on Recommendation Statement - A-FIB
Evidence Review - CVD
Draft Recommendation Statement - CVD
Comment on Recommendation Statement - CVD

Factors affecting the health of older sexual and gender minorities

A special issue of LGBT Health includes the latest research, clinical practice innovations, and policy aimed at addressing disparities and enhancing healthcare for older LGBT populations. A collection of informative and insightful articles that contribute to the understanding of factors that affect the health of older gay, lesbian, bisexual, and transgender Americans is published in LGBT Health.

Guest Editors Judith B. Bradford, PhD and Sean R. Cahill, PhD coordinated this special issue of LGBT Health. Included is an article entitled "Health Indicators for Older Sexual Minorities: National Health Interview Survey, 2013-2014," in which Christina Dragon, MSPH, Centers for Medicare & Medicaid Services (Baltimore, MD) and coauthors from NORC at the University of Chicago (Bethesda, MD), KPMG (McLean, VA), and The Fenway Institute (Boston, MA) explored differences between older sexual minorities and heterosexuals across multiple health indicators. The researchers found better outcomes or health-related behaviors among sexual minorities for some of the indicators, but sexual minorities were more than twice as likely to report binge drinking compared with their heterosexual peers.
Stuart Michaels, PhD, NORC at the University of Chicago, IL and colleagues from NORC and the Centers for Medicare & Medicaid Services coauthored the article entitled "Improving Measures of Sexual and Gender Identity in English and Spanish to Identify LGBT Older Adults in Surveys." They demonstrated that efforts to identify LGBT older adults may be hindered by language-related obstacles among non-LGBT Spanish speakers who might have difficulty understanding terms used to designate sexual identities.
In the article "Transgender Medicare Beneficiaries and Chronic Conditions: Exploring Fee-for-Service Claims Data," a team of authors from the Centers for Medicare & Medicaid Services and NORC at the University of Chicago (Bethesda, MD), led by Christina Dragon, MSPH, report on differences in the chronic conditions burden between transgender and cisgender Medicare beneficiaries. Overall, transgender beneficiaries were found to have a greater burden of chronic conditions, and higher rates of asthma, autism spectrum disorder, chronic obstructive pulmonary disease, depression, hepatitis, HIV, schizophrenia, and substance use disorders compared with cisgender beneficiaries. Transgender Medicare beneficiaries also had higher observed rates of potentially disabling mental health and neurological/chronic pain conditions.
"This special issue of LGBT Health highlights innovations in research, practice, and policy to improve healthcare and services for LGBT older adults. The articles in the issue contribute to our understanding of health disparities and resiliencies in these populations, and suggest ways to improve care and integrate support services to ensure healthy aging," says Guest Editor Sean Cahill, The Fenway Institute. "The timing of this special issue is important, as the federal government is rolling back sexual orientation and gender identity nondiscrimination regulations and data collection. The special issue is dedicated to Judy Bradford, a leader in LGBT aging and LGBT health research, and to her vision of LGBT health and equality."


Provided by Mary Ann Liebert, Inc

Researchers find common psychological traits in group of Italians aged 90 to 101

Study participants and residents of the Cilentro region of southern Italy. 

In remote Italian villages nestled between the Mediterranean Sea and mountains lives a group of several hundred citizens over the age of 90. Researchers at the University of Rome La Sapienza and University of California San Diego School of Medicine have identified common psychological traits in members of this group.

18 dec 2017--The study, publishing in International Psychogeriatrics, found participants who were 90 to 101 years old had worse physical health, but better mental well-being than their younger family members ages 51 to 75.
"There have been a number of studies on very old adults, but they have mostly focused on genetics rather than their mental health or personalities," said Dilip V. Jeste MD, senior author of the study, senior associate dean for the Center of Healthy Aging and Distinguished Professor of Psychiatry and Neurosciences at UC San Diego School of Medicine. "The main themes that emerged from our study, and appear to be the unique features associated with better mental health of this rural population, were positivity, work ethic, stubbornness and a strong bond with family, religion and land."
There were 29 study participants from nine villages in the Cilento region of southern Italy. The researchers used quantitative rating scales for assessing mental and physical health, as well as qualitative interviews to gather personal narratives of the participants, including topics such as migrations, traumatic events and beliefs. Their children or other younger family members were also given the same rating scales and additionally asked to describe their impressions about the personality traits of their older relatives.
"The group's love of their land is a common theme and gives them a purpose in life. Most of them are still working in their homes and on the land. They think, 'This is my life and I'm not going to give it up,'" said Anna Scelzo, first author of the study with the Department of Mental Health and Substance Abuse in Chiavarese, Italy.
Interview responses also suggested that the participants had considerable self-confidence and decision-making skills.

Study participants and residents of the Cilentro region of southern Italy.

"This paradox of aging supports the notion that well-being and wisdom increase with aging even though physical health is failing," said Jeste, also the Estelle and Edgar Levi Chair in Aging and director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego.
Some direct quotes from the study's interviews include:

• "I lost my beloved wife only a month ago and I am very sad for this. We were married for 70 years. I was close to her during all of her illness and I have felt very empty after her loss. But thanks to my sons, I am now recovering and feeling much better. I have four children, ten grandchildren and nine great-grandchildren. I have fought all my life and I am always ready for changes. I think changes bring life and give chances to grow."
• "I am always thinking for the best. There is always a solution in life. This is what my father has taught me: to always face difficulties and hope for the best."
• "I am always active. I do not know what stress is. Life is what it is and must be faced ... always."
• "If I have to say, I feel younger now than when I was young."

"We also found that this group tended to be domineering, stubborn and needed a sense of control, which can be a desirable trait as they are true to their convictions and care less about what others think," said Scelzo. "This tendency to control the environment suggests notable grit that is balanced by a need to adapt to changing circumstances."
The researchers plan to follow the participants with multiple longitudinal assessments and compare biological associations with physical and psychological health.
"Studying the strategies of exceptionally long-lived and lived-well individuals, who not just survive but also thrive and flourish, enhances our understanding of health and functional capacities in all age groups," said Jeste.

More information: International Psychogeriatrics, DOI: 10.1017/S1041610217002721


Provided by University of California - San Diego

ESMO publishes new position paper on supportive and palliative care

ESMO, the leading professional organisation for medical oncology, published a position paper on supportive and palliative care in its leading scientific journal, Annals of Oncology today.

17 dec 2017--Taking stock of new evidence in the field and building on previous ESMO statements and dedicated Clinical Practice Guidelines, ESMO is calling attention to the evolving and growing gap between the needs of cancer patients and the actual provision of patient centred care, from the time of diagnosis, including supportive, palliative, end-of-life and survivorship care.
"New studies in the field of supportive and palliative care show that there may be a gap between what doctors think is important or disturbing for patients, and what patients really need. With this new position paper, we wanted to call attention to the fact that, as well as anti-tumour treatment, cancer patients need physical, psychological, social, and spiritual support, at every stage of the disease, from diagnosis. We refer to this as patient centred care," said Dr Karin Jordan, Department of Medicine V, Haematology, Oncology and Rheumatology, University of Heidelberg, Germany, ESMO Faculty Coordinator for Supportive and Palliative Care, ESMO Clinical Practice Guidelines subject editor for the supportive care section, as well as main author of the paper. Jordan continued: "Patients must 'set the tone' in supportive and palliative care. We need to make it easy for them to tell us how they feel, what they need and, of course, allow them to be fully involved in decision-making if we are to provide optimal patient centred care."
"The concept of patient centred cancer care is described in this paper (encompassing both supportive and palliative care), along with key requisites and areas for further work. We chose this term because we believe in a continuum of care focused on alleviating patients' physical symptoms and psychological concerns," explained Jordan.
Dr Matti Aapro, Cancer Centre, Clinique de Genolier, Switzerland, co-author of the position paper, ESMO Faculty member, Past-president of the Multinational Association of Supportive Care in Cancer (MASCC), said: "Recent studies show that palliative and supportive care not only improves treatment, it also contributes to better use of existing resources, avoids waste and may ultimately also reduce the cost of treatment."
The ESMO Position Paper states that individual cancer patients will express different physical, psychological, social, existential and spiritual needs at different stages of the disease, that will often evolve over time. Therefore, patient centred care cannot be standardised, even though it is provided through a standard framework. To ensure that patients can voice their needs, oncologists should incorporate detailed and routine physical and psychological assessments allowing for supportive and palliative interventions to be personalised and integrated in the continuum of care. Patient reported outcomes (PROs) should be highly encouraged as requesting them has shown to be associated with better quality of life, fewer hospitalisations and even increased survival compared with usual care.
"A cancer diagnosis, the disease itself and the effects of anticancer treatment are major stress factors for patients. Around 14 million people are diagnosed with cancer around the world every year (6)," explained Jordan. "Over the last decade clinicians have accepted that, while survival and disease-free survival are both fundamental factors, overall quality of life is also crucial for patients."
"Patient centred interventions should be routinely discussed and evaluated by the multidisciplinary team (supervised by the oncologist) together with tumour directed treatment," said Jordan. "Of course, patient preferences and cultural specificities should be respected."
"We hope that this paper will contribute to develop a generalised culture and acceptance of supportive and palliative care, worldwide," said Aapro. "Basic patient needs such as pain relief are still not being widely met (7). Education is vital to make sure that essential supportive care is accessible to all cancer patients, everywhere. Quoting Dorothy Keefe, past MASCC president, I would say: 'supportive care makes excellent cancer care possible'."
"ESMO is committed to increasing awareness and education to bring patient centred care closer to all professionals; to improving collaboration between healthcare providers for the good of patients; and to promoting research, so that patient centred interventions are not only integrated, but also based on the best evidence," said Andrés Cervantes, Chair of the ESMO Educational Committee.
"Despite growing awareness of the need to develop patient centred care and recent progress in the field, more and better scientific evidence is required so that effective interventions can be proposed to cancer patients at each stage of their illness," said Jordan.
"This paper is important because it takes ESMO's long standing interest in supportive and palliative care - shown, for example in its Designated Centres of Integrated Oncology and Palliative Care accreditation programme (8) - a step further. Developments since the last ESMO position statement in supportive and palliative care in 2003 show that, not only do these interventions improve patient's quality of life (QoL), but also overall outcomes."
"ESMO appeals to health authorities in Europe and beyond to ensure that cancer patients have equal access to the best possible patient centred cancer care that resources allow," concludes Jordan. "This is a medical and ethical imperative."
The ESMO position paper includes chapters on:

• Key patient centred care interventions
• End of life care
• Need for specific training in patient centred care
• The role of multidisciplinary teams
• Integrating healthcare resources
• Research needs and resources in supportive and palliative care

More information: K Jordan et al, European Society for Medical Oncology (ESMO) position paper on supportive and palliative care, Annals of Oncology (2017). DOI: 10.1093/annonc/mdx757
N. I. Cherny. ESMO takes a stand on supportive and palliative care, Annals of Oncology (2003). DOI: 10.1093/annonc/mdg379


Provided by European Society for Medical Oncology

LDL cholesterol found to be the main modifiable predictor of atherosclerosis in individuals with no risk factor

Cholesterol plaque in a carotid artery, visualized by vascular magnetic resonance imaging.

LDL cholesterol (LDL-C), known as 'bad' cholesterol, is the underlying reason why many apparently healthy individuals have heart attacks or strokes during middle age despite not having cardiovascular risk factors such as hypertension, smoking, obesity, dyslipidemia or diabetes. Even at levels considered normal, LDL-C, after age and male sex, is the main predictor of the presence of atherosclerotic plaques in the arteries.

16 dec 2017--This is the finding of research conducted at the Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC) and published today in the Journal of the American College of Cardiology (JACC). The results of the new study, led by CNIC Director Dr. Valentín Fuster, support the use of more aggressive strategies to reduce LDL-C, including for individuals considered at minimum risk. Fortunately, LDL-C is the main risk factor that can be modified in order to avoid the appearance of atherosclerotic plaques.
As study first author Dr. Leticia Fernández-Friera explained, "Although the absence of classical cardiovascular risk factors is linked to a low risk of cardiovascular events, people in this situation still have heart attacks and strokes. We therefore need to define new markers of early atherosclerosis in these apparently healthy individuals."
This subanalysis of the PESA study (Progression of Early Subclinical Atherosclerosis) evaluated 1779 study participants who had no classical risk factors. The main goal of the study was to define predictors of subclinical atherosclerosis in this population. The research team evaluated the association of a battery of biometric, analytical, and lifestyle parameters with the presence of atherosclerotic plaques. The results demonstrate that, after age and male sex, the most prominent association is shown by LDL-C. Study author Dr. Javier Sanz commented that "even in people with optimal blood pressure, blood sugar, and total cholesterol, we detected an independent association between the level of circulating LDL-C and the presence and extent of subclinical atherosclerosis."

Calcium deposits (white) in the coronary arteries.

Cardiovascular prevention

The JACC study shows a relationship between LDL-C levels that are considered healthy in current clinical guidelines and the extent of atherosclerosis in multiple vascular territories: the aorta and the carotid, iliofemoral, and coronary arteries. Using the latest noninvasive vascular imaging technology, the study demonstrates that "atherosclerotic plaques are present in 50 percent of middle-aged individuals (40-54 years old) with no classical cardiovascular risk factors: non-smokers with no hypertension, diabetes mellitus, or dyslipidemia. These findings could help to improve cardiovascular prevention in the general population even before the appearance of conventional risk factors, an example of primordial prevention," explained Dr. Leticia Fernandez-Friera.
Cardiovascular disease is the principal cause of death in the world, and the worldwide high prevalence of cardiovascular diseases makes the development of effective prevention strategies a major health care priority. Current guidelines from the US National Cholesterol Education Program categorize LDL-C levels above 160 mg/dL as high and levels from 130 mg/dL 159 mg/dL as borderline high. The research team on the JACC article believe that the new findings will have important societal and clinical implications because they demonstrate the importance of aggressively reducing LDL-C, both on an individual level and in the general population. Drs. Valentín Fuster and Borja Ibañez affirm that "we should be more restrictive, and consider lowering the threshold values stipulated in the guidelines." The new results point the way to defining new lower levels of normal LDL-C.
This ambitious project was made possible through the shared commitment of the CNIC and Banco Santander and the leadership of principal investigator Dr. Fuster. The PESA study uses the latest noninvasive vascular imaging technology (magnetic resonance, PET, CT, and 2D and 3D ultrasound) in an attempt to answer important unresolved questions about cardiovascular disease: when and how it begins and what has to happen for it to manifest clinically. As study author Dr. Antonio Fernández-Ortiz explained, "Thanks to vascular ultrasound, we can directly visualize the presence of cholesterol plaques in the carotid arteries, the aorta, and the iliofemoral arteries; and with computed tomography, we can detect calcification in the coronary arteries. With these approaches, we are able to evaluate the progress of the disease in an individual."
Normally, atherosclerosis is detected at an advanced stage, after it has provoked clinical events such as a heart attack, stroke, or another condition. Treatment options after the event are limited, and affected patients experience a permanent decline in quality of life. Moreover, the long term care of these patients places a major cost burden on health care systems. Drs. Fuster and Sanz conclude that "the ability to identify patients with the disease before the appearance of symptoms could help to avoid or reduce the associated complications and translate into an enormous societal and economic benefit. The major impact of the PESA project will felt over the long term, 15 or 20 years after its launch. At that stage, we will be able to relate the initial study findings to participants' clinical progress."


Provided by Centro Nacional de Investigaciones Cardiovasculares

Postmenopausal women should still steer clear of HRT: task force

Yet again, the nation's leading authority on preventive medicine says postmenopausal women should avoid hormone replacement therapy (HRT).
The U.S. Preventive Services Task Force is standing by its original recommendation that women who have already gone through menopause should avoid using female hormones to guard against osteoporosis or diabetes, said task force chairman Dr. David Grossman, a senior investigator at the Kaiser Permanente Washington Health Research Institute in Seattle.

15 dec 2017--"Basically, the task force concluded there was no overall benefit from taking hormones to prevent chronic conditions," Grossman said. "There are some benefits, but we believe those potential benefits are outweighed by the harms, making this essentially no net benefit overall."
The advisory covers all formulations of hormone replacement therapy, the task force said. The therapy can consist of pills or patches containing either estrogen or an estrogen/progesterone mix.
However, women undergoing menopause can use hormone replacement therapy short-term to treat symptoms such as hot flashes and vaginal dryness, said Dr. Suzanne Fenske, an assistant professor of obstetrics, gynecology and reproductive science with the Icahn School of Medicine at Mount Sinai in New York City.
"Hormone replacement therapy does still have a benefit to women with menopause whose symptoms do not respond to other treatment options," Fenske said. "It really should be used to manage menopausal symptoms, rather than being used for any sort of preventative medicine."
The task force first recommended against hormone replacement therapy for postmenopausal women in 2012. It updates its recommendations every four years to make sure they reflect the latest medical evidence.
In its evidence review, the task force considered results from 18 clinical trials including more than 40,000 women.
All of the evidence suggests that combined estrogen and progesterone increase older women's risk of breast cancer and heart disease, while estrogen alone increases risk of stroke, blood clots and gallbladder disease, the task force said.
Those risks outweigh hormone therapy's benefits in preventing brittle bones and diabetes, the task force concluded.
"When hormone replacement therapy first was brought out on the market in the 1960s, it was touted as a way to keep feminine forever," Fenske said. "Then in the 1980s they began to see there were some potential benefits otherwise, like [preventing] osteoporosis.
"Then the infamous and famous Women's Health Initiative [WHI] study came out, which kind of put the kibosh on hormone replacement therapy," Fenske added.
Results from the WHI trials were published in the early 2000s; the trials were halted early after linking hormone therapy with increased risk of breast cancer, heart disease and stroke.
The updated task force recommendation contains the latest long-term follow-up data from the WHI trials, Grossman said.
"It didn't change our conclusion, but there is new information available that we incorporated into our evidence review," Grossman said.
Dr. Stephanie Faubion, director of the Mayo Clinic Office of Women's Health in Rochester, Minn., took issue with the task force's recommendation.
"I think this report is going to scare women," Faubion said. "Even those who are having symptoms and not excluded from hormone therapy according to this guideline are going to avoid it because they're afraid of it."
For example, the guideline does not apply to women who go through menopause early or prematurely, at age 45 or younger, Faubion said.
"Those women actually have adverse health consequences if they don't use hormone therapy at least until the natural age of menopause," Faubion said.
She said she also takes issue with a blanket recommendation covering all age groups.
"This is a key issue," Faubion said. "If you do break it down by age, there are more clear benefits for women in their 50s than women in their 60s and 70s.
"The task force is trying to make this more black-and-white than it can ever be," Faubion concluded.
Fenske said women in menopause suffering from hot flashes, vaginal dryness and other related symptoms can still safely turn to hormone therapy to ease their discomfort.
There are no clear guidelines for how long a menopausal woman can remain on hormone replacement therapy, or what dose is best for treating menopause symptoms, Fenske said. In large part, doctors are urged to be cautious because of the long-term health risks.
"It should be the smallest dose possible for the shortest period of time necessary," Fenske said.
Women interested in using hormone therapy to treat their menopause symptoms should talk with their doctor, because there is a lot of false and misleading information out there, Fenske said.
The task force recommendation was published online Dec. 12 in the Journal of the American Medical Association.

More information: David Grossman, M.D., M.P.H., pediatrician and senior investigator, Kaiser Permanente Washington Health Research Institute, Seattle; Suzanne Fenske, M.D., assistant professor, obstetrics, gynecology and reproductive science, Icahn School of Medicine at Mount Sinai, New York City; Stephanie Faubion, M.D., director, Mayo Clinic Office of Women's Health, Rochester, Minn.; Dec. 12, 2017, Journal of the American Medical Association

Recommendation Statement
Evidence Report
Editorial 1
Editorial 2
Editorial 3

For more on hormone replacement therapy, visit the American Congress of Obstetricians and Gynecologists.

Holiday treats, hectic schedules may increase risk of heart attack

Between the ubiquitous goody trays, unending to-do lists and stressful travel itineraries, it can be tough to stay on track when it comes to health during the holiday season, whether it's sticking to a diet or maintaining an exercise regimen.

11 dec 2017--Such holiday-fueled pressures may also contribute to the fact that the holidays are also the most dangerous time of year for heart attacks.

Research shows deaths from heart attacks peak during December and January, possibly due to changes in diet and alcohol consumption, stress from family interactions, strained finances, travel and entertaining, and respiratory problems from burning wood.
"We tend to exercise less and eat more during the holidays," said John Osborne, M.D., Ph.D., a Dallas-area preventive cardiologist. "It's a very stressful time. There's a lot of emotion attached to the holidays and that can be another factor to why we have more cardiovascular events."
As the holidays upend routines, taking medications as prescribed can also get lost in the shuffle, Osborne said.
"I can't tell you how often I get calls from patients who have traveled somewhere and forgot their medications," he said, adding that he worries more about the patients who don't contact him. "Some people figure they'll be fine to be off them for a week or so, but if you start missing medications, that can have a big impact on causing your blood pressure to be out of control."
For those who have already had a heart attack, the heightened risk during the holidays is particularly dangerous. That's because about one in five heart attack survivors age 45 and older will have another heart attack within five years.
Being with family during the holidays is a good time for patients to talk about their health history—not just heart attacks, but also high blood pressure and high cholesterol, experts say.
"We can dramatically lower the risk of cardiovascular events with lifestyle changes, but don't ignore your family history," Osborne said. "Genetics can catch up to you, even if you're doing all the right stuff."
Heart disease can be prevented in many cases through lifestyle factors, such as maintaining a healthy weight, exercising regularly, controlling cholesterol and blood pressure and not smoking, but "making lifestyle changes can be difficult," Osborne said.
"I admit to my patients that I don't love to exercise, but I really feel great having exercised," he said. "Getting that motivation can be painful, but it's fantastic when you get to the other side."
Osborne said tools such as mobile apps can provide education and electronic reminders to help people stay focused on heart health.
"I have a very brief period with patients," he said. "Tools like apps can encourage good health behaviors, being that gentle in-your-face technology."

More information: D. P. Phillips. Cardiac Mortality Is Higher Around Christmas and New Year's Than at Any Other Time: The Holidays as a Risk Factor for Death, Circulation (2004). DOI: 10.1161/01.CIR.0000151424.02045.F7


Provided by American Heart Association

How to talk to your doctor about information you find online

More and more people are going online to search for information about their health. Though it can be a minefield, where unverified sources abound, searching the internet can help people to understand different health problems, and give them access to emotional and social support.

10 dec 2017--For many in the UK, getting to actually see a GP remains difficult, and constraints around appointment times mean that some discussions are often cut short. But by using the internet, patients can prepare for appointments, or follow up on issues that were raised in the consulting room but left them with unanswered questions.
But not everyone is so keen on patients using the internet in this way. Some GPs and other heath professionals have doubts about the quality and usefulness of the information available. There are also suggestions that "cyberchrondria" may be fuelling a surge in unnecessary tests and appointments.
Similarly, though so many people are using online resources to fill in gaps in their knowledge, or to help them ask the right questions, they may not be comfortable bringing it up in the consulting room.
For our latest research project, we wanted to find out just why it can be so difficult to discuss online information with doctors. We found that in addition to people being embarrassed in case they have misunderstood the information, or can't remember it accurately, they also fear a negative reaction from the GP who may think they are difficult or challenging.

How to make it work

So how can you as a patient bring up online information with your doctor? First, it sounds obvious but you need a good, open relationship with your GP. Tell them you have been looking online, but ask for their feedback on the information, and for any useful sites they know of. We found that patients with a good doctor relationship felt able to discuss information and ideas from websites and online forums in a considered and critical manner.
Importantly, it is not about the patient trying to be the doctor. Ideally, patients should bring along their information, use it to help explain their key concerns, or detail the options they've explored, but also make clear that they still want and value their GP's input on their findings.
Some of the patients we spoke to told us that they are acutely aware of their doctor's negative feelings towards the internet. In these situations, people are sometimes tempted to disguise the source of their information. Rather than openly discussing their findings from the internet, they may pretend they got the information elsewhere when mentioning it to their doctor or be very careful not to reveal its origin at all.
For some people we spoke to, the process of trying to integrate the results of their web searches into their communications with the GP was frustrating to say the least. They felt uncomfortable, embarrassed, and sometimes held back key information. This made for unproductive meetings which were felt to be a waste of time.
This process can definitely be improved. As more appointments are going to be conducted over smartphone rather than face to face, and some GPs have admitted using Wikipedia to diagnose patients, the rest of the process needs to catch up with technology.
There needs to be a new and more productive way to integrate online information into doctor-patient discussions. First of all, there should be better ways for patients to collect and organise accurate information online so that they can organise their thoughts and prepare for a visit.
In the consulting room itself, GPs should use the research as an opportunity to have more productive discussions, and use it as a way to teach patients more about their own health issues. They need to question the information source, message and credibility, but GPs could also use it as an opportunity to nudge patients to think about their health options and consider what's important to them.
Just as a GP is not solely responsible for the health of a patient, neither is the patient themselves. Internet research can no longer be dismissed. Even if inaccurate, it can help build a better relationship between patient and doctor, and give them both a better understanding of managing health in the modern world.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

Is prescribing drugs 'off label' bad medicine?

A woman, let's call her Sarah, is a young actor looking to make her debut at a major theatre. She is fit and healthy, but gets nervous on opening nights and can't sleep. She's tried zopiclone, but it didn't work, so her GP prescribes a course of quetiapine. Quetiapine is usually used to treat bipolar disorder, but the doctor explains to Sarah that he is prescribing it "off label". In other words, for a condition the drug wasn't licensed to treat.

09 dec 2017--There are legitimate reason for prescribing off label – although, there are also legitimate criticisms of the practice.
In the UK, doctors, dentists, optometrists and other prescribers are discouraged from prescribing drugs off-label when a licensed alternative is available. But off-label prescribing is done, with caution, for several reasons.
First, each prescription drug has a product licence, that is, the company that makes it had to submit a mountain of evidence to the regulator proving not only that the drug is effective, but it is safe.
Second, the prescriber and the dispensing pharmacist are legally liable when things go wrong, so the patient can sue.
Finally, sometimes there are no alternative drugs for a given health problem. For example, in Sarah's case, quetiapine is not licensed to treat insomnia. However, she has tried all available drugs licensed to treat insomnia, and none of them have worked.

The right to say 'no thanks'

Drugs are prescribed off label based on limited evidence. Sometimes, doctors have to build the evidence as they use each medicine off label and learn from their experience – what works for a given condition and what doesn't. Published case studies can also provide clues about what other uses a drug might be useful for. Case studies, though, are at the bottom of the hierarchy of medical evidence.
GPs and other prescribers have to make decisions based on the available evidence, which may not be very much. Sometimes it's based on little more than an educated guess.
In Sarah's case, the doctor feels that quetiapine might help. If the drug doesn't work for her, she'll have to come back to see him, and perhaps try a different drug – also off label.
This highlights another problem, though. Some patients – especially the elderly – take their doctor's advice as gospel and follow it regardless of how a drug makes them feel. As a result, they can end up taking pills that aren't effective and may even have unpleasant side effects.
In this example, Sarah should go back to her GP if she is concerned and she has the right not to take medicine that she doesn't want to.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

New clinician resource available explains biological impact of aging on immunity

The American College of Physicians (ACP), the American Pharmacists Association (APhA), and The Gerontological Society of America (GSA), representing 220,000 clinicians, today released "Aging and Immunity: The Important Role of Vaccines", a new resource highlighting the biological impact of aging on immunity.

08 dec 2017--Developed with support by GSK, the guidebook is designed to help health care professionals understand the biological impact of aging on immunity and reinforce the importance of adult immunization, especially for vaccine-preventable diseases such as shingles, pneumonia, and influenza. The guidebook also offers practical tips and strategies for supporting aging patients' health and overcoming barriers to vaccination.

Age-related decline in immunity

"As we age, our immune system declines, making older adults more susceptible to serious conditions," said Jack Ende, MD, MACP, President, ACP. "Understanding the aging immune system is becoming increasingly important for clinicians because vaccination is an effective solution to overcoming some of this age-related decline in immunity."
Research has shown that one of the most important things health care professionals can do to support aging patients is to provide a strong recommendation for them to be vaccinated.
"At every opportunity, clinicians should recommend vaccination according to the schedule from the Advisory Committee on Immunization Practices, have a program that supports vaccine administration, or refer patients to a health care professional who administers vaccines, and document administration of vaccines," said Kelly Goode, PharmD, BCPS, FAPhA, Board of Trustees Member and Immediate Past President, APhA.

As individuals age, the chances of getting shingles increases

"Aging and Immunity" details how cell-mediated immunity deteriorates as a person ages. For instance, in people who had chickenpox as children, deteriorating cell-mediated immunity is considered a factor for why latent varicella zoster virus commonly becomes reactivated in older adults, causing shingles. About one million cases of shingles are diagnosed in the United States every year. Shingles occurs in one in every three people in the United States, mostly adults over the age of 50. For those who live to age 85, one in every two people will contract shingles. The painful condition occurs in people who are healthy as well as people with chronic diseases or immunosuppression. Vaccination is an important way of reducing risk of getting shingles and its complications, like postherpetic neuralgia (PHN) and necessity of prescribing pain relievers.
"Shingles is an example of a disease that afflicts one million adults every year and costs the economy $1 billion in health care expenses. It especially impacts older adults as a direct result of age-related decline in immunity," said James Appleby, BSPharm, MPH, Executive Director and CEO, GSA. "Shingles can affect anyone who carries the varicella zoster virus, and virtually all adults do, whether they had chickenpox during their childhood or not."

Addressing barriers to vaccination

"Aging and Immunity" explains barriers to vaccination at the patient and practice levels and offers recommendations about how clinicians can overcome them. Strategies to improve vaccination rates include using standing orders, collaborating with other health care team members, identifying a staff vaccine champion in the practice, adding reminders to charts, and counseling patients about recommended vaccines.
"We recognize the critical role health care professionals play in educating patients about vaccine-preventable diseases," said Barbara Howe, M.D., Vice President and Director, North American Vaccine Development, GSK. "Our collaboration with ACP, APhA, and GSA reinforces our commitment to educating health care professionals and patients about the importance of vaccination throughout an individual's life.
"
More information: www.acponline.org/system/files … d_immunity_guide.pdf


Provided by American College of Physicians

New easy-to-use tool can help determine Alzheimer's risk, similar to pediatric growth curves

A simple new tool that tracks cognitive performance in adults aims to help physicians identify people who may be on the path to Alzheimer disease or another form of dementia. The tool, called the QuoCo (cognitive quotient), is published in CMAJ (Canadian Medical Association Journal).

06 dec 2017--"Similar to 'growth charts' used in pediatrics, the QuoCo cognitive charts allow physicians to plot cognitive performance of any patient based on age, education and score on the Mini-Mental State Examination, and track cognitive change over time," says Dr. Robert Laforce Jr., Université Laval and CHU de Québec-Université Laval. "This would allow physicians to intervene and potentially treat an older adult who 'fell off' the curve."
Dementia is a growing problem world-wide with many undiagnosed cases. Although there are no cures, potential treatments are being tested and some risk factors, such as diet and exercise, can be addressed to delay onset.
The authors hope that the QuoCo tool will be used by health care professionals, especially family physicians, to monitor cognitive decline in patients before irreversible damage occurs.
"Dementing illnesses have reached pandemic levels," write the authors. "Early detection of cognitive impairment remains our best approach to disease management before irreversible brain damage occurs. Family physicians are in a key position to contribute to this approach; however, they are ill-equipped."
The authors note that the Mini-Mental State Examination is an imperfect screening measure and has its own limitations, although it is used internationally clinically and in research on dementia and cognitive decline.
In a related commentary, Dr. Andrew Costa, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, writes "the widespread benefits derived from cognitive charts for any screening examination rests on the assumption that at-risk patients are being screened systematically over time and that cognitive test results are communicated, or can be readily referenced by, physicians. We seem to be some distance away from that reality."
He notes that the success of any innovation rests upon training health care professionals to use these tools in clinical practice properly.

More information: Canadian Medical Association 
Journal (2017). www.cmaj.ca/lookup/doi/10.1503/cmaj.160792


Provided by Canadian Medical Association Journal

Lack of communication puts older adults at risk of clashes between their medicines

Key results from the National Poll on Healthy Aging. 

Most older Americans take multiple medicines every day. But a new poll suggests they don't get - or seek - enough help to make sure those medicines actually mix safely.
That lack of communication could be putting older adults at risk of health problems from interactions between their drugs, and between their prescription drugs and other substances such as over-the-counter medicines, supplements, food and alcohol.

03 dec 2017--The new results, from the National Poll on Healthy Aging, show that only about one in three older Americans who take at least one prescription drug have talked to anyone about possible drug interactions in the past two years.
Even among those taking six or more different medicines, only 44 percent had talked to someone about possible drug interactions.
The results come from a nationally representative sample of 1,690 Americans between the ages of 50 and 80. The poll was conducted by the University of Michigan Institute for Healthcare Policy and Innovation, and sponsored by AARP and Michigan Medicine, U-M's academic medical center.

Disjointed sources of care

Part of the reason for lack of communication about drug interactions may lie in how older Americans get their health care and their medicines. One in five poll respondents said they have used more than one pharmacy in the past two years, including both retail and mail-order pharmacies. Three in five see multiple doctors for their care.
And even though 63 percent said their doctor and pharmacist are equally responsible for spotting and talking about possible drug interactions, only 36 percent said their pharmacist definitely knew about all the medications they're taking when they fill a prescription.
"Interactions between drugs, and other substances, can put older people at a real risk of everything from low blood sugar to kidney damage and accidents caused by sleepiness," says Preeti Malani, M.D., the director of the poll and a professor of internal medicine at the U-M Medical School.
"At the very least, a drug interaction could keep their medicine from absorbing properly," she adds. "It's important for anyone who takes medications to talk with a health care professional about these possibilities."
Malani notes that although 90 percent of poll respondents said they were confident that they knew how to avoid drug interactions, only 21 percent were very confident.
Given the wide range of prescription and over-the-counter drugs on the market, and the number of drugs that interact with supplements, alcohol and certain foods, Malani says it's hard for even medical professionals to catch all potential interactions.
Newer medical computer systems that flag patients' records for potential interactions automatically, based on the names of their drugs, are helping, Malani says.
Also helpful is Medicare coverage for prescription drug reviews, called Medication Therapy Management, for people who take medicines for multiple chronic conditions. But not all medical computer systems talk to one another, and an MTM must be approved by the patient's Medicare prescription drug benefit provider.
"Even with trackers and systems in place, patients need to be open with their providers and tell them all the medications and supplements they're taking, including herbal remedies," says Alison Bryant, Ph.D., senior vice president of research for AARP. "It's especially important for older adults to be vigilant about this because they tend to take multiple medications."
AARP has put together a free online drug interaction tracker that can identify potential risks. It's available at http://healthtools.aarp.org/drug-interactions, but should be used in conjunction with a patient's conversations with their health care providers and pharmacists.

Recommendations for patients and providers

Malani and her colleagues say that it is up to patients, pharmacists and doctors alike to reduce drug interaction risks.
Patents should write down the names and dosages of their prescription medicines, and of any supplements and over-the-counter drugs they take, and bring it all to their doctors' appointments or pharmacies, she says. It is also important to be truthful about alcohol consumption when asked, since alcohol use can affect many medications. And patients shouldn't just stop taking a medicine if they think they're experiencing a side effect - they should also call their doctor's office or speak with a pharmacist first.
Meanwhile, health care providers should ask patients more about what medicines and supplements they take, and counsel patients at risk of side effects using language they can understand.
The poll results are based on answers from those who said they took at least one prescription drug, among a nationally representative sample of about 2,000 people ages 50 to 80. The poll respondents answered a wide range of questions online. Questions were written, and data interpreted and compiled, by the IHPI team. Laptops and Internet access were provided to poll respondents who did not already have it.


Provided by University of Michigan

Dual virtual reality/treadmill exercises promote brain plasticity in Parkinson's patients

A new Tel Aviv University study suggests that a therapy that combines Virtual Reality and treadmill exercise dramatically lowers the incidence of falling among Parkinson's patients by changing the brain's behavior and promoting beneficial brain plasticity, even in patients with neurodegenerative disease.

02 dec 2017--Patients with Parkinson's disease experience gradual neuronal loss, leading to cognitive and motor impairments that damage their ability to walk and cause debilitating, often fatal, falls. The new study shows that fall rates are reduced in response to treadmilltraining with Virtual Reality. The number of neurons activated in the pre-frontal cortex is also reduced in response to the same combination. This reduction likely reflects enhancements in motor control and greater automaticity of cognitively demanding tasks.
The research underlines the importance of combining cognitive rehabilitation with the motor rehabilitation of Parkinson's disease patients.
The study was conducted by Prof. Jeff Hausdorff of TAU's Sackler School of Medicine and Tel Aviv Medical Center along with colleagues Dr. Inbal Maidan of Tel Aviv Medical Center and Dr. Anat Mirelman and Prof. Nir Giladi, both of TAU's Sackler School of Medicine and Tel Aviv Medical Center. The findings were recently published in the journal Neurology.
"In previous research, we showed that patients with Parkinson's disease use cognitive function, which is reflected in activation of the pre-frontal cortex of the brain, to compensate for impaired motor function," Prof. Hausdorff says. "We also showed that a specific form of exercise targeting the cognitive control of gait—combined treadmill training with a Virtual Reality representation of obstacles in a path—leads to a significantly lower fall rate in Parkinson's patients.
"The Virtual Reality gait program, in which patients must avoid obstacles, enhances the patient's cognitive performance and thus reduces the requirement for prefrontal brain activity," Prof. Hausdorff continues.
Seventeen subjects in two groups, one which combined treadmill training with Virtual Reality and one which used treadmill training alone, underwent a six-week intervention, exercising three times a week for about an hour each time. The Virtual Reality group played a "game" in which they viewed their feet walking in a city or park environment. Through the game, they implicitly learned how to deal with obstacles in the virtual environment, how to plan ahead and how to do two things at once—that is, address cognitive challenges related to safe ambulation.
The other group just walked on a treadmill without the VR components or cognitive challenges. Before and after the subjects participated in the exercise programs, the researchers used functional MRI imagery to evaluate the patients' brain activation patterns.
"The study's findings reinforce the hypothesis that training improves motor and cognitive performance through improved neuroplasticity—more so than that seen with treadmill training alone," Prof. Hausdorff explains. "Interestingly, the benefits of treadmill training with VR were specifically seen during walking conditions that require cognitive input (i.e., obstacle negotiation and dual tasking), conditions associated with falls in everyday environments. In these conditions, fewer neurons were needed after training with VR, while no change was seen in the group that trained by walking on a treadmill without VR."
Previous research conducted on mouse models of Parkinson's disease suggested the importance of task-specific exercises on the brain. However, the new TAU study is the first to show such findings in people with Parkinson's disease.
"Exercise that focuses on motor components promotes plasticity in brain areas associated with sensory-motor integration and coordination," Prof. Hausdorff says. "But exercise incorporating cognitive components also stimulates changes in brain regions related to cognition. It may therefore have a greater impact on compensatory brain function and the cognitive functions related to safe ambulation (i.e., walking without falling)."
"The takeaway here is that even relatively late in the disease, when 60-80 percent of dopaminergic neurons have died, there is still an opportunity to promote plasticity in the brain," Prof. Hausdorff concludes. "Moreover, to induce specific brain changes, exercise should be personalized and targeted to a specific clinical problem."


Provided by Tel Aviv University