Loss of Protective Barrier May Link DCIS to Invasive Breast Cancer
By Charles Bankhead
BOSTON, 06 may 2008-- Ductal carcinoma in situ progresses to invasive breast cancer because of the loss of a protective cellular barrier, leading to fibroblast-induced disintegration of milk duct walls, investigators here reported.
The findings provided insight into the mechanism of how DCIS transitions into invasive cancer. Molecular profiling studies comparing DCIS and invasive cancer have failed to explain the transformation the authors said.
"These findings made it clear that fibroblasts promote tumor growth and invasion and normal myoepithelial cells suppress it," said Dr. Polyak.
Myoepithelial cells inhibit tumor cell growth, invasion, and angiogenesis. During the progression of DCIS to invasive cancer, the inhibitory activity dissipates before disappearing altogether, Dr. Polyak and colleagues said.
To examine the effect of tumor microenvironment on disease progression, the investigators used the DCIS model MCFDCIS, which spontaneously progresses from a DCIS-like state to invasive cancer. They conducted a series of experiments wherein MCFDCIS was introduced into mice, along with either myoepithelial cells or fibroblasts.
When MCFDCIS was injected with myoepithelial cells, DCIS-like lesions arose, but the lesions were confined to the milk ducts. Repeating the experiments with MCFDCIS and fibroblasts, the investigators found that the resulting tumors invaded the walls of the ducts and subsequently escaped into surrounding tissue.
Additional studies focused on gene expression and signaling associated with progression from DCIS to invasive cancer. The observed abnormal activity in several myoepithelial-cell genes, including tumor growth factor-beta, Hedgehog, p63, and several genes involved in myoepithelial-cell adhesion to basement cells on milk ducts' exterior wall.
"We found a constant, complex interplay of signals among these genes, both within myoepithelial cells themselves, and between myoepithelial cells and their neighbors," said Dr. Polyak. "The presence of DCIS causes the pattern of signals to change significantly, upsetting the normal development of myoepithelial cells."
The findings suggest the possibility that examining myoepithelial tissue for genetic abnormalities could identify patients with the greatest risk of progression from DCIS to invasive breast cancer, she added.
Dr. Polyak reported no disclosures.
Primary source: Cancer CellSource reference:Hu Min, et al "Regulation of in situ to invasive breast carcinoma transition"Cancer Cell. 2008; 13: DOI: 10.1016/j.ccr.2008.03.007.Additional Breast Cancer Coverage
Wednesday, May 07, 2008
Pandemic flu threat remains substantial, health experts say
By ELIANE ENGELER
06 may 2008--The world still faces a substantial threat of a flu pandemic and countries need to speed up preparations for a global outbreak, health experts said Tuesday.
"We can't delude ourselves. The threat of a pandemic influenza has not diminished," said Keiji Fukuda, coordinator for the World Health Organization's Global Influenza Program.
Fukuda spoke to a meeting of around 150 health experts from governments, WHO and other agencies to update WHO's pandemic influenza preparedness plan.
Scientists fear that the H5N1 strain of bird flu virus — which began ravaging Asian poultry stocks in late 2003 — could mutate into a form that spreads easily among humans, potentially sparking a pandemic that kills millions. So far, most human cases have been linked to contact with infected birds.
Fukuda said more than 150 countries had some kind of national preparedness plans but some of them were merely a piece of paper acknowledging the risk.
He said it was crucial that all levels of society were involved in the preparations and that everyone knows where to go for information.
"If somebody is sick in the family for example and it's difficult to get to hospital, they need to know what sort of advice might be available," Fukuda told The Associated Press.
WHO says 382 people have come down with bird flu since 2003, and that 241 of them have died. Indonesia, with 108 of the deaths, is seen by experts as a potential hotspot for a pandemic.
WHO is updating its 2005 preparedness plan to include progress in research on flu viruses, stronger international cooperation and experience with human cases of bird flu.
"Our understanding of the virus, the effects on people, the epidemiology how viruses move around the world, is much greater than it was a few years ago and this continues," Fukuda said.
Stockpiles of antivirals have been built since 2005, he said. WHO has stockpiled a total of 5 million antiviral treatment courses ready to be handed out if a pandemic breaks out.
He said the development of a possible pandemic vaccine have made significant strides.
"A few years ago it would not have been possible to talk about pandemic vaccines," he said. "All of a sudden we have new things to work with."
Experience and research over the last few years have led experts to believe that it is possible to stop a pandemic influenza right at the beginning of the outbreak, said Fukuda, adding that they recognized it will be difficult.
Fukuda said WHO will take into account the revised International Health Regulations in updating its pandemic preparedness plan, which is expected to be published by the end of the year.
Max Hardiman from WHO's secretariat for the health regulations said the agreement, which took effect in 2007, should help the world to know about a pandemic outbreak as soon as possible.
The health regulations oblige countries to report new disease threats with global public health significance, such as new flu subtypes. They also allow the WHO to act on credible information sources, rather than being reliant strictly on official government channels.
Hardiman said measures to contain a pandemic should avoid unnecessary travel restrictions.
Under the health regulations countries are putting in place measures to curb the spread of a pandemic, he said. These include assuring access to medical centers, control of airports and other points of entry and preparations to isolate sick people and quarantine contacts.
"One day we will face a pandemic but we don't know when," Fukuda said.
By ELIANE ENGELER
06 may 2008--The world still faces a substantial threat of a flu pandemic and countries need to speed up preparations for a global outbreak, health experts said Tuesday.
"We can't delude ourselves. The threat of a pandemic influenza has not diminished," said Keiji Fukuda, coordinator for the World Health Organization's Global Influenza Program.
Fukuda spoke to a meeting of around 150 health experts from governments, WHO and other agencies to update WHO's pandemic influenza preparedness plan.
Scientists fear that the H5N1 strain of bird flu virus — which began ravaging Asian poultry stocks in late 2003 — could mutate into a form that spreads easily among humans, potentially sparking a pandemic that kills millions. So far, most human cases have been linked to contact with infected birds.
Fukuda said more than 150 countries had some kind of national preparedness plans but some of them were merely a piece of paper acknowledging the risk.
He said it was crucial that all levels of society were involved in the preparations and that everyone knows where to go for information.
"If somebody is sick in the family for example and it's difficult to get to hospital, they need to know what sort of advice might be available," Fukuda told The Associated Press.
WHO says 382 people have come down with bird flu since 2003, and that 241 of them have died. Indonesia, with 108 of the deaths, is seen by experts as a potential hotspot for a pandemic.
WHO is updating its 2005 preparedness plan to include progress in research on flu viruses, stronger international cooperation and experience with human cases of bird flu.
"Our understanding of the virus, the effects on people, the epidemiology how viruses move around the world, is much greater than it was a few years ago and this continues," Fukuda said.
Stockpiles of antivirals have been built since 2005, he said. WHO has stockpiled a total of 5 million antiviral treatment courses ready to be handed out if a pandemic breaks out.
He said the development of a possible pandemic vaccine have made significant strides.
"A few years ago it would not have been possible to talk about pandemic vaccines," he said. "All of a sudden we have new things to work with."
Experience and research over the last few years have led experts to believe that it is possible to stop a pandemic influenza right at the beginning of the outbreak, said Fukuda, adding that they recognized it will be difficult.
Fukuda said WHO will take into account the revised International Health Regulations in updating its pandemic preparedness plan, which is expected to be published by the end of the year.
Max Hardiman from WHO's secretariat for the health regulations said the agreement, which took effect in 2007, should help the world to know about a pandemic outbreak as soon as possible.
The health regulations oblige countries to report new disease threats with global public health significance, such as new flu subtypes. They also allow the WHO to act on credible information sources, rather than being reliant strictly on official government channels.
Hardiman said measures to contain a pandemic should avoid unnecessary travel restrictions.
Under the health regulations countries are putting in place measures to curb the spread of a pandemic, he said. These include assuring access to medical centers, control of airports and other points of entry and preparations to isolate sick people and quarantine contacts.
"One day we will face a pandemic but we don't know when," Fukuda said.
Tuesday, May 06, 2008
Blood Pressure Is Most Lethal in Poor and Middle-Income Countries
By DONALD G. McNEIL Jr.
Defying popular wisdom about wealthy countries and coronary disease, a new study has found that about 80 percent of the world’s deaths from high blood pressure occur in poor and middle-income countries.
The study, published last week in The Lancet, found that strokes and heart attacks caused by high blood pressure were responsible for nearly eight million premature deaths worldwide.
About half of them, the study estimated, occurred in people older than 45 but younger than 70 — ages at which they were probably still supporting families — and in people whose blood pressure was not so high that they would certainly be on treatment in a wealthy country.
In wealthy countries over the last 50 years, such premature deaths have dropped rapidly as heart drugs have proliferated and even small hospitals have learned to treat heart attacks with blood thinners, catheterization and surgery.
An editorial in the journal noted that no major donor campaigned against high blood pressure and that “none of the major international drug companies have offered material assistance in this global health crisis, despite gargantuan profits from the sales of blood-pressure-lowering drugs in high-income countries.”
In the past, some scientists have proposed a “polypill” combining low doses of aspirin, a cholesterol-lowering statin and three pressure-lowering drugs, to be available without prescription to anyone 55 or older. At that age, they argued, the lives saved would outweigh the lives lost from rare side effects.
By DONALD G. McNEIL Jr.
Defying popular wisdom about wealthy countries and coronary disease, a new study has found that about 80 percent of the world’s deaths from high blood pressure occur in poor and middle-income countries.
The study, published last week in The Lancet, found that strokes and heart attacks caused by high blood pressure were responsible for nearly eight million premature deaths worldwide.
About half of them, the study estimated, occurred in people older than 45 but younger than 70 — ages at which they were probably still supporting families — and in people whose blood pressure was not so high that they would certainly be on treatment in a wealthy country.
In wealthy countries over the last 50 years, such premature deaths have dropped rapidly as heart drugs have proliferated and even small hospitals have learned to treat heart attacks with blood thinners, catheterization and surgery.
An editorial in the journal noted that no major donor campaigned against high blood pressure and that “none of the major international drug companies have offered material assistance in this global health crisis, despite gargantuan profits from the sales of blood-pressure-lowering drugs in high-income countries.”
In the past, some scientists have proposed a “polypill” combining low doses of aspirin, a cholesterol-lowering statin and three pressure-lowering drugs, to be available without prescription to anyone 55 or older. At that age, they argued, the lives saved would outweigh the lives lost from rare side effects.
For the Elderly, Being Heard About Life’s End
By JANE GROSS
HANOVER, N.H. — Edie Gieg, 85, strides ahead of people half her age and plays a fast-paced game of tennis. But when it comes to health care, she is a champion of “slow medicine,” an approach that encourages less aggressive — and less costly — care at the end of life.
Grounded in research at the Dartmouth Medical School, slow medicine encourages physicians to put on the brakes when considering care that may have high risks and limited rewards for the elderly, and it educates patients and families how to push back against emergency room trips and hospitalizations designed for those with treatable illnesses, not the inevitable erosion of advanced age.
Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.
At the end of her husband’s life, Ms. Gieg was spared these extreme options because she lives in Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School that has become a laboratory for the slow medicine movement. At Kendal, it is possible — even routine — for residents to say “No” to hospitalization, tests, surgery, medication or nutrition.
Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal disorder and the early stages of Alzheimer’s disease when doctors suspected he also had throat cancer.
A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce back. She worried, instead, that such treatments would accelerate his downward trajectory, ushering in a prolonged period of decline and dependence. This is what the Giegs said they feared even more than dying, what some call “death by intensive care.”
Such fears are rarely shared among old people, health care professionals or family members, because etiquette discourages it. But at Kendal — which offers a continuum of care, from independent living apartments to a nursing home — death and dying is central to the conversation from Day 1.
So it was natural for Ms. Gieg to stay in touch with Joanne Sandberg-Cook, a nurse practitioner there, during her husband’s out-of-town consultation.
“I think that it is imperative that none of this be rushed!” Ms. Sandberg-Cook wrote in an e-mail message to Ms. Gieg. The doctor the Giegs had chosen, the nurse explained, “tends to be a ‘do-it-now’ kind of guy.” But the Giegs’ circumstances “demand the time to think about all the what-ifs.”
Ms. Sandberg-Cook asked whether Mr. Gieg would want treatment if he was found to have cancer. If not, why go through a biopsy, which might further weaken his voice? Or risk anesthesia, which could accelerate her husband’s dementia?
“Those are the very questions on my mind, too,” Ms. Gieg replied. The Giegs took their time, opted for no further tests or treatment, and Charley came back to the retirement community to die.
Such decisions are not made lightly, and not without debate, especially in an aging society.
Many in their 80s and 90s — and their boomer children — want to pull out all the stops to stay alive, and doctors get paid for doing a procedure, not discussing whether it should be done. The costliest patients — the elderly with chronic illnesses — are the only group with universal health coverage under Medicare, leading to huge federal expenditures that experts agree are unsustainable as boomers age.
Most of that money is spent at certain academic medical centers, which offer the most advanced tests, the newest remedies, the most renowned specialists. According to the Dartmouth Health Atlas, which ranks hospitals on the cost and quantity of medical care to elderly patients, New York University Medical Center in Manhattan, for instance, spends $105,000 on an elderly patient with multiple chronic conditions during the last two years of life; U.C.L.A. Medical Center spends $94,000. By contrast, the Mayo Clinic’s main teaching hospital in Rochester, Minn., spends $53, 432.
The chief medical officer at U.C.L.A., Dr. Tom Rosenthal, said that aggressive treatment for the elderly at acute care hospitals can be “inhumane,” and that once a patient and family were drawn into that system, “it’s really hard to pull back from it.”
“The culture has a built-in bias that everything that can be done will be done,” Dr. Rosenthal said, adding that the pace of a hospital also discourages “real heart-to-heart discussions.”
Beginning that conversation earlier, as they do at Kendal, he said, “sounds like fundamentally the right way to practice.”
That means explaining that elderly people are rarely saved from cardiac arrest by CPR, or advising women with broken hips that they may never walk again, with or without surgery, unless they can stand physical therapy.
“It’s almost an accident when someone gets what they want,” said Dr. Mark B. McClellan, a former administrator of Medicare and now at the Brookings Institution. “Personal control, quality of life and the opportunity to make good decisions is not automatic in our system. We have to do better.”
The term slow medicine was coined by Dr. Dennis McCullough, a Dartmouth geriatrician, Kendal’s founding medical director and author of “My Mother, Your Mother: Embracing Slow Medicine, the Compassionate Approach to Caring for Your Aging Loved One.”
Among the hard truths, he said, is that 9 of 10 people who live into their 80s will wind up unable to take care of themselves, either because of frailty or dementia. “Everyone thinks they’ll be the lucky one, but we can’t go along with that myth,” Dr. McCullough said.
Ms. Sandberg-Cook agrees. “If you’re never again going to live independently or face an indeterminate period in a disabled state, you may have to reorganize your thinking,” she said. “You need to understand what you face, what you most want to avoid and what you most want to happen.”
Kendal begins by asking newcomers whether they want to be resuscitated or go to the hospital and under what circumstances. “They give me an amazingly puzzled look, like ‘Why wouldn’t I?’ “ said Brenda Jordan, Kendal’s second nurse practitioner.
She replies with CPR survival statistics: A 2002 study, published in the journal Heart, found that fewer than 2 percent of people in their 80s and 90s who had been resuscitated for cardiac arrest at home lived for one month. “They about fall out of their chairs when they find out the extent to which we’ll go to let people choose,” Ms. Jordan said.
Kendal, where the average age is 84, is generally not a place where people want heroics. Dr. George Klabaugh, 88, a resident and retired internist, found himself at the center of controversy a few years back when he tried to revive a 93-year-old neighbor who had collapsed from cardiac arrest during a theatrical performance. Dr. Klabaugh, who was unaware that the man had a “Do Not Resuscitate” order, said he regretted his “automatic reaction,” a vestige of a professional training that predisposes most physicians to aggressive care.
Ms. Jordan surveyed Kendal residents and found only one that wanted CPR — Brad Dewey, 92, who dismissed the statistics. “I want them to try anyway,” he said. “Our daughter saved a man on a tennis court. Who’s to say I won’t recover?”
Some of the 400 residents, who pay $120,000 to $400,000 for an entry fee, and monthly rent from $2,000, which includes all health care, pursue no-holds-barred treatment longer than others. One woman, for example, arrived with cardiac and pulmonary disease but was still capable of living in her own apartment. First, she had cataract surgery that left her vision worse. Next, during surgery to replace a worn-out artificial hip, her thigh bone snapped. She spent a year in bed and wound up with blood clots. Then she broke the other leg.
Only then, Ms. Jordan said, did the woman decide to forgo further surgery or hospitalizations. The woman was too ill to be interviewed.
Some of those most in tune with slow medicine are the adult children who watch a parent’s daily decline. Suzanne Brian, for one, was grateful that her father, then 88 and debilitated by congestive heart failure, was able to stop medications to end his life.
“It wasn’t ‘Oh, you have to do this or do that,’ “ Ms. Brian said. “It was my father’s choice. He could have changed his mind at any time. They slowly weaned him from the meds and he was comfortable the whole time. All he wanted was honor and dignity, and that’s what he got.”
By JANE GROSS
HANOVER, N.H. — Edie Gieg, 85, strides ahead of people half her age and plays a fast-paced game of tennis. But when it comes to health care, she is a champion of “slow medicine,” an approach that encourages less aggressive — and less costly — care at the end of life.
Grounded in research at the Dartmouth Medical School, slow medicine encourages physicians to put on the brakes when considering care that may have high risks and limited rewards for the elderly, and it educates patients and families how to push back against emergency room trips and hospitalizations designed for those with treatable illnesses, not the inevitable erosion of advanced age.
Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.
At the end of her husband’s life, Ms. Gieg was spared these extreme options because she lives in Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School that has become a laboratory for the slow medicine movement. At Kendal, it is possible — even routine — for residents to say “No” to hospitalization, tests, surgery, medication or nutrition.
Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal disorder and the early stages of Alzheimer’s disease when doctors suspected he also had throat cancer.
A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce back. She worried, instead, that such treatments would accelerate his downward trajectory, ushering in a prolonged period of decline and dependence. This is what the Giegs said they feared even more than dying, what some call “death by intensive care.”
Such fears are rarely shared among old people, health care professionals or family members, because etiquette discourages it. But at Kendal — which offers a continuum of care, from independent living apartments to a nursing home — death and dying is central to the conversation from Day 1.
So it was natural for Ms. Gieg to stay in touch with Joanne Sandberg-Cook, a nurse practitioner there, during her husband’s out-of-town consultation.
“I think that it is imperative that none of this be rushed!” Ms. Sandberg-Cook wrote in an e-mail message to Ms. Gieg. The doctor the Giegs had chosen, the nurse explained, “tends to be a ‘do-it-now’ kind of guy.” But the Giegs’ circumstances “demand the time to think about all the what-ifs.”
Ms. Sandberg-Cook asked whether Mr. Gieg would want treatment if he was found to have cancer. If not, why go through a biopsy, which might further weaken his voice? Or risk anesthesia, which could accelerate her husband’s dementia?
“Those are the very questions on my mind, too,” Ms. Gieg replied. The Giegs took their time, opted for no further tests or treatment, and Charley came back to the retirement community to die.
Such decisions are not made lightly, and not without debate, especially in an aging society.
Many in their 80s and 90s — and their boomer children — want to pull out all the stops to stay alive, and doctors get paid for doing a procedure, not discussing whether it should be done. The costliest patients — the elderly with chronic illnesses — are the only group with universal health coverage under Medicare, leading to huge federal expenditures that experts agree are unsustainable as boomers age.
Most of that money is spent at certain academic medical centers, which offer the most advanced tests, the newest remedies, the most renowned specialists. According to the Dartmouth Health Atlas, which ranks hospitals on the cost and quantity of medical care to elderly patients, New York University Medical Center in Manhattan, for instance, spends $105,000 on an elderly patient with multiple chronic conditions during the last two years of life; U.C.L.A. Medical Center spends $94,000. By contrast, the Mayo Clinic’s main teaching hospital in Rochester, Minn., spends $53, 432.
The chief medical officer at U.C.L.A., Dr. Tom Rosenthal, said that aggressive treatment for the elderly at acute care hospitals can be “inhumane,” and that once a patient and family were drawn into that system, “it’s really hard to pull back from it.”
“The culture has a built-in bias that everything that can be done will be done,” Dr. Rosenthal said, adding that the pace of a hospital also discourages “real heart-to-heart discussions.”
Beginning that conversation earlier, as they do at Kendal, he said, “sounds like fundamentally the right way to practice.”
That means explaining that elderly people are rarely saved from cardiac arrest by CPR, or advising women with broken hips that they may never walk again, with or without surgery, unless they can stand physical therapy.
“It’s almost an accident when someone gets what they want,” said Dr. Mark B. McClellan, a former administrator of Medicare and now at the Brookings Institution. “Personal control, quality of life and the opportunity to make good decisions is not automatic in our system. We have to do better.”
The term slow medicine was coined by Dr. Dennis McCullough, a Dartmouth geriatrician, Kendal’s founding medical director and author of “My Mother, Your Mother: Embracing Slow Medicine, the Compassionate Approach to Caring for Your Aging Loved One.”
Among the hard truths, he said, is that 9 of 10 people who live into their 80s will wind up unable to take care of themselves, either because of frailty or dementia. “Everyone thinks they’ll be the lucky one, but we can’t go along with that myth,” Dr. McCullough said.
Ms. Sandberg-Cook agrees. “If you’re never again going to live independently or face an indeterminate period in a disabled state, you may have to reorganize your thinking,” she said. “You need to understand what you face, what you most want to avoid and what you most want to happen.”
Kendal begins by asking newcomers whether they want to be resuscitated or go to the hospital and under what circumstances. “They give me an amazingly puzzled look, like ‘Why wouldn’t I?’ “ said Brenda Jordan, Kendal’s second nurse practitioner.
She replies with CPR survival statistics: A 2002 study, published in the journal Heart, found that fewer than 2 percent of people in their 80s and 90s who had been resuscitated for cardiac arrest at home lived for one month. “They about fall out of their chairs when they find out the extent to which we’ll go to let people choose,” Ms. Jordan said.
Kendal, where the average age is 84, is generally not a place where people want heroics. Dr. George Klabaugh, 88, a resident and retired internist, found himself at the center of controversy a few years back when he tried to revive a 93-year-old neighbor who had collapsed from cardiac arrest during a theatrical performance. Dr. Klabaugh, who was unaware that the man had a “Do Not Resuscitate” order, said he regretted his “automatic reaction,” a vestige of a professional training that predisposes most physicians to aggressive care.
Ms. Jordan surveyed Kendal residents and found only one that wanted CPR — Brad Dewey, 92, who dismissed the statistics. “I want them to try anyway,” he said. “Our daughter saved a man on a tennis court. Who’s to say I won’t recover?”
Some of the 400 residents, who pay $120,000 to $400,000 for an entry fee, and monthly rent from $2,000, which includes all health care, pursue no-holds-barred treatment longer than others. One woman, for example, arrived with cardiac and pulmonary disease but was still capable of living in her own apartment. First, she had cataract surgery that left her vision worse. Next, during surgery to replace a worn-out artificial hip, her thigh bone snapped. She spent a year in bed and wound up with blood clots. Then she broke the other leg.
Only then, Ms. Jordan said, did the woman decide to forgo further surgery or hospitalizations. The woman was too ill to be interviewed.
Some of those most in tune with slow medicine are the adult children who watch a parent’s daily decline. Suzanne Brian, for one, was grateful that her father, then 88 and debilitated by congestive heart failure, was able to stop medications to end his life.
“It wasn’t ‘Oh, you have to do this or do that,’ “ Ms. Brian said. “It was my father’s choice. He could have changed his mind at any time. They slowly weaned him from the meds and he was comfortable the whole time. All he wanted was honor and dignity, and that’s what he got.”
Can You Become a Creature of New Habits?
By JANET RAE-DUPREE
HABITS are a funny thing. We reach for them mindlessly, setting our brains on auto-pilot and relaxing into the unconscious comfort of familiar routine. “Not choice, but habit rules the unreflecting herd,” William Wordsworth said in the 19th century. In the ever-changing 21st century, even the word “habit” carries a negative connotation.
So it seems antithetical to talk about habits in the same context as creativity and innovation. But brain researchers have discovered that when we consciously develop new habits, we create parallel synaptic paths, and even entirely new brain cells, that can jump our trains of thought onto new, innovative tracks.
Rather than dismissing ourselves as unchangeable creatures of habit, we can instead direct our own change by consciously developing new habits. In fact, the more new things we try — the more we step outside our comfort zone — the more inherently creative we become, both in the workplace and in our personal lives.
But don’t bother trying to kill off old habits; once those ruts of procedure are worn into the hippocampus, they’re there to stay. Instead, the new habits we deliberately ingrain into ourselves create parallel pathways that can bypass those old roads.
“The first thing needed for innovation is a fascination with wonder,” says Dawna Markova, author of “The Open Mind” and an executive change consultant for Professional Thinking Partners. “But we are taught instead to ‘decide,’ just as our president calls himself ‘the Decider.’ ” She adds, however, that “to decide is to kill off all possibilities but one. A good innovational thinker is always exploring the many other possibilities.”
All of us work through problems in ways of which we’re unaware, she says. Researchers in the late 1960s discovered that humans are born with the capacity to approach challenges in four primary ways: analytically, procedurally, relationally (or collaboratively) and innovatively. At puberty, however, the brain shuts down half of that capacity, preserving only those modes of thought that have seemed most valuable during the first decade or so of life.
The current emphasis on standardized testing highlights analysis and procedure, meaning that few of us inherently use our innovative and collaborative modes of thought. “This breaks the major rule in the American belief system — that anyone can do anything,” explains M. J. Ryan, author of the 2006 book “This Year I Will...” and Ms. Markova’s business partner. “That’s a lie that we have perpetuated, and it fosters mediocrity. Knowing what you’re good at and doing even more of it creates excellence.”
This is where developing new habits comes in. If you’re an analytical or procedural thinker, you learn in different ways than someone who is inherently innovative or collaborative. Figure out what has worked for you when you’ve learned in the past, and you can draw your own map for developing additional skills and behaviors for the future.
“I apprentice myself to someone when I want to learn something new or develop a new habit,” Ms. Ryan says. “Other people read a book about it or take a course. If you have a pathway to learning, use it because that’s going to be easier than creating an entirely new pathway in your brain.”
Ms. Ryan and Ms. Markova have found what they call three zones of existence: comfort, stretch and stress. Comfort is the realm of existing habit. Stress occurs when a challenge is so far beyond current experience as to be overwhelming. It’s that stretch zone in the middle — activities that feel a bit awkward and unfamiliar — where true change occurs.
“Getting into the stretch zone is good for you,” Ms. Ryan says in “This Year I Will... .” “It helps keep your brain healthy. It turns out that unless we continue to learn new things, which challenges our brains to create new pathways, they literally begin to atrophy, which may result in dementia, Alzheimer’s and other brain diseases. Continuously stretching ourselves will even help us lose weight, according to one study. Researchers who asked folks to do something different every day — listen to a new radio station, for instance — found that they lost and kept off weight. No one is sure why, but scientists speculate that getting out of routines makes us more aware in general.”
She recommends practicing a Japanese technique called kaizen, which calls for tiny, continuous improvements.
“Whenever we initiate change, even a positive one, we activate fear in our emotional brain,” Ms. Ryan notes in her book. “If the fear is big enough, the fight-or-flight response will go off and we’ll run from what we’re trying to do. The small steps in kaizen don’t set off fight or flight, but rather keep us in the thinking brain, where we have access to our creativity and playfulness.”
Simultaneously, take a look at how colleagues approach challenges, Ms. Markova suggests. We tend to believe that those who think the way we do are smarter than those who don’t. That can be fatal in business, particularly for executives who surround themselves with like-thinkers. If seniority and promotion are based on similarity to those at the top, chances are strong that the company lacks intellectual diversity.
“Try lacing your hands together,” Ms. Markova says. “You habitually do it one way. Now try doing it with the other thumb on top. Feels awkward, doesn’t it? That’s the valuable moment we call confusion, when we fuse the old with the new.”
AFTER the churn of confusion, she says, the brain begins organizing the new input, ultimately creating new synaptic connections if the process is repeated enough.
But if, during creation of that new habit, the “Great Decider” steps in to protest against taking the unfamiliar path, “you get convergence and we keep doing the same thing over and over again,” she says.
“You cannot have innovation,” she adds, “unless you are willing and able to move through the unknown and go from curiosity to wonder.”
By JANET RAE-DUPREE
HABITS are a funny thing. We reach for them mindlessly, setting our brains on auto-pilot and relaxing into the unconscious comfort of familiar routine. “Not choice, but habit rules the unreflecting herd,” William Wordsworth said in the 19th century. In the ever-changing 21st century, even the word “habit” carries a negative connotation.
So it seems antithetical to talk about habits in the same context as creativity and innovation. But brain researchers have discovered that when we consciously develop new habits, we create parallel synaptic paths, and even entirely new brain cells, that can jump our trains of thought onto new, innovative tracks.
Rather than dismissing ourselves as unchangeable creatures of habit, we can instead direct our own change by consciously developing new habits. In fact, the more new things we try — the more we step outside our comfort zone — the more inherently creative we become, both in the workplace and in our personal lives.
But don’t bother trying to kill off old habits; once those ruts of procedure are worn into the hippocampus, they’re there to stay. Instead, the new habits we deliberately ingrain into ourselves create parallel pathways that can bypass those old roads.
“The first thing needed for innovation is a fascination with wonder,” says Dawna Markova, author of “The Open Mind” and an executive change consultant for Professional Thinking Partners. “But we are taught instead to ‘decide,’ just as our president calls himself ‘the Decider.’ ” She adds, however, that “to decide is to kill off all possibilities but one. A good innovational thinker is always exploring the many other possibilities.”
All of us work through problems in ways of which we’re unaware, she says. Researchers in the late 1960s discovered that humans are born with the capacity to approach challenges in four primary ways: analytically, procedurally, relationally (or collaboratively) and innovatively. At puberty, however, the brain shuts down half of that capacity, preserving only those modes of thought that have seemed most valuable during the first decade or so of life.
The current emphasis on standardized testing highlights analysis and procedure, meaning that few of us inherently use our innovative and collaborative modes of thought. “This breaks the major rule in the American belief system — that anyone can do anything,” explains M. J. Ryan, author of the 2006 book “This Year I Will...” and Ms. Markova’s business partner. “That’s a lie that we have perpetuated, and it fosters mediocrity. Knowing what you’re good at and doing even more of it creates excellence.”
This is where developing new habits comes in. If you’re an analytical or procedural thinker, you learn in different ways than someone who is inherently innovative or collaborative. Figure out what has worked for you when you’ve learned in the past, and you can draw your own map for developing additional skills and behaviors for the future.
“I apprentice myself to someone when I want to learn something new or develop a new habit,” Ms. Ryan says. “Other people read a book about it or take a course. If you have a pathway to learning, use it because that’s going to be easier than creating an entirely new pathway in your brain.”
Ms. Ryan and Ms. Markova have found what they call three zones of existence: comfort, stretch and stress. Comfort is the realm of existing habit. Stress occurs when a challenge is so far beyond current experience as to be overwhelming. It’s that stretch zone in the middle — activities that feel a bit awkward and unfamiliar — where true change occurs.
“Getting into the stretch zone is good for you,” Ms. Ryan says in “This Year I Will... .” “It helps keep your brain healthy. It turns out that unless we continue to learn new things, which challenges our brains to create new pathways, they literally begin to atrophy, which may result in dementia, Alzheimer’s and other brain diseases. Continuously stretching ourselves will even help us lose weight, according to one study. Researchers who asked folks to do something different every day — listen to a new radio station, for instance — found that they lost and kept off weight. No one is sure why, but scientists speculate that getting out of routines makes us more aware in general.”
She recommends practicing a Japanese technique called kaizen, which calls for tiny, continuous improvements.
“Whenever we initiate change, even a positive one, we activate fear in our emotional brain,” Ms. Ryan notes in her book. “If the fear is big enough, the fight-or-flight response will go off and we’ll run from what we’re trying to do. The small steps in kaizen don’t set off fight or flight, but rather keep us in the thinking brain, where we have access to our creativity and playfulness.”
Simultaneously, take a look at how colleagues approach challenges, Ms. Markova suggests. We tend to believe that those who think the way we do are smarter than those who don’t. That can be fatal in business, particularly for executives who surround themselves with like-thinkers. If seniority and promotion are based on similarity to those at the top, chances are strong that the company lacks intellectual diversity.
“Try lacing your hands together,” Ms. Markova says. “You habitually do it one way. Now try doing it with the other thumb on top. Feels awkward, doesn’t it? That’s the valuable moment we call confusion, when we fuse the old with the new.”
AFTER the churn of confusion, she says, the brain begins organizing the new input, ultimately creating new synaptic connections if the process is repeated enough.
But if, during creation of that new habit, the “Great Decider” steps in to protest against taking the unfamiliar path, “you get convergence and we keep doing the same thing over and over again,” she says.
“You cannot have innovation,” she adds, “unless you are willing and able to move through the unknown and go from curiosity to wonder.”
ASBS: BRCA-Negative Breast Cancer Patients May Have Higher Risk of New Lesions
By Charles Bankhead
NEW YORK, 06 may 2008 -- Women with a history of breast cancer but who are negative for BRCA 1 or BRCA 2 may have a greater risk of occult malignancies than previously believed, a surgeon reported here.Occult breast cancer was found in 11% of breast specimens from women who opted for prophylactic mastectomy after a malignancy was discovered in the contralateral breast, Shawna Willey, M.D., of Georgetown University, said at the American Society of Breast Surgeons meeting.The frequency of occult cancer was about twice as great as previously reported for BRCA 1-2-negative women who have such prophylactic mastectomies. The rate also was higher than for carriers of the BRCA susceptibility gene mutations, who had a bilateral prophylactic mastectomy.
"The higher rate of occult cancers may be because they all had contralateral known malignancies," said Dr. Willey. "Even so, this study supports the use of prophylactic mastectomy as an option for these women, as it is for those who have a BRCA mutation."
Unlike with carriers of BRCA 1-2 mutations, the decision to have the contralateral breast removed for noncarriers with a history of breast cancer is complicated by a lack of data on the risk of a second malignancy, said Dr. Willey. A common estimate is 5%.
To gather additional data on the issue, investigators studied 119 women who had at least a 10% prior probability of BRCA 1-2 mutation. Genetic testing identified 74 women as mutation carriers. The remaining 45 patients had developed breast cancer but their genetic testing results were uninformative.
The BRCA mutation carriers had bilateral prophylactic mastectomy. Those with uninformative genetic results underwent prophylactic removal of the contralateral breast.
Pathologic assessment of breast specimens revealed atypical histopathology in 12.6% of specimens from the BRCA mutation carriers and 26.7% of specimens from the noncarriers (P=0.04).
"The higher rate of atypical histopathology in women with uninformative results may be due to selection bias because this population of women all had contralateral known malignancies," said Dr. Willey.
Pathologic examination also showed that 7.4% of specimens from BRCA-positive patients had occult malignancies compared with 11.1% of specimens from women who had uninformative test results. Four of seven (57.1%) occult malignancies were invasive in the BRCA carrier group versus two of five (40%) in the women with uninformative test results.
"The trend in this study highlights the importance of counseling all high-risk women about their risk of developing another cancer when considering surgical options," said Dr. Willey.
Dr. Willey reported no disclosures.
Primary source: American Society of Breast SurgeonsSource reference:Feldman E, et al "The incidence of occult malignancy and atypical histopathology in prophylactic mastectomy specimens after uninformative BRCA testing" ASBS Meeting 2008.
By Charles Bankhead
NEW YORK, 06 may 2008 -- Women with a history of breast cancer but who are negative for BRCA 1 or BRCA 2 may have a greater risk of occult malignancies than previously believed, a surgeon reported here.Occult breast cancer was found in 11% of breast specimens from women who opted for prophylactic mastectomy after a malignancy was discovered in the contralateral breast, Shawna Willey, M.D., of Georgetown University, said at the American Society of Breast Surgeons meeting.The frequency of occult cancer was about twice as great as previously reported for BRCA 1-2-negative women who have such prophylactic mastectomies. The rate also was higher than for carriers of the BRCA susceptibility gene mutations, who had a bilateral prophylactic mastectomy.
"The higher rate of occult cancers may be because they all had contralateral known malignancies," said Dr. Willey. "Even so, this study supports the use of prophylactic mastectomy as an option for these women, as it is for those who have a BRCA mutation."
Unlike with carriers of BRCA 1-2 mutations, the decision to have the contralateral breast removed for noncarriers with a history of breast cancer is complicated by a lack of data on the risk of a second malignancy, said Dr. Willey. A common estimate is 5%.
To gather additional data on the issue, investigators studied 119 women who had at least a 10% prior probability of BRCA 1-2 mutation. Genetic testing identified 74 women as mutation carriers. The remaining 45 patients had developed breast cancer but their genetic testing results were uninformative.
The BRCA mutation carriers had bilateral prophylactic mastectomy. Those with uninformative genetic results underwent prophylactic removal of the contralateral breast.
Pathologic assessment of breast specimens revealed atypical histopathology in 12.6% of specimens from the BRCA mutation carriers and 26.7% of specimens from the noncarriers (P=0.04).
"The higher rate of atypical histopathology in women with uninformative results may be due to selection bias because this population of women all had contralateral known malignancies," said Dr. Willey.
Pathologic examination also showed that 7.4% of specimens from BRCA-positive patients had occult malignancies compared with 11.1% of specimens from women who had uninformative test results. Four of seven (57.1%) occult malignancies were invasive in the BRCA carrier group versus two of five (40%) in the women with uninformative test results.
"The trend in this study highlights the importance of counseling all high-risk women about their risk of developing another cancer when considering surgical options," said Dr. Willey.
Dr. Willey reported no disclosures.
Primary source: American Society of Breast SurgeonsSource reference:Feldman E, et al "The incidence of occult malignancy and atypical histopathology in prophylactic mastectomy specimens after uninformative BRCA testing" ASBS Meeting 2008.
Monday, May 05, 2008
AHA Quality: Remote Monitoring May Improve Heart Failure Outcomes
By Charles Bankhead
BALTIMORE, 05 may 2008 -- When heart failure patients do a daily home self-assessment of vital signs that is automatically sent by phone to physicians, the likelihood of hospital readmissions and emergency room visits tends to be reduced, a preliminary study suggested.
Patients who provided such daily information about their health status had nonsignificant trends toward a lower readmission rate and fewer ER visits compared with those given usual management, Ambar Kulshreshtha, M.D., of Harvard, reported at the American Heart Association meeting here on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
Although the between-group differences did not reach statistical significance, they suggest that telemonitoring has the potential to improve heart failure outcomes.
"Patients could see the fluctuation in their vitals and realize they hadn't taken their medications or weren't eating right or exercising," said Dr. Kulshreshtha. "A weekly call from the nurse reinforces lifestyle management of the patient's heart failure."
The study evolved from previous research showing that remote monitoring improved outcomes in homebound patients with heart failure. Dr. Kulshreshtha and colleagues hypothesized that daily telemonitoring would encourage behavior change and intervention that would improve outcomes in ambulatory patients, as well.
The study involved 150 heart failure patients, 68 of them randomized to usual care (mean age 70) and 82 to remote telemonitoring. Forty of the 82 patients declined to participate (mean age 68), leaving 42 participants (mean age 65) in the monitoring group.
Using special telemonitoring equipment, patients in the remote monitoring arm assessed vital signs and weighed themselves daily. The information was transmitted to a nurse who coordinated care with a physician. The nurse also called each patient weekly or more often if any vital signs were abnormal.
The primary aim of the study was to compare hospital readmissions and ER visits between patients who participated in remote monitoring and those who were assigned to usual care or who declined remote monitoring.
After three months of follow-up, the remote monitoring group had a hospital readmission rate of 0.31 (31 per 100 patients) compared with 0.38 for the usual care group and 0.45 for the nonparticipants. The usual-care group and nonparticipants also had more ER visits compared with the remotely monitored patients. None of the differences was statistically significant.
Results of a post-study survey showed that 95% of remotely monitored patients said the program improved their heart failure and helped them avoid hospitalization. Additionally, 95% said the program helped them manage their condition better and expressed overall satisfaction with the program. Telemonitoring participants also said the equipment was easy to use.
Dr. Kulshreshtha and colleagues reported no disclosures.
Primary source: AHA Quality MeetingSource reference:Kulshreshtha A, et al "Using information technology to improve outcomes in patients with heart failure: The value of remote monitoring" AHA Quality Meeting 2008; Abstract 21.
By Charles Bankhead
BALTIMORE, 05 may 2008 -- When heart failure patients do a daily home self-assessment of vital signs that is automatically sent by phone to physicians, the likelihood of hospital readmissions and emergency room visits tends to be reduced, a preliminary study suggested.
Patients who provided such daily information about their health status had nonsignificant trends toward a lower readmission rate and fewer ER visits compared with those given usual management, Ambar Kulshreshtha, M.D., of Harvard, reported at the American Heart Association meeting here on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
Although the between-group differences did not reach statistical significance, they suggest that telemonitoring has the potential to improve heart failure outcomes.
"Patients could see the fluctuation in their vitals and realize they hadn't taken their medications or weren't eating right or exercising," said Dr. Kulshreshtha. "A weekly call from the nurse reinforces lifestyle management of the patient's heart failure."
The study evolved from previous research showing that remote monitoring improved outcomes in homebound patients with heart failure. Dr. Kulshreshtha and colleagues hypothesized that daily telemonitoring would encourage behavior change and intervention that would improve outcomes in ambulatory patients, as well.
The study involved 150 heart failure patients, 68 of them randomized to usual care (mean age 70) and 82 to remote telemonitoring. Forty of the 82 patients declined to participate (mean age 68), leaving 42 participants (mean age 65) in the monitoring group.
Using special telemonitoring equipment, patients in the remote monitoring arm assessed vital signs and weighed themselves daily. The information was transmitted to a nurse who coordinated care with a physician. The nurse also called each patient weekly or more often if any vital signs were abnormal.
The primary aim of the study was to compare hospital readmissions and ER visits between patients who participated in remote monitoring and those who were assigned to usual care or who declined remote monitoring.
After three months of follow-up, the remote monitoring group had a hospital readmission rate of 0.31 (31 per 100 patients) compared with 0.38 for the usual care group and 0.45 for the nonparticipants. The usual-care group and nonparticipants also had more ER visits compared with the remotely monitored patients. None of the differences was statistically significant.
Results of a post-study survey showed that 95% of remotely monitored patients said the program improved their heart failure and helped them avoid hospitalization. Additionally, 95% said the program helped them manage their condition better and expressed overall satisfaction with the program. Telemonitoring participants also said the equipment was easy to use.
Dr. Kulshreshtha and colleagues reported no disclosures.
Primary source: AHA Quality MeetingSource reference:Kulshreshtha A, et al "Using information technology to improve outcomes in patients with heart failure: The value of remote monitoring" AHA Quality Meeting 2008; Abstract 21.
Decline in Heart Disease Deaths in Women Leveling Off
By Todd Neale
OXFORD, England, 05 may 2008 -- The rate of decline in coronary heart disease mortality is slowing considerably for women younger than 50, according to trends reported by researchers here.
After a steep drop in the rate of coronary disease mortality for women younger than 50 in England and Wales starting 30 years ago, the new trends indicate a grimmer picture.
They indicate trends toward "a future plateau and possible reversal of previous improvement," Steven Allender, Ph.D., of the University of Oxford, and colleagues reported online in BMC Public Health.
From 1986-1995 to 1996-2005, the coronary heart disease mortality rate in England and Wales dropped by 19.5%, half the rate of decline from the previous decade, they found. The rate had dropped by 40.4% from 1976-1985 to 1986-1995.
The rate of decline in coronary heart disease mortality rate also slowed for men younger than 50 -- falling from 41.5% to 34.6% -- but has been steady since 1990.
On the other hand, although the actual burden of coronary heart disease deaths remains greatest in patients ages 50 to 69, the rate of decline has accelerated for men and women in this age group. For men, the coronary heart disease mortality rate fell by 23.9% from 1976-1985 to 1986-1995 and by 45.1% from the latter time period to 1996-2005.
For older women, the corresponding changes were 19.7% and 46.1%.
Overall rates of death from coronary heart disease increased steadily in both men and women in England and Wales until the mid-1970s when the rates began to fall, the researchers said.
Studies on long-term trends in coronary heart disease mortality rates stratified by age group are important, the researchers said, because, "when only age-standardized rates are considered, reductions in the mortality rate in older age groups may obscure less positive trends in younger men and women."
They noted that the rising prevalence of cardiovascular risk factors such as obesity, diabetes, smoking, and physical inactivity among the younger population could begin to slow or reverse the rate of decline of deaths from coronary heart disease.
Indeed, a U.S. study last year found that the rate of decline had completely reversed and had begun increasing in women ages 35 to 44 and had slowed considerably in men ages 35 to 54.
o explore these trends in England and Wales, Dr. Allender and colleagues examined mortality data in 10-year birth cohorts from the 1930s through 2005.
In both genders and all age groups up to age 69, coronary heart disease deaths and mortality rates increased from 1936 until the mid-1970s, after which they started to decline. Overall, from 1936-1945 to 1966-1975, the rate increased by 287% in men and by 264% in women.
From 1976-1985 to 1996-2005, the coronary heart disease mortality rate dropped by 58.5% in men and by 56.5% in women.
The trend for older age groups to have a higher burden of coronary heart disease has been established in women much longer than in men, the researchers said. For example, the number of coronary heart disease deaths in women ages 80 to 84 exceeded those in women ages 60 to 64 for the first time in 1949. That did not happen in men until 1985.
The researchers noted that the pattern of an accelerating rate of decline in coronary heart disease mortality in older patients and a slowing rate of decline in younger patients suggested that advances are disproportionately being made in the older population.
"There are a number of reasons for this," they said, "including the targeting and efficacy of screening, the inclusion criteria for beginning of treatment regimes (which include age as a standard risk factor), and the current public health focus on mortality reduction in older populations."
The authors noted that the study was limited by the fact that the definition of coronary heart disease has changed slightly over time. Consequently, all comparisons between age cohorts should be interpreted cautiously, they said.
Methods of death certification have also changed over time, they said.
The authors declared that they have no conflicts of interest.
Primary source: BMC Public HealthSource reference:Allender S, et al "Patterns of coronary heart disease mortality over the 20th century in England and Wales: Possible plateaus in the rate of decline" BMC Public Health 2008; DOI: 10.1186/1471-2458-8-148.
By Todd Neale
OXFORD, England, 05 may 2008 -- The rate of decline in coronary heart disease mortality is slowing considerably for women younger than 50, according to trends reported by researchers here.
After a steep drop in the rate of coronary disease mortality for women younger than 50 in England and Wales starting 30 years ago, the new trends indicate a grimmer picture.
They indicate trends toward "a future plateau and possible reversal of previous improvement," Steven Allender, Ph.D., of the University of Oxford, and colleagues reported online in BMC Public Health.
From 1986-1995 to 1996-2005, the coronary heart disease mortality rate in England and Wales dropped by 19.5%, half the rate of decline from the previous decade, they found. The rate had dropped by 40.4% from 1976-1985 to 1986-1995.
The rate of decline in coronary heart disease mortality rate also slowed for men younger than 50 -- falling from 41.5% to 34.6% -- but has been steady since 1990.
On the other hand, although the actual burden of coronary heart disease deaths remains greatest in patients ages 50 to 69, the rate of decline has accelerated for men and women in this age group. For men, the coronary heart disease mortality rate fell by 23.9% from 1976-1985 to 1986-1995 and by 45.1% from the latter time period to 1996-2005.
For older women, the corresponding changes were 19.7% and 46.1%.
Overall rates of death from coronary heart disease increased steadily in both men and women in England and Wales until the mid-1970s when the rates began to fall, the researchers said.
Studies on long-term trends in coronary heart disease mortality rates stratified by age group are important, the researchers said, because, "when only age-standardized rates are considered, reductions in the mortality rate in older age groups may obscure less positive trends in younger men and women."
They noted that the rising prevalence of cardiovascular risk factors such as obesity, diabetes, smoking, and physical inactivity among the younger population could begin to slow or reverse the rate of decline of deaths from coronary heart disease.
Indeed, a U.S. study last year found that the rate of decline had completely reversed and had begun increasing in women ages 35 to 44 and had slowed considerably in men ages 35 to 54.
o explore these trends in England and Wales, Dr. Allender and colleagues examined mortality data in 10-year birth cohorts from the 1930s through 2005.
In both genders and all age groups up to age 69, coronary heart disease deaths and mortality rates increased from 1936 until the mid-1970s, after which they started to decline. Overall, from 1936-1945 to 1966-1975, the rate increased by 287% in men and by 264% in women.
From 1976-1985 to 1996-2005, the coronary heart disease mortality rate dropped by 58.5% in men and by 56.5% in women.
The trend for older age groups to have a higher burden of coronary heart disease has been established in women much longer than in men, the researchers said. For example, the number of coronary heart disease deaths in women ages 80 to 84 exceeded those in women ages 60 to 64 for the first time in 1949. That did not happen in men until 1985.
The researchers noted that the pattern of an accelerating rate of decline in coronary heart disease mortality in older patients and a slowing rate of decline in younger patients suggested that advances are disproportionately being made in the older population.
"There are a number of reasons for this," they said, "including the targeting and efficacy of screening, the inclusion criteria for beginning of treatment regimes (which include age as a standard risk factor), and the current public health focus on mortality reduction in older populations."
The authors noted that the study was limited by the fact that the definition of coronary heart disease has changed slightly over time. Consequently, all comparisons between age cohorts should be interpreted cautiously, they said.
Methods of death certification have also changed over time, they said.
The authors declared that they have no conflicts of interest.
Primary source: BMC Public HealthSource reference:Allender S, et al "Patterns of coronary heart disease mortality over the 20th century in England and Wales: Possible plateaus in the rate of decline" BMC Public Health 2008; DOI: 10.1186/1471-2458-8-148.
AHA Quality: More Attention to Palliative Care Suggested for Heart Failure Patients
By Charles Bankhead
BALTIMORE, 05 may 2008-- Patients with heart failure have symptom and psychoemotional burdens similar to those of cancer patients, according to a study reported here.
The number of symptoms and scores on assessments of depression and spiritual well-being were no different in 60 outpatients with heart failure than they were in 30 outpatients with advanced lung or pancreatic cancer, David Bekelman, M.D., of the University of Colorado at Denver, said.
In fact, he told attendees at the American Heart Association's Conference on Quality of Care and Outcomes in Cardiovascular Disease and Stroke, heart failure patients with poor health status had more symptoms, were more depressed, and had a lower sense of spiritual well-being than did the cancer patients.
The findings have implications about palliative care for heart failure patients, Dr. Bekelman said.
"Advanced cancer patients are often quite sick and need care focused on quality of life in addition to care focused on the disease," he said. "We don't usually think about providing similar care to outpatients with heart failure."
"Patients with heart failure who are not at the end of life have palliative care needs, but palliative care has been markedly underused in heart failure patients," he added.
The study examined the validity of the assumption that the physical and emotional burdens imposed by heart failure are less severe than those associated with advanced cancer. Most patients with advanced cancer receive palliative care, whereas most patients with heart failure do not.
Dr. Bekelman and colleagues compared patients with heart failure or advanced cancer with respect to three palliative care domains: symptom burden, psychosocial comorbidity, and spiritual well-being. The objective was to assess the relative need for palliative care in the two types of patients.
The heart failure patients were grouped according to ejection fraction and heart failure-specific health status, as assessed by the Kansas City Cardiomyopathy Questionnaire. A score of 50 or lower on the 100-point scale reflected poor health status. All of the cancer patients had nonresectable or metastatic lung or pancreatic cancer.
Both groups of patients completed validated surveys for assessing symptoms, depression, and spiritual well-being. Tabulation of the responses showed no difference between the heart failure and cancer patients with respect to:
Average number of symptoms, 9.1 versus 8.6
Depression score, 3.9 versus 3.2
Spiritual well-being score, 35.9 versus 39.0
Analysis of the data by health status showed that heart failure patients with poor health status had a significantly higher symptom burden (13.2 versus 8.6, P=0.03), depression score (6.7 versus 3.2, P=0.001), and lower spiritual well-being score (29 versus 38.9, P=0.004).
The results suggest that palliative care should be a treatment option for heart failure patients, particularly those with poor health status, the researchers said.
"Clinicians should not underestimate the importance of using supportive communication and empathy with heart failure patients to reduce both symptoms and depression," said Dr. Bekelman.
Dr. Bekelman and co-authors reported no disclosures.
Primary source: AHA Quality ConferenceSource reference:Bekelman D, et al "Symptoms, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients" AHA Quality Conference 2008; Abstract 171.
By Charles Bankhead
BALTIMORE, 05 may 2008-- Patients with heart failure have symptom and psychoemotional burdens similar to those of cancer patients, according to a study reported here.
The number of symptoms and scores on assessments of depression and spiritual well-being were no different in 60 outpatients with heart failure than they were in 30 outpatients with advanced lung or pancreatic cancer, David Bekelman, M.D., of the University of Colorado at Denver, said.
In fact, he told attendees at the American Heart Association's Conference on Quality of Care and Outcomes in Cardiovascular Disease and Stroke, heart failure patients with poor health status had more symptoms, were more depressed, and had a lower sense of spiritual well-being than did the cancer patients.
The findings have implications about palliative care for heart failure patients, Dr. Bekelman said.
"Advanced cancer patients are often quite sick and need care focused on quality of life in addition to care focused on the disease," he said. "We don't usually think about providing similar care to outpatients with heart failure."
"Patients with heart failure who are not at the end of life have palliative care needs, but palliative care has been markedly underused in heart failure patients," he added.
The study examined the validity of the assumption that the physical and emotional burdens imposed by heart failure are less severe than those associated with advanced cancer. Most patients with advanced cancer receive palliative care, whereas most patients with heart failure do not.
Dr. Bekelman and colleagues compared patients with heart failure or advanced cancer with respect to three palliative care domains: symptom burden, psychosocial comorbidity, and spiritual well-being. The objective was to assess the relative need for palliative care in the two types of patients.
The heart failure patients were grouped according to ejection fraction and heart failure-specific health status, as assessed by the Kansas City Cardiomyopathy Questionnaire. A score of 50 or lower on the 100-point scale reflected poor health status. All of the cancer patients had nonresectable or metastatic lung or pancreatic cancer.
Both groups of patients completed validated surveys for assessing symptoms, depression, and spiritual well-being. Tabulation of the responses showed no difference between the heart failure and cancer patients with respect to:
Average number of symptoms, 9.1 versus 8.6
Depression score, 3.9 versus 3.2
Spiritual well-being score, 35.9 versus 39.0
Analysis of the data by health status showed that heart failure patients with poor health status had a significantly higher symptom burden (13.2 versus 8.6, P=0.03), depression score (6.7 versus 3.2, P=0.001), and lower spiritual well-being score (29 versus 38.9, P=0.004).
The results suggest that palliative care should be a treatment option for heart failure patients, particularly those with poor health status, the researchers said.
"Clinicians should not underestimate the importance of using supportive communication and empathy with heart failure patients to reduce both symptoms and depression," said Dr. Bekelman.
Dr. Bekelman and co-authors reported no disclosures.
Primary source: AHA Quality ConferenceSource reference:Bekelman D, et al "Symptoms, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients" AHA Quality Conference 2008; Abstract 171.
Sunday, May 04, 2008
AHA Quality: Educating Patients and Providers Boosts BP Control
By John Gever
BALTIMORE, 05 may 2008-- More patients were able to control their hypertension after an education program targeting both patients and healthcare providers, a researcher said here.
Note that this study was published as an abstract and presented as a poster at a conference. These data and conclusions should be considered preliminary until published in a peer-reviewed journal.
In two Veterans Affairs hospitals and nine clinics where the program was implemented, the percentage of patients achieving their target blood pressure levels increased to 64.3%, versus 61.8% at baseline (P<0.0001), reported Christianne L. Roumie, M.D., M.P.H., of the VA Tennessee Valley Healthcare System in Nashville.
With 53,936 patients under treatment at these facilities during the study, the improvement translated into 1,349 additional people achieving blood pressure control, Dr. Roumie said in an interview prior to her presentation at the American Heart Association's Conference on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
She noted that hypertension is the most common chronic condition among patients treated in the VA health system.
The program had four components:
Standardizing blood pressure measurement procedures using a protocol to increase accuracy and improve documentation
Educating patients about achieving and maintaining adequate control
Developing and distributing pocket cards and posters for providers outlining VA-sanctioned treatment algorithms
Developing a review process for individual providers' and institutions' performance relative to program goals.
Patients' blood pressure measurements were obtained from the VA health system records.
Baseline data on 28,620 patients were collected for the 21 weeks before implementation of the program. The program's effectiveness was determined from data collected over 18 weeks, on the basis of 25,316 patients' last recorded blood pressure measurement.
Adequate control was defined as systolic pressure less than 140 mm Hg and diastolic pressure less than 90 mm Hg.
Dr. Roumie said there was wide variation among the participating facilities in how well the program worked.
One of the hospitals had an absolute improvement in the prevalence of adequate control from baseline of 2.8 percentage points (63.5% before versus 66.3% after, P=0.001), whereas the other hospital showed no improvement at all (59.9% before versus 59.7% after).
She said most of the team members who developed the program were based at the first hospital. "They may have had more ownership of the program," she said.
Only one of the team members worked at the second hospital, where more than 7,000 patients were treated, and other staff there were less enthusiastic about the program, Dr. Roumie said.
She said there was also significant variability in the success of the program among the nine outpatient clinics.
"One had a huge improvement, more than 7 percentage points," she said.
The prevalence of blood pressure control at the outpatient clinics overall increased 1.9 percentage points (61.9% before versus 63.7% after, P=0.053).
Dr. Roumie said the experience in this effort, as well as previous published research, indicates that dedicated and enthusiastic leaders are needed to make such programs work.
"You need champions of your cause," she said.
She said improvements of two or three percentage points are clinically important, given that hypertension is so common.
She also noted that these percentage points were gained at relatively little monetary cost.
No external funding was reported. No potential conflicts of interest were reported.
Primary source: AHA Quality of Care and Outcomes ConferenceSource reference:Not available until May 27
By John Gever
BALTIMORE, 05 may 2008-- More patients were able to control their hypertension after an education program targeting both patients and healthcare providers, a researcher said here.
Note that this study was published as an abstract and presented as a poster at a conference. These data and conclusions should be considered preliminary until published in a peer-reviewed journal.
In two Veterans Affairs hospitals and nine clinics where the program was implemented, the percentage of patients achieving their target blood pressure levels increased to 64.3%, versus 61.8% at baseline (P<0.0001), reported Christianne L. Roumie, M.D., M.P.H., of the VA Tennessee Valley Healthcare System in Nashville.
With 53,936 patients under treatment at these facilities during the study, the improvement translated into 1,349 additional people achieving blood pressure control, Dr. Roumie said in an interview prior to her presentation at the American Heart Association's Conference on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
She noted that hypertension is the most common chronic condition among patients treated in the VA health system.
The program had four components:
Standardizing blood pressure measurement procedures using a protocol to increase accuracy and improve documentation
Educating patients about achieving and maintaining adequate control
Developing and distributing pocket cards and posters for providers outlining VA-sanctioned treatment algorithms
Developing a review process for individual providers' and institutions' performance relative to program goals.
Patients' blood pressure measurements were obtained from the VA health system records.
Baseline data on 28,620 patients were collected for the 21 weeks before implementation of the program. The program's effectiveness was determined from data collected over 18 weeks, on the basis of 25,316 patients' last recorded blood pressure measurement.
Adequate control was defined as systolic pressure less than 140 mm Hg and diastolic pressure less than 90 mm Hg.
Dr. Roumie said there was wide variation among the participating facilities in how well the program worked.
One of the hospitals had an absolute improvement in the prevalence of adequate control from baseline of 2.8 percentage points (63.5% before versus 66.3% after, P=0.001), whereas the other hospital showed no improvement at all (59.9% before versus 59.7% after).
She said most of the team members who developed the program were based at the first hospital. "They may have had more ownership of the program," she said.
Only one of the team members worked at the second hospital, where more than 7,000 patients were treated, and other staff there were less enthusiastic about the program, Dr. Roumie said.
She said there was also significant variability in the success of the program among the nine outpatient clinics.
"One had a huge improvement, more than 7 percentage points," she said.
The prevalence of blood pressure control at the outpatient clinics overall increased 1.9 percentage points (61.9% before versus 63.7% after, P=0.053).
Dr. Roumie said the experience in this effort, as well as previous published research, indicates that dedicated and enthusiastic leaders are needed to make such programs work.
"You need champions of your cause," she said.
She said improvements of two or three percentage points are clinically important, given that hypertension is so common.
She also noted that these percentage points were gained at relatively little monetary cost.
No external funding was reported. No potential conflicts of interest were reported.
Primary source: AHA Quality of Care and Outcomes ConferenceSource reference:Not available until May 27
Boxed Warning for Infections and TB Added to Etanercept (Enbrel)
By Todd Neale
ROCKVILLE, Md., 05 may 2008-- A boxed warning has been added to the label for etanercept (Enbrel), the tumor necrosis factor-alpha inhibitor for rheumatoid arthritis, to strengthen awareness of the risk of infections, particularly tuberculosis, the FDA announced today.
The warning, which points out that serious infections leading to hospitalization or death can occur with the use of the agent, has been changed to recommend screening for latent tuberculosis infection (LTBI) before treatment.
It also says that patients who develop an infection should be monitored for possible antimicrobial treatment and that etanercept should be stopped if a serious infection develops.
"Tuberculosis (frequently disseminated or extrapulmonary at clinical presentation) has been observed in patients receiving TNF-blocking agents, including Enbrel," the warning points out. "Tuberculosis may be due to reactivation of latent tuberculosis infection or to new infection. Data from clinical trials and preclinical studies suggest that the risk of reactivation of latent tuberculosis infection is lower with Enbrel than with TNF-blocking monoclonal antibodies. Nonetheless, postmarketing cases of tuberculosis reactivation have been reported for TNF blockers, including Enbel."
The section on adverse events now reads, "In global clinical studies of 20,070 patients (28,308 patient-years of therapy), tuberculosis was observed in approximately 0.01% of patients. In 15,438 patients (23,524 patient-years of therapy) from clinical studies in the U.S. and Canada, tuberculosis was observed in approximately 0.007% of patients. These studies include reports of pulmonary and extra-pulmonary tuberculosis."
The changes were distributed to clinicians in a letter from Amgen and Wyeth, which market the drug for the manufacturer, Immunex.
Etanercept is approved for moderate-to-severe rheumatoid arthritis, moderate-to-severe polyarticular juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, and moderate to severe plaque psoriasis
By Todd Neale
ROCKVILLE, Md., 05 may 2008-- A boxed warning has been added to the label for etanercept (Enbrel), the tumor necrosis factor-alpha inhibitor for rheumatoid arthritis, to strengthen awareness of the risk of infections, particularly tuberculosis, the FDA announced today.
The warning, which points out that serious infections leading to hospitalization or death can occur with the use of the agent, has been changed to recommend screening for latent tuberculosis infection (LTBI) before treatment.
It also says that patients who develop an infection should be monitored for possible antimicrobial treatment and that etanercept should be stopped if a serious infection develops.
"Tuberculosis (frequently disseminated or extrapulmonary at clinical presentation) has been observed in patients receiving TNF-blocking agents, including Enbrel," the warning points out. "Tuberculosis may be due to reactivation of latent tuberculosis infection or to new infection. Data from clinical trials and preclinical studies suggest that the risk of reactivation of latent tuberculosis infection is lower with Enbrel than with TNF-blocking monoclonal antibodies. Nonetheless, postmarketing cases of tuberculosis reactivation have been reported for TNF blockers, including Enbel."
The section on adverse events now reads, "In global clinical studies of 20,070 patients (28,308 patient-years of therapy), tuberculosis was observed in approximately 0.01% of patients. In 15,438 patients (23,524 patient-years of therapy) from clinical studies in the U.S. and Canada, tuberculosis was observed in approximately 0.007% of patients. These studies include reports of pulmonary and extra-pulmonary tuberculosis."
The changes were distributed to clinicians in a letter from Amgen and Wyeth, which market the drug for the manufacturer, Immunex.
Etanercept is approved for moderate-to-severe rheumatoid arthritis, moderate-to-severe polyarticular juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, and moderate to severe plaque psoriasis
AGS: Faster, More Accurate Tool Evaluates Depression in Nursing Home Residents
By Peggy Peck
WASHINGTON, 04 may 2008-- An assessment tool that closely tracks the DSM-IV, was more accurate and took only about half the time to complete as the more widely used Geriatric Depression Scale (GDS) for evaluating mood disorders in nursing home patients, researchers reported here.
The nine-question Patient Health Questionnaire-9 (PHQ-9) is even more useful when it is administered using "an unfolding technique," in which the patient is first asked queue questions, such as "have you been feeling sad" before being asked to estimate frequency and severity of symptoms, said Debra Saliba, M.D., M.P.H., of the University of California Los Angeles School of Medicine, in a plenary presentation at the American Geriatrics Society meeting.
Dr. Saliba and colleagues enrolled 418 residents from 70 nursing homes in eight states. Participants included only residents who were scheduled for a regular Minimum Data Set (MDS) assessment and were capable of communication.
Assessments were conducted by 16 nurses who were specially trained for the study and worked in pairs.
Participants were evaluated using the 15-question GDS, and the PHQ-9, as well as the MDS. They were also assessed using the modified Standard for Affective Disorders Scale, which was considered the gold standard. One nurse conducted the GDS, PHQ-9, and MDS and another nurse, working on a different day, conducted the affective disorders scale. The nurses then switched tasks for the next set of evaluations. Interview order was reversed for half the sample.
Completion rates were similar for each instrument -- 84% completed the PHQ-9 versus 78% for the GDS. But on average, it took eight minutes to complete the GDS, and only four minutes to complete the PHQ-9.
Correlation with the modified Standard for Affective Disorders Scale was greatest for the PHG-9 (0.83), versus 0.71 with GDS and 0.23 with MDS (P<0.001),>
Pain a Part of Daily Life for One in Four
By Crystal Phend
PRINCETON, N.J., 04 may 2008-- More than a quarter of all Americans are in pain at any given time during the day, particularly those with lower income and less education, researchers said.In a population-based survey, 28.8% of men and 26.6% of women reported some level of pain during everyday activities at randomly sampled times through the day, according to Alan B. Kruger, Ph.D., of Princeton University, and Arthur A. Stone, Ph.D., of Stony Brook University in Stony Brook, N.Y.Activities associated with the highest average levels of pain were lawn care and caregiving as well as medical care among women and sports and exercise among men, they reported in the May 3 issue of The Lancet.
"If the relation with pain is causal, palliative care could increase the quality of life and range of activities in which people participate," the researchers said.
Even changing the mix of activities could lower a person's level of pain, they added.
So when doing a pain assessment, clinicians might consider asking for information about daily activities, Drs. Kruger and Stone suggested.
Previous studies have found that 17% to 29% of the general population suffers chronic pain, commented Juha H.O. Turunen, Ph.D., of the University of Kuopio in Kuopio, Finland, in an accompanying editorial.
Because little is known about pain prevalence other than chronic or condition-specific pain, such as arthritis, the researchers conducted the Princeton Affect and Time Survey (PATS). The Gallup Organization administered the community-based telephone survey to a nationally representative sample of households.
The 3,982 respondents provided a pain diary for one 24-hour period during which they rated pain on a seven-point scale. The researchers randomly selected three 15-minute intervals during waking hours for each participant.
Overall, respondents averaged 17.8 episodes of any degree of pain during the day before the survey.
Reports were similar from men and women. Race and ethnic origin were likewise not significant predictors of pain.
Pain ratings generally rose with age, although scores tended to plateau from the mid-40s to the mid-70s.
Along with age, education was a strong predictor of pain. Participants with less than a high school diploma had an average pain rating twice that of college graduates (1.21 versus 0.69, P<0.001).
Likewise, average pain ratings were about twice as high for men and women in households with yearly income below $30,000 as for those with an annual income of more than $100,000 (1.27 versus 0.67, P<0.001).
Individuals in the lowest income category spent 34.2% of their time in some degree of pain and 18.5% of their time in more severe pain (pain scores of three or higher on the seven-point scale). Those proportions were 22.9% and 7.7% for those in the highest income category.
The reason for these disparities, the authors suggested, was at least partly related to occupational status. Blue-collar workers had higher average pain ratings both during and outside of work than did white-collar workers (1.00 and 0.84 versus 0.61 and 0.61, respectively).
"Such a disparity emphasizes the need for pain-prevention measures, such as better ergonomics and better availability of occupational health services, in jobs with high physical strains," Dr. Turunen said in his editorial.
Drs. Kruger and Stone also found that disability and lack of satisfaction with life and health status were associated with the highest pain levels (all P<0.001).
Those participants who reported significant pain during much of the day reported spending 24.1% of their time watching television, whereas others spent 16% of the day in front of the TV.
Those individuals also spent more time relaxing and less time working and traveling than others, even when controlling for age and other demographic factors.
However, the researchers cautioned that the survey response rate was low (37%) and noted that the study lacked information on causes, location, and duration of pain, as well as medical conditions and treatments.
Further study is needed to identify groups of patients needing help with pain, Dr. Turunen said, "for example, to enable pain sufferers to obtain quicker and easier access to multidisciplinary pain clinics."
The study was supported by the National Institute of Aging and the Hewlett Foundation. Drs. Kruger and Stone reported being consulting senior scientists to the Gallup Organization. Dr. Stone also reported being associate chair of the scientific advisory board for Invivodata. Dr. Turunen reported no conflicts of interest.
Primary source: The LancetSource reference:Krueger AB, Stone AA "Assessment of pain: A community-based diary survey in the USA" Lancet 2008; 371: 1519-25. Additional source: The LancetSource reference: Turunen JHO "Depicting the pain profile with the diary-day method" Lancet 2008; 371: 1482-83.
By Crystal Phend
PRINCETON, N.J., 04 may 2008-- More than a quarter of all Americans are in pain at any given time during the day, particularly those with lower income and less education, researchers said.In a population-based survey, 28.8% of men and 26.6% of women reported some level of pain during everyday activities at randomly sampled times through the day, according to Alan B. Kruger, Ph.D., of Princeton University, and Arthur A. Stone, Ph.D., of Stony Brook University in Stony Brook, N.Y.Activities associated with the highest average levels of pain were lawn care and caregiving as well as medical care among women and sports and exercise among men, they reported in the May 3 issue of The Lancet.
"If the relation with pain is causal, palliative care could increase the quality of life and range of activities in which people participate," the researchers said.
Even changing the mix of activities could lower a person's level of pain, they added.
So when doing a pain assessment, clinicians might consider asking for information about daily activities, Drs. Kruger and Stone suggested.
Previous studies have found that 17% to 29% of the general population suffers chronic pain, commented Juha H.O. Turunen, Ph.D., of the University of Kuopio in Kuopio, Finland, in an accompanying editorial.
Because little is known about pain prevalence other than chronic or condition-specific pain, such as arthritis, the researchers conducted the Princeton Affect and Time Survey (PATS). The Gallup Organization administered the community-based telephone survey to a nationally representative sample of households.
The 3,982 respondents provided a pain diary for one 24-hour period during which they rated pain on a seven-point scale. The researchers randomly selected three 15-minute intervals during waking hours for each participant.
Overall, respondents averaged 17.8 episodes of any degree of pain during the day before the survey.
Reports were similar from men and women. Race and ethnic origin were likewise not significant predictors of pain.
Pain ratings generally rose with age, although scores tended to plateau from the mid-40s to the mid-70s.
Along with age, education was a strong predictor of pain. Participants with less than a high school diploma had an average pain rating twice that of college graduates (1.21 versus 0.69, P<0.001).
Likewise, average pain ratings were about twice as high for men and women in households with yearly income below $30,000 as for those with an annual income of more than $100,000 (1.27 versus 0.67, P<0.001).
Individuals in the lowest income category spent 34.2% of their time in some degree of pain and 18.5% of their time in more severe pain (pain scores of three or higher on the seven-point scale). Those proportions were 22.9% and 7.7% for those in the highest income category.
The reason for these disparities, the authors suggested, was at least partly related to occupational status. Blue-collar workers had higher average pain ratings both during and outside of work than did white-collar workers (1.00 and 0.84 versus 0.61 and 0.61, respectively).
"Such a disparity emphasizes the need for pain-prevention measures, such as better ergonomics and better availability of occupational health services, in jobs with high physical strains," Dr. Turunen said in his editorial.
Drs. Kruger and Stone also found that disability and lack of satisfaction with life and health status were associated with the highest pain levels (all P<0.001).
Those participants who reported significant pain during much of the day reported spending 24.1% of their time watching television, whereas others spent 16% of the day in front of the TV.
Those individuals also spent more time relaxing and less time working and traveling than others, even when controlling for age and other demographic factors.
However, the researchers cautioned that the survey response rate was low (37%) and noted that the study lacked information on causes, location, and duration of pain, as well as medical conditions and treatments.
Further study is needed to identify groups of patients needing help with pain, Dr. Turunen said, "for example, to enable pain sufferers to obtain quicker and easier access to multidisciplinary pain clinics."
The study was supported by the National Institute of Aging and the Hewlett Foundation. Drs. Kruger and Stone reported being consulting senior scientists to the Gallup Organization. Dr. Stone also reported being associate chair of the scientific advisory board for Invivodata. Dr. Turunen reported no conflicts of interest.
Primary source: The LancetSource reference:Krueger AB, Stone AA "Assessment of pain: A community-based diary survey in the USA" Lancet 2008; 371: 1519-25. Additional source: The LancetSource reference: Turunen JHO "Depicting the pain profile with the diary-day method" Lancet 2008; 371: 1482-83.
Vitamin E Offers No Protection from Cataracts
By John Gever
BOSTON, 04 may 2008-- Ten years of vitamin E supplements were associated with no effect on cataract development among middle-age and older women, researchers here found.
Among 37,675 participants in the Women's Health Study, involving women 45 and older, 1,159 of those taking vitamin E supplements and 1,217 of those taking placebo developed cataracts, reported William G. Christen, D.Sc., of Brigham and Women's Hospital, and colleagues in the May issue of Ophthalmology.
That worked out to a relative risk of 0.96 (95% CI 0.88 to 1.04), the researchers said.
The Women's Health Study randomized health professionals to 600 IU of vitamin E or placebo every other day, and to 100 mg of aspirin or placebo every other day. Early participants also took beta-carotene. The primary endpoints involved cardiovascular events and cancer. The study began in 1993 and is ongoing.
Because cataracts are thought to arise from oxidative damage to the lens, a number of prospective trials have examined whether vitamin E supplements can prevent them.
None of them identified a benefit, but the longest follow-up in those studies was 6.5 years. Cataracts are slow to develop, and finding a benefit from vitamin E may require a longer trial, Dr. Christen and colleagues said.
Mean follow-up in the Women's Health Study was 9.7 years, with data through March 2004 analyzed in the study.
Participants completed annual questionnaires, which included an item asking whether they had a new diagnosis of cataract or had undergone a cataract extraction.
Those with "yes" answers were asked to give consent for their ophthalmologists or optometrists to be consulted. These professionals then were asked to submit detailed information on the participants' diagnosis and treatment.
Dr. Christen and colleagues obtained adequate information for more than 91% of participants reporting new cataracts.
The data failed to show any effect of vitamin E on subgroups of participants, stratified by age or type of cataract (nuclear sclerosis, cortical, or posterior subcapsular).
Nor did stratification by risk factor reveal a benefit for vitamin E.
Risk factors analyzed in the study included smoking status, alcohol use, body mass index, hypertension, hyperlipidemia, diabetes, menopausal status, use of hormone replacement therapy, parental history of early heart attack, and current multivitamin use.
The only risk-factor subgroups that came close to a significant benefit from vitamin E were those with a parental history of early heart attack (RR 0.80, P=0.08), those with body mass index less than 25 (RR 0.91, P=0.10), and those with hypertension (RR 0.91, P=0.16).
Dr. Christen and colleagues said the apparent lack of effect, while consistent with earlier trials, does not absolutely rule out the possibility that anti-oxidant treatment could help prevent cataracts.
Other researchers have suggested that a barrier forms by middle age that prevents anti-oxidant molecules from reaching the lens nucleus.
"If real, such a barrier might have contributed to the null findings," Dr. Christen and colleagues wrote.
Poor participant compliance seemed unlikely to explain the findings. Thus "averaged throughout the trial, compliance (defined as taking at least two-thirds of the study capsules) was 75.8%, with no difference between the active and placebo groups (P=0.64)," they wrote.
Confounding factors not taken into account in the study design and bias in measuring cataract formation were also possible, though unlikely, the researchers said.
Dr. Christen and colleagues noted that several large ongoing trials are also testing anti-oxidants for preventing eye disease, including the Physicians' Health Study II, a male counterpart to the Women's Health Study.
Data from the large Nurses' Health Study in 2005 found that participants taking vitamin E supplements had slower progression of cataracts. However, that was a retrospective analysis derived from nutrient intake questionnaires, and participants decided on their own whether to take supplements.
The Women's Health Study analysis was funded by the National Institutes of Health. The Women's Health Study is sponsored by the National Heart, Lung, and Blood Institute.
No potential conflicts of interest were reported.
Primary source: OphthalmologySource reference:Christen W, et al "Vitamin E and age-related cataract in a randomized trial of women" Ophthalmology 2008; 115: 822-29.
By John Gever
BOSTON, 04 may 2008-- Ten years of vitamin E supplements were associated with no effect on cataract development among middle-age and older women, researchers here found.
Among 37,675 participants in the Women's Health Study, involving women 45 and older, 1,159 of those taking vitamin E supplements and 1,217 of those taking placebo developed cataracts, reported William G. Christen, D.Sc., of Brigham and Women's Hospital, and colleagues in the May issue of Ophthalmology.
That worked out to a relative risk of 0.96 (95% CI 0.88 to 1.04), the researchers said.
The Women's Health Study randomized health professionals to 600 IU of vitamin E or placebo every other day, and to 100 mg of aspirin or placebo every other day. Early participants also took beta-carotene. The primary endpoints involved cardiovascular events and cancer. The study began in 1993 and is ongoing.
Because cataracts are thought to arise from oxidative damage to the lens, a number of prospective trials have examined whether vitamin E supplements can prevent them.
None of them identified a benefit, but the longest follow-up in those studies was 6.5 years. Cataracts are slow to develop, and finding a benefit from vitamin E may require a longer trial, Dr. Christen and colleagues said.
Mean follow-up in the Women's Health Study was 9.7 years, with data through March 2004 analyzed in the study.
Participants completed annual questionnaires, which included an item asking whether they had a new diagnosis of cataract or had undergone a cataract extraction.
Those with "yes" answers were asked to give consent for their ophthalmologists or optometrists to be consulted. These professionals then were asked to submit detailed information on the participants' diagnosis and treatment.
Dr. Christen and colleagues obtained adequate information for more than 91% of participants reporting new cataracts.
The data failed to show any effect of vitamin E on subgroups of participants, stratified by age or type of cataract (nuclear sclerosis, cortical, or posterior subcapsular).
Nor did stratification by risk factor reveal a benefit for vitamin E.
Risk factors analyzed in the study included smoking status, alcohol use, body mass index, hypertension, hyperlipidemia, diabetes, menopausal status, use of hormone replacement therapy, parental history of early heart attack, and current multivitamin use.
The only risk-factor subgroups that came close to a significant benefit from vitamin E were those with a parental history of early heart attack (RR 0.80, P=0.08), those with body mass index less than 25 (RR 0.91, P=0.10), and those with hypertension (RR 0.91, P=0.16).
Dr. Christen and colleagues said the apparent lack of effect, while consistent with earlier trials, does not absolutely rule out the possibility that anti-oxidant treatment could help prevent cataracts.
Other researchers have suggested that a barrier forms by middle age that prevents anti-oxidant molecules from reaching the lens nucleus.
"If real, such a barrier might have contributed to the null findings," Dr. Christen and colleagues wrote.
Poor participant compliance seemed unlikely to explain the findings. Thus "averaged throughout the trial, compliance (defined as taking at least two-thirds of the study capsules) was 75.8%, with no difference between the active and placebo groups (P=0.64)," they wrote.
Confounding factors not taken into account in the study design and bias in measuring cataract formation were also possible, though unlikely, the researchers said.
Dr. Christen and colleagues noted that several large ongoing trials are also testing anti-oxidants for preventing eye disease, including the Physicians' Health Study II, a male counterpart to the Women's Health Study.
Data from the large Nurses' Health Study in 2005 found that participants taking vitamin E supplements had slower progression of cataracts. However, that was a retrospective analysis derived from nutrient intake questionnaires, and participants decided on their own whether to take supplements.
The Women's Health Study analysis was funded by the National Institutes of Health. The Women's Health Study is sponsored by the National Heart, Lung, and Blood Institute.
No potential conflicts of interest were reported.
Primary source: OphthalmologySource reference:Christen W, et al "Vitamin E and age-related cataract in a randomized trial of women" Ophthalmology 2008; 115: 822-29.
Gene Expression May Identify High-Risk Prostate Neoplasia
By Charles Bankhead
BARCELONA, 04 may 2008 -- The risk that high-grade prostatic intraepithelial neoplasia will turn malignant may stem from overexpression of a prostate tumor gene, found investigators here.
A negative biopsy finding for overexpression of the gene in high-grade PINs could save men from future biopsies, added the investigators. Conversely, a positive finding could mean quick action.
Malignant high-grade PINs had 60% greater expression of PTOV1 (prostate tumor overexpressed-1) compared with benign lesions, Rosanna Paciucci, Ph.D., of Vall d'Hebron Hospital Research Institute, and colleagues, reported in the May 1 issue of Clinical Cancer Research.
But as expression of PTOV1 decreased, so did the risk of malignant transformation.
If validated in other studies, the findings could help focus prostate biopsy on high-risk high-grade PIN and allow men with benign disease to avoid unnecessary biopsies.
"Those patients with a high PTOV1 score should undergo an immediate repeat biopsy," said Dr. Paciucci. "Men who have low PTOV1 scores might not need additional annoying and useless biopsies. We estimate that we can save 40% of unnecessary biopsies that are repetitively negative and contain high-grade PIN lesions that do not develop into cancer."
Originally identified by Dr. Paciucci and colleagues, PTOV1 and its protein are differentially expressed in prostate cancer and regulated by androgens. Increased expression of PTOV1 correlates with increased proliferative activity and is associated with nuclear localization of POTV1 protein.
Because POTV1 is overexpressed in high-grade PIN associated with cancer, the investigators hypothesized that prostate needle biopsy specimens that test positive for PTOV1 would aid clinical decision making.
To test the hypothesis, Dr. Paciucci and colleagues examined PTOV1 expression in high-grade PIN lesions from 140 patients. Seventy-nine of them had undergone radical prostatectomy for prostate cancer (true positives); 11 had bladder cancer and normal prostate tissue (true negatives); and 50 patients had initial prostate biopsies that contained high-grade PIN but no cancer.
The 50 patients in the study group were followed for an average of 12.4 months, during which time they had an average of 2.5 prostate biopsies. All patients had at least one follow-up biopsy.
For all specimens examined, investigators calculated a histology score based on the percentage of stained cells in a specimen and the intensity of staining. Possible scores could range from 0 to 300.
High-grade PIN in radical prostatectomy specimens had an average score of 162.6 for PTOV1 expression, compared with 67 for specimens from the patients with bladder cancer (P<0.01). In the study group, 11 of 50 patients (22%) had cancer at follow-up, and PTOV1 expression averaged 151.4, whereas the 39 patients with no cancer at follow-up had a mean PTOV1 expression of 94.6 (P<0.01).
PTOV1 expression did not differ between the 11 study patients with cancer at follow-up and the 79 positive controls or between the 39 study patients with no cancer at follow-up and the patients with bladder cancer.
A threshold histology score of 100 for PTOV1 expression resulted in a sensitivity of 90% and a specificity of 57%. A threshold value of 63 was associated with a sensitivity of 95% and a specificity of 38%.
Applying a histology score of 100 to the 50 patients in the study group resulted in a sensitivity of 90.9%, specificity of 51.3%, positive predictive value of 34.5%, and negative predictive value of 95.2%.
Because the study was small and developments in this field, such as PSA velocity, are expanding rapidly, the authors suggest further prospective investigations are needed.
"We suggest that the analysis of PTOV1 expression might be helpful in the follow-up of men with isolated high-grade PIN in biopsies, especially after an extended biopsy scheme," the authors concluded. "An immediate repeated biopsy should be considered if the [histology score] is >100. If cancer is still not detected, the patient would be followed-up for his PSA velocity indicating the need to repeat the biopsy."
The authors reported no disclosures.
Primary source: Clinical Cancer ResearchSource reference:Morote J, et al "PTOV1 expression predicts prostate cancer in men with isolated high-grade prostatic intraepithelial neoplasia in needle biopsy" Clin Cancer Res 2008; 14: 2617-2622.
By Charles Bankhead
BARCELONA, 04 may 2008 -- The risk that high-grade prostatic intraepithelial neoplasia will turn malignant may stem from overexpression of a prostate tumor gene, found investigators here.
A negative biopsy finding for overexpression of the gene in high-grade PINs could save men from future biopsies, added the investigators. Conversely, a positive finding could mean quick action.
Malignant high-grade PINs had 60% greater expression of PTOV1 (prostate tumor overexpressed-1) compared with benign lesions, Rosanna Paciucci, Ph.D., of Vall d'Hebron Hospital Research Institute, and colleagues, reported in the May 1 issue of Clinical Cancer Research.
But as expression of PTOV1 decreased, so did the risk of malignant transformation.
If validated in other studies, the findings could help focus prostate biopsy on high-risk high-grade PIN and allow men with benign disease to avoid unnecessary biopsies.
"Those patients with a high PTOV1 score should undergo an immediate repeat biopsy," said Dr. Paciucci. "Men who have low PTOV1 scores might not need additional annoying and useless biopsies. We estimate that we can save 40% of unnecessary biopsies that are repetitively negative and contain high-grade PIN lesions that do not develop into cancer."
Originally identified by Dr. Paciucci and colleagues, PTOV1 and its protein are differentially expressed in prostate cancer and regulated by androgens. Increased expression of PTOV1 correlates with increased proliferative activity and is associated with nuclear localization of POTV1 protein.
Because POTV1 is overexpressed in high-grade PIN associated with cancer, the investigators hypothesized that prostate needle biopsy specimens that test positive for PTOV1 would aid clinical decision making.
To test the hypothesis, Dr. Paciucci and colleagues examined PTOV1 expression in high-grade PIN lesions from 140 patients. Seventy-nine of them had undergone radical prostatectomy for prostate cancer (true positives); 11 had bladder cancer and normal prostate tissue (true negatives); and 50 patients had initial prostate biopsies that contained high-grade PIN but no cancer.
The 50 patients in the study group were followed for an average of 12.4 months, during which time they had an average of 2.5 prostate biopsies. All patients had at least one follow-up biopsy.
For all specimens examined, investigators calculated a histology score based on the percentage of stained cells in a specimen and the intensity of staining. Possible scores could range from 0 to 300.
High-grade PIN in radical prostatectomy specimens had an average score of 162.6 for PTOV1 expression, compared with 67 for specimens from the patients with bladder cancer (P<0.01). In the study group, 11 of 50 patients (22%) had cancer at follow-up, and PTOV1 expression averaged 151.4, whereas the 39 patients with no cancer at follow-up had a mean PTOV1 expression of 94.6 (P<0.01).
PTOV1 expression did not differ between the 11 study patients with cancer at follow-up and the 79 positive controls or between the 39 study patients with no cancer at follow-up and the patients with bladder cancer.
A threshold histology score of 100 for PTOV1 expression resulted in a sensitivity of 90% and a specificity of 57%. A threshold value of 63 was associated with a sensitivity of 95% and a specificity of 38%.
Applying a histology score of 100 to the 50 patients in the study group resulted in a sensitivity of 90.9%, specificity of 51.3%, positive predictive value of 34.5%, and negative predictive value of 95.2%.
Because the study was small and developments in this field, such as PSA velocity, are expanding rapidly, the authors suggest further prospective investigations are needed.
"We suggest that the analysis of PTOV1 expression might be helpful in the follow-up of men with isolated high-grade PIN in biopsies, especially after an extended biopsy scheme," the authors concluded. "An immediate repeated biopsy should be considered if the [histology score] is >100. If cancer is still not detected, the patient would be followed-up for his PSA velocity indicating the need to repeat the biopsy."
The authors reported no disclosures.
Primary source: Clinical Cancer ResearchSource reference:Morote J, et al "PTOV1 expression predicts prostate cancer in men with isolated high-grade prostatic intraepithelial neoplasia in needle biopsy" Clin Cancer Res 2008; 14: 2617-2622.
Dementia Risk Factors Diverge by Gender
By Crystal Phend
4 may 2008-- Men with mild cognitive impairment tend to take a different fork in the road than women on the way to progression to dementia, researchers here found.Stroke conferred almost three-fold risk of dementia progression as one of the strongest predictive factors among men but had no prognostic value for women, reported Karen Ritchie, Ph.D., of the Université de Montpellier and La Colombière Hospital here, and colleagues, online in the Journal of Neurology, Neurosurgery, and Psychiatry. Major factors in progression to Alzheimer's and other types of dementia for women but not men included subclinical depression and use of anticholinergic drugs, according to the prospective population-based study of brain aging.
Because preventable risk factors differed between the sexes, the findings might have implications for practice, the researchers said.
"Intervention programs should focus principally on risk of stroke in men and depressive symptomatology and use of anticholinergic medication in women," they wrote.
Most previous studies have adjusted for sex when determining risk factors for cognitive impairment but not considered that risk profiles may not be the same for men and women, Dr. Ritchie and colleagues said.
So the researchers analyzed four-year follow-up data from the Three City Study of men and women age 65 years and older randomly selected from the community-dwelling French populations in Bordeaux, Dijon, and Montpellier.
The analysis included 6,892 participants without dementia (mean age 74) who completed a baseline interview at a study center, or in their own homes if disabled, and were followed up every two years.
Overall, 42% of patients were classified as having mild cognitive impairment at baseline. During four years of follow-up, 6.6% of patients went on to be diagnosed with dementia, predominantly Alzheimer's disease (122 of 189 patients). Other dementia cases included 19 patients with vascular dementia and four with Lewy body dementia.
Another 37% of patients returned to normal cognitive functioning.
Women in the study were less likely than men to return to normal cognition (36% versus 39%) but also slightly less likely to progress from mild cognitive impairment to dementia (6% versus 8%).
Risk factors largely varied between men and women for both mild cognitive impairment and progression to dementia.
For both genders, mild cognitive impairment was more common among participants with depressive symptoms and use of anticholinergic medications. Other factors in mild cognitive impairment for men were older age, higher body mass index, and diabetes or stroke. For women, the factors were disability, social isolation, insomnia, and self-rated poor health.
Although not a factor in early impairment, the ApoE4 genotype associated with dementia in previous studies was the single strongest predictor of progression to dementia for men in the Three Cities Study (odds ratio 3.2, 95% confidence interval 1.7 to 5.7).
The ApoE4 allele was likewise a strong risk factor for progression among women (OR 2.3, 95% CI 1.4 to 4.0), but the best predictor of progression for them was loss of ability to perform daily tasks independently (OR 3.5, 95% CI 2.1 to 5.9).
Other main factors for progression to dementia rather than stable cognitive impairment or return to normal function for men were:
Stroke (OR 2.8, 95% CI 1.2 to 6.9)
Low level of education (OR 2.3, 95% CI 1.3 to 4.1)
Loss of ability to perform activities of daily living without assistance (OR 2.2, 95% CI 1.1 to 4.5)
Older age (OR 1.2, 95% CI 1.1 to 1.2)
For women, significant factors in dementia progression included:
Low level of education (OR 2.2, 95% CI 1.3 to 3.6)
Subclinical depression with symptoms but not diagnosis of major depression (OR 2.0, 95% CI 1.1 to 3.6)
Use of anticholinergic drugs (OR 1.8, 95% CI 1.0 to 3.0)
Older age (OR 1.1, 95% CI 1.1 to 1.2)
These differences between the sexes were not due to varying prevalence of these conditions in men and women, Dr. Ritchie and colleagues said.
Rather, "these findings support the notion that mild cognitive impairment is a common end point to multiple etiological pathways, which are not the same for men and women," they said.
The explanation could be different endocrinological risk factors and exposures to environmental hazards, such as life events, diet, and injury, they said.
However, the researchers noted that the study could have been limited by the duration of follow-up, which might have been too short for slowly evolving cases of dementia, and lack of analysis by domain-specific mild cognitive impairment.
The Three City Study was conducted under a partnership agreement between Inserm, the Victor Segalen--Bordeaux II University, and Sanofi-Synthelabo. The first phase of the study was funded by the Fondation pour la Recherche Médicale. The study was also supported by the Caisse Nationale Maladie des Travailleurs Salariés, Direction Générale de la Santé, MGEN, the Institut de la Longévite´, Agence Française de Sécurité Sanitaire des Produits de Santé, the regional governments of the areas where the study was conducted, and the Fondation de France. The Lille Génopôle received an unconditional grant from Eisai.
The researchers reported no conflicts of interest.
Primary source: Journal of Neurology Neurosurgery and PsychiatrySource reference:Artero S, et al "Risk profiles for mild cognitive impairment and progression to dementia are gender specific" Neurol Neurosurg Psychiatry 2008; DOI: 10.1136/jnnp.2007.136903.
By Crystal Phend
4 may 2008-- Men with mild cognitive impairment tend to take a different fork in the road than women on the way to progression to dementia, researchers here found.Stroke conferred almost three-fold risk of dementia progression as one of the strongest predictive factors among men but had no prognostic value for women, reported Karen Ritchie, Ph.D., of the Université de Montpellier and La Colombière Hospital here, and colleagues, online in the Journal of Neurology, Neurosurgery, and Psychiatry. Major factors in progression to Alzheimer's and other types of dementia for women but not men included subclinical depression and use of anticholinergic drugs, according to the prospective population-based study of brain aging.
Because preventable risk factors differed between the sexes, the findings might have implications for practice, the researchers said.
"Intervention programs should focus principally on risk of stroke in men and depressive symptomatology and use of anticholinergic medication in women," they wrote.
Most previous studies have adjusted for sex when determining risk factors for cognitive impairment but not considered that risk profiles may not be the same for men and women, Dr. Ritchie and colleagues said.
So the researchers analyzed four-year follow-up data from the Three City Study of men and women age 65 years and older randomly selected from the community-dwelling French populations in Bordeaux, Dijon, and Montpellier.
The analysis included 6,892 participants without dementia (mean age 74) who completed a baseline interview at a study center, or in their own homes if disabled, and were followed up every two years.
Overall, 42% of patients were classified as having mild cognitive impairment at baseline. During four years of follow-up, 6.6% of patients went on to be diagnosed with dementia, predominantly Alzheimer's disease (122 of 189 patients). Other dementia cases included 19 patients with vascular dementia and four with Lewy body dementia.
Another 37% of patients returned to normal cognitive functioning.
Women in the study were less likely than men to return to normal cognition (36% versus 39%) but also slightly less likely to progress from mild cognitive impairment to dementia (6% versus 8%).
Risk factors largely varied between men and women for both mild cognitive impairment and progression to dementia.
For both genders, mild cognitive impairment was more common among participants with depressive symptoms and use of anticholinergic medications. Other factors in mild cognitive impairment for men were older age, higher body mass index, and diabetes or stroke. For women, the factors were disability, social isolation, insomnia, and self-rated poor health.
Although not a factor in early impairment, the ApoE4 genotype associated with dementia in previous studies was the single strongest predictor of progression to dementia for men in the Three Cities Study (odds ratio 3.2, 95% confidence interval 1.7 to 5.7).
The ApoE4 allele was likewise a strong risk factor for progression among women (OR 2.3, 95% CI 1.4 to 4.0), but the best predictor of progression for them was loss of ability to perform daily tasks independently (OR 3.5, 95% CI 2.1 to 5.9).
Other main factors for progression to dementia rather than stable cognitive impairment or return to normal function for men were:
Stroke (OR 2.8, 95% CI 1.2 to 6.9)
Low level of education (OR 2.3, 95% CI 1.3 to 4.1)
Loss of ability to perform activities of daily living without assistance (OR 2.2, 95% CI 1.1 to 4.5)
Older age (OR 1.2, 95% CI 1.1 to 1.2)
For women, significant factors in dementia progression included:
Low level of education (OR 2.2, 95% CI 1.3 to 3.6)
Subclinical depression with symptoms but not diagnosis of major depression (OR 2.0, 95% CI 1.1 to 3.6)
Use of anticholinergic drugs (OR 1.8, 95% CI 1.0 to 3.0)
Older age (OR 1.1, 95% CI 1.1 to 1.2)
These differences between the sexes were not due to varying prevalence of these conditions in men and women, Dr. Ritchie and colleagues said.
Rather, "these findings support the notion that mild cognitive impairment is a common end point to multiple etiological pathways, which are not the same for men and women," they said.
The explanation could be different endocrinological risk factors and exposures to environmental hazards, such as life events, diet, and injury, they said.
However, the researchers noted that the study could have been limited by the duration of follow-up, which might have been too short for slowly evolving cases of dementia, and lack of analysis by domain-specific mild cognitive impairment.
The Three City Study was conducted under a partnership agreement between Inserm, the Victor Segalen--Bordeaux II University, and Sanofi-Synthelabo. The first phase of the study was funded by the Fondation pour la Recherche Médicale. The study was also supported by the Caisse Nationale Maladie des Travailleurs Salariés, Direction Générale de la Santé, MGEN, the Institut de la Longévite´, Agence Française de Sécurité Sanitaire des Produits de Santé, the regional governments of the areas where the study was conducted, and the Fondation de France. The Lille Génopôle received an unconditional grant from Eisai.
The researchers reported no conflicts of interest.
Primary source: Journal of Neurology Neurosurgery and PsychiatrySource reference:Artero S, et al "Risk profiles for mild cognitive impairment and progression to dementia are gender specific" Neurol Neurosurg Psychiatry 2008; DOI: 10.1136/jnnp.2007.136903.
Saturday, May 03, 2008
AGS: Long-Term Proton Pump Inhibitor Use Does Not Reduce Vitamin B12 Absorption
By Peggy Peck
3 may 2008-- Long-term use of proton pump inhibitors did not adversely impact vitamin B12 status, researchers here reported.
In a study of 125 couples in which one partner used the drugs and the other did not, there was no significant difference in the prevalence of low vitamin B12 levels, said Wendy P.J. den Elzen, M.Sc., of Leiden University Medical Center in the Netherlands.
Den Elzen said several short-term studies have suggested that proton pump inhibitors use was associated with decreased absorption of vitamin B12, which has prompted some geriatricians to recommend periodic screening of elderly users for vitamin deficiency.
"But in this study, the average vitamin B12 level was 345 pmol/L among the drug users and 339 pmol/L among non-users," she said.
They defined low vitamin B12 levels as less than 150 pmol/L, which was observed in 3% of users versus 2% of non-users,
By Peggy Peck
3 may 2008-- Long-term use of proton pump inhibitors did not adversely impact vitamin B12 status, researchers here reported.
In a study of 125 couples in which one partner used the drugs and the other did not, there was no significant difference in the prevalence of low vitamin B12 levels, said Wendy P.J. den Elzen, M.Sc., of Leiden University Medical Center in the Netherlands.
Den Elzen said several short-term studies have suggested that proton pump inhibitors use was associated with decreased absorption of vitamin B12, which has prompted some geriatricians to recommend periodic screening of elderly users for vitamin deficiency.
"But in this study, the average vitamin B12 level was 345 pmol/L among the drug users and 339 pmol/L among non-users," she said.
They defined low vitamin B12 levels as less than 150 pmol/L, which was observed in 3% of users versus 2% of non-users,
The participants were recruited from 39 general practices in the Leiden Primary Care Research Network; 206 couples were invited to participate and 125 completed study questionnaires and agreed to blood tests.
Partners who shared the same dwelling for three or more years served as controls. Long-term use was defined as at least 840 doses in three years.
The median age of drug users and non-users was 73, and 55% of users were women. Among PPI users, 21% also took over-the-counter multivitamins, compared with 19% of non-users.
The median duration of proton pump inhibitors use was six years. Most users (66%) said they took the drug to treat gastroesophageal reflux disease, 5% said they used it for peptic ulcers, 5% to treat GI side-effects of NSAIDs, and 25% said they took PPIs for other reasons.
Persons who used parenteral vitamin B12 supplements, folic acid supplements, H2-blockers, and antacids for the three years preceding study entry were excluded.
Among study participants, 32% of the proton pump inhibitors users and 41% of non-users tested positive for Helicobacter pylori.
When the data were analyzed by duration of use, "we found no increased risk of vitamin B12 deficiency with increased duration," den Elzen said.
There were also no differences in homocysteine levels or in mean corpuscular volume (MCV).
Asked about fracture risk or increased risk of peritonitis or Clostridium difficile-associated disease -- both of which have been reported in other studies -- among the PPI users, den Elzen said she and her colleagues did not collect data on either condition .The study was funded by the Leiden University Medical Center, Public Health and Primary Care Division.
Ms. den Elzen said she had no financial disclosures.
Primary source: American Geriatrics Society MeetingSource reference:den Elzen W, et al "Long-term use of proton pump inhibitors and vitamin B12 status in elderly individuals" C53
Alzheimer's Disease Risk Factors May Be Gender-Specific
03 may 2008 -- Depression in women and stroke in men are critical factors in the development of Alzheimer's disease, French researchers report.
They analyzed data from almost 7,000 people over the age of 65 in three French cities. None of them had dementia, but about 40 percent had mild cognitive impairment at the start of the study.
They were assessed two and four years later. Of those with mild cognitive impairment at the start of the study, just over 6.5 percent developed dementia over the next four years, about half had no change, and about one-third regained normal levels of cognitive ability.
People with depression, those taking anticholinergic drugs (which influence chemical signaling in the brain), and those with a variation in the ApoE gene (a known risk factor for dementia) were more likely to progress from mild cognitive impairment to dementia.
The researchers also found that risk factors varied according to gender. Men with mild cognitive impairment were more likely to be overweight, diabetic and to have had a stroke. Men who'd suffered a stroke were almost three times more likely to progress from mild cognitive impairment to dementia.
Women with mild cognitive impairment were more likely to be in poorer general health, disabled, suffering from insomnia, and to have a poor support network. Women with depression were twice as likely to progress from mild cognitive impairment to dementia, while women unable to perform routine daily tasks (which would allow them to live without assistance) were 3.5 times more likely to progress to dementia.
Stroke was not a risk factor for women, even though both women and men had similar rates of stroke.
The study was published online in the Journal of Neurology Neurosurgery & Psychiatry.
03 may 2008 -- Depression in women and stroke in men are critical factors in the development of Alzheimer's disease, French researchers report.
They analyzed data from almost 7,000 people over the age of 65 in three French cities. None of them had dementia, but about 40 percent had mild cognitive impairment at the start of the study.
They were assessed two and four years later. Of those with mild cognitive impairment at the start of the study, just over 6.5 percent developed dementia over the next four years, about half had no change, and about one-third regained normal levels of cognitive ability.
People with depression, those taking anticholinergic drugs (which influence chemical signaling in the brain), and those with a variation in the ApoE gene (a known risk factor for dementia) were more likely to progress from mild cognitive impairment to dementia.
The researchers also found that risk factors varied according to gender. Men with mild cognitive impairment were more likely to be overweight, diabetic and to have had a stroke. Men who'd suffered a stroke were almost three times more likely to progress from mild cognitive impairment to dementia.
Women with mild cognitive impairment were more likely to be in poorer general health, disabled, suffering from insomnia, and to have a poor support network. Women with depression were twice as likely to progress from mild cognitive impairment to dementia, while women unable to perform routine daily tasks (which would allow them to live without assistance) were 3.5 times more likely to progress to dementia.
Stroke was not a risk factor for women, even though both women and men had similar rates of stroke.
The study was published online in the Journal of Neurology Neurosurgery & Psychiatry.
Complications Found in Proposed Prostate Cancer Treatment
03 may 2008-- The idea that prostate cancer can be treated successfully just by blocking the activity of a protein called insulin-like growth factor (IGF-1) has been undermined by two new studies.
IGF-1 blockage is a goal being pursed by a number of drug companies and academic researchers, stimulated by studies showing an association between high levels of the protein and prostate cancer risk. Many efforts are aimed at blocking the receptors for IGF-1 in prostate cancer cells.
The new studies showing that blocking IGF-1 receptors isn't as simple a matter as might be wished are published back to back in the May 1 issue of Cancer Research.
One of the studies, by a group led by Norman Greenberg, a member of the clinical research division at the Fred Hutchinson Cancer Research Center in Seattle, found an unexpected interaction with a tumor suppressor gene, p53. The researchers created mice whose prostate cells lacked receptors for IGF-1 and crossed them with mice whose P53 gene function was crippled.
"When the function of p53 is abrogated, the cancers seem to accelerate," Greenberg said. "So when you interfere with the IGF-1 receptor, you might be taking the foot off the brake."
That wouldn't matter in human males whose p53 genes were working properly, Greenberg said. "What we are suggesting is that when p53 is compromised, patients might not respond as indicated," he said.
This might mean that a check of p53 function in someone with prostate cancer might be needed before IGF-1 blockage therapy is started, Greenberg said. That idea has to be checked out, he said.
"So we would get data on a patient's tumor before treatment and after treatment, and see if the status of p53 shows whether it would respond more or less to IGF-1 treatment," Greenberg said.
The other study, this one led by Dr. Pinchas Cohen, chief of pediatric endocrinology at the University of California, Los Angeles, also used mice bred to develop prostate cancer, with some also bred to lack IGF-1 receptors.
"The conventional wisdom was that without the IGF receptors, the tumors would fail to develop or be much smaller," Cohen said. "What happened was that they were not reduced in size. In fact, they were exactly the same size."
Low IGF-1 levels in the mice were accompanied by higher levels of growth hormone and insulin, which stimulated growth of the cancer cells, Cohen said.
"This doesn't argue against IGF-1 blockage as a treatment," he said. "But it shows the need for targeting multiple pathways. As the cancers find ways to overcome IGF-1 blockage, it should be used in conjunction with other therapies."
03 may 2008-- The idea that prostate cancer can be treated successfully just by blocking the activity of a protein called insulin-like growth factor (IGF-1) has been undermined by two new studies.
IGF-1 blockage is a goal being pursed by a number of drug companies and academic researchers, stimulated by studies showing an association between high levels of the protein and prostate cancer risk. Many efforts are aimed at blocking the receptors for IGF-1 in prostate cancer cells.
The new studies showing that blocking IGF-1 receptors isn't as simple a matter as might be wished are published back to back in the May 1 issue of Cancer Research.
One of the studies, by a group led by Norman Greenberg, a member of the clinical research division at the Fred Hutchinson Cancer Research Center in Seattle, found an unexpected interaction with a tumor suppressor gene, p53. The researchers created mice whose prostate cells lacked receptors for IGF-1 and crossed them with mice whose P53 gene function was crippled.
"When the function of p53 is abrogated, the cancers seem to accelerate," Greenberg said. "So when you interfere with the IGF-1 receptor, you might be taking the foot off the brake."
That wouldn't matter in human males whose p53 genes were working properly, Greenberg said. "What we are suggesting is that when p53 is compromised, patients might not respond as indicated," he said.
This might mean that a check of p53 function in someone with prostate cancer might be needed before IGF-1 blockage therapy is started, Greenberg said. That idea has to be checked out, he said.
"So we would get data on a patient's tumor before treatment and after treatment, and see if the status of p53 shows whether it would respond more or less to IGF-1 treatment," Greenberg said.
The other study, this one led by Dr. Pinchas Cohen, chief of pediatric endocrinology at the University of California, Los Angeles, also used mice bred to develop prostate cancer, with some also bred to lack IGF-1 receptors.
"The conventional wisdom was that without the IGF receptors, the tumors would fail to develop or be much smaller," Cohen said. "What happened was that they were not reduced in size. In fact, they were exactly the same size."
Low IGF-1 levels in the mice were accompanied by higher levels of growth hormone and insulin, which stimulated growth of the cancer cells, Cohen said.
"This doesn't argue against IGF-1 blockage as a treatment," he said. "But it shows the need for targeting multiple pathways. As the cancers find ways to overcome IGF-1 blockage, it should be used in conjunction with other therapies."
Daily Aspirin May Reduce Breast Cancer Risk
By Steven Reinberg
3 may 2008-- Women who take an aspirin each day may reduce their risk of developing the most common type of breast cancer by 16 percent, according to the results of a large study.
Estrogen receptor-positive breast cancer accounts for some 75 percent of all breast cancers, experts say. While aspirin reduced the risk of this form of breast malignancy, other painkillers did not, the U.S. team found.
"Many studies have looked at the relationship between nonsteroidal anti-inflammatory drugs (NSAIDs) and cancer, and the results have been all over the board," said lead researcher Gretchen Gierach, a cancer prevention fellow at the U.S. National Cancer Institute. "We want to further examine the question to see if we can add some clarity, since studies have looked at NSAIDs but haven't broken them down by type of NSAID."
The report is published in the April 30 online edition of Breast Cancer Research.
In the study, Gierach's team collected data on more than 127,000 women aged 51 to 72 with no history of cancer. All had participated in the U.S. National Institutes of Health-AARP Diet and Health Study. That study was designed to look at diet, health-related behaviors, and the risk for cancer.
Gierach noted that aspirin does has different biological effects compared to other NSAIDs.
Aspirin is one of many NSAIDs but unlike other NSAIDs it has irreversible effects on cyclooxygenase (COX) enzymes. For this reason, the researchers looked at the differences in cancer risk based on whether women took aspirin or other NSAIDs.
"Among women who reported taking aspirin on a daily basis there was a modest reduction in estrogen receptor-positive breast cancer," Gierach said.
Overall, NSAIDs did not affect the total risk of breast cancer. However, the daily use of aspirin was associated with a 16 percent reduction in the risk for estrogen receptor-positive breast tumors.
There was no link between daily aspirin and the incidence of estrogen receptor-negative breast cancer, the researchers report.
The finding could have important implications for cancer prevention, Gierach says, but a lot more work is needed to see if the effect is real. Moreover, she believes that it is still too early to recommend that women start taking aspirin to prevent breast malignancy.
"This is an exciting implication, if it's true," Gierach said. "But we need further clarity from other studies."
One expert noted that chronic aspirin use can have serious consequences and should not be used for cancer prevention.
"The American Cancer Society does not recommend using aspirin for cancer prevention because aspirin can cause serious gastrointestinal bleeding," said Eric J. Jacobs, Strategic Director of Pharmacoepidemiology in the department of epidemiology and surveillance research at the American Cancer Society.
Whether or not you should use aspirin for disease prevention is a question that should be discussed with your doctor, who can take your medical history into account, Jacobs said. "This decision should be based on balancing the proven benefits of aspirin in preventing heart disease against the proven risks of serious gastrointestinal bleeding," he said.
Another expert was intrigued by the findings.
"This theory has been around for many years," said Barbara Brenner, executive director of Breast Cancer Action. "If this works, it is a very exciting development for a lot of people who are thinking about how we can control not only cancer, but the price of cancer drugs."
The finding is confirming what many people have thought for a long time, Brenner added. But she stressed that aspirin would not be "a cure-all, it's only reducing the risk of estrogen positive-breast cancer."
Like the other experts, Brenner doesn't advise women to start taking aspirin to prevent breast cancer. "There are risks with aspirin, and there are people for whom aspirin is not indicated," she said. "But they might want to talk to their doctors about this study and whether aspirin is appropriate for them."
By Steven Reinberg
3 may 2008-- Women who take an aspirin each day may reduce their risk of developing the most common type of breast cancer by 16 percent, according to the results of a large study.
Estrogen receptor-positive breast cancer accounts for some 75 percent of all breast cancers, experts say. While aspirin reduced the risk of this form of breast malignancy, other painkillers did not, the U.S. team found.
"Many studies have looked at the relationship between nonsteroidal anti-inflammatory drugs (NSAIDs) and cancer, and the results have been all over the board," said lead researcher Gretchen Gierach, a cancer prevention fellow at the U.S. National Cancer Institute. "We want to further examine the question to see if we can add some clarity, since studies have looked at NSAIDs but haven't broken them down by type of NSAID."
The report is published in the April 30 online edition of Breast Cancer Research.
In the study, Gierach's team collected data on more than 127,000 women aged 51 to 72 with no history of cancer. All had participated in the U.S. National Institutes of Health-AARP Diet and Health Study. That study was designed to look at diet, health-related behaviors, and the risk for cancer.
Gierach noted that aspirin does has different biological effects compared to other NSAIDs.
Aspirin is one of many NSAIDs but unlike other NSAIDs it has irreversible effects on cyclooxygenase (COX) enzymes. For this reason, the researchers looked at the differences in cancer risk based on whether women took aspirin or other NSAIDs.
"Among women who reported taking aspirin on a daily basis there was a modest reduction in estrogen receptor-positive breast cancer," Gierach said.
Overall, NSAIDs did not affect the total risk of breast cancer. However, the daily use of aspirin was associated with a 16 percent reduction in the risk for estrogen receptor-positive breast tumors.
There was no link between daily aspirin and the incidence of estrogen receptor-negative breast cancer, the researchers report.
The finding could have important implications for cancer prevention, Gierach says, but a lot more work is needed to see if the effect is real. Moreover, she believes that it is still too early to recommend that women start taking aspirin to prevent breast malignancy.
"This is an exciting implication, if it's true," Gierach said. "But we need further clarity from other studies."
One expert noted that chronic aspirin use can have serious consequences and should not be used for cancer prevention.
"The American Cancer Society does not recommend using aspirin for cancer prevention because aspirin can cause serious gastrointestinal bleeding," said Eric J. Jacobs, Strategic Director of Pharmacoepidemiology in the department of epidemiology and surveillance research at the American Cancer Society.
Whether or not you should use aspirin for disease prevention is a question that should be discussed with your doctor, who can take your medical history into account, Jacobs said. "This decision should be based on balancing the proven benefits of aspirin in preventing heart disease against the proven risks of serious gastrointestinal bleeding," he said.
Another expert was intrigued by the findings.
"This theory has been around for many years," said Barbara Brenner, executive director of Breast Cancer Action. "If this works, it is a very exciting development for a lot of people who are thinking about how we can control not only cancer, but the price of cancer drugs."
The finding is confirming what many people have thought for a long time, Brenner added. But she stressed that aspirin would not be "a cure-all, it's only reducing the risk of estrogen positive-breast cancer."
Like the other experts, Brenner doesn't advise women to start taking aspirin to prevent breast cancer. "There are risks with aspirin, and there are people for whom aspirin is not indicated," she said. "But they might want to talk to their doctors about this study and whether aspirin is appropriate for them."
Common Medications Could Cause Physical Impairment in the Elderly
3 may 2008 -- Two new studies show that anticholinergics, a commonly prescribed group of drugs, may cause elderly people to "slow down" in their daily physical activities.
The two reports from researchers at Wake Forest University School of Medicine support findings released a few weeks ago that anticholinergic drugs -- which treat a variety of diseases and conditions, including acid reflux, Parkinson's disease and urinary incontinence -- may cause older people to lose their thinking skills more quickly than those who don't take the medicines.
Anticholinergic drugs work by stopping acetylcholine, a chemical that enhances communication between nerve cells in the brain, from binding to its receptors in nerve cells.
In the first Wake Forest study, older adults taking anticholinergics became more likely to walk more slowly and to need help in other daily activities.
"These results were true even in older adults who have normal memory and thinking abilities," study author Dr. Kaycee M. Sink said in a prepared statement. "For older adults taking a moderately anticholinergic medication, or two or more mildly anticholinergic medications, their function was similar to that of someone three to four years older."
Common anticholinergic medicines cited in the study included the blood pressure medication nifedipine (Adalat or Procardia), the stomach antacid ranitidine (Zantac) and the incontinence medication tolterodine (Detrol).
The findings, which involved more than 3,000 people, average age 78, were scheduled to be presented Saturday at the American Geriatrics Society annual meeting, in Washington, D.C.
In a separate Wake Forest study, published online in April in the Journal of the American Geriatrics Society, Sink found that older nursing home residents who took medicines for dementia along with anticholingerics for incontinence declined in function 50 percent faster than those only treated only for dementia.
"Over a year's time, the decline we observed would represent a resident going from requiring only limited assistance in an activity to being completely dependent, or from requiring only supervision to requiring extensive assistance in an activity," said Sink, an assistant professor of internal medicine-gerontology at Wake Forest.
The seniors in the second study had completed at least two consecutive prescriptions for cholinesterase inhibitors, a family of drugs used to treat dementia by increasing levels of acetylcholine. These include donepezil (brand name Aricept), galantamine (Razadyne), rivastigmine (Exelon) and tacrine (Cognex).
About 10 percent of those studied were also taking either oxybutynin or tolterodine, the two most commonly prescribed drugs for urinary incontinence.
"The two drugs are pharmacological opposites, which led us to hypothesize that the simultaneous treatment of dementia and incontinence could lead to reduced effectiveness of one or both drugs, Sink said.
As an estimated 33 percent of people with dementia also take a medicine to control incontinence, this finding is especially alarming.
The two studies suggest that physicians should carefully consider the implications when prescribing anticholingeric medications to older adults.
3 may 2008 -- Two new studies show that anticholinergics, a commonly prescribed group of drugs, may cause elderly people to "slow down" in their daily physical activities.
The two reports from researchers at Wake Forest University School of Medicine support findings released a few weeks ago that anticholinergic drugs -- which treat a variety of diseases and conditions, including acid reflux, Parkinson's disease and urinary incontinence -- may cause older people to lose their thinking skills more quickly than those who don't take the medicines.
Anticholinergic drugs work by stopping acetylcholine, a chemical that enhances communication between nerve cells in the brain, from binding to its receptors in nerve cells.
In the first Wake Forest study, older adults taking anticholinergics became more likely to walk more slowly and to need help in other daily activities.
"These results were true even in older adults who have normal memory and thinking abilities," study author Dr. Kaycee M. Sink said in a prepared statement. "For older adults taking a moderately anticholinergic medication, or two or more mildly anticholinergic medications, their function was similar to that of someone three to four years older."
Common anticholinergic medicines cited in the study included the blood pressure medication nifedipine (Adalat or Procardia), the stomach antacid ranitidine (Zantac) and the incontinence medication tolterodine (Detrol).
The findings, which involved more than 3,000 people, average age 78, were scheduled to be presented Saturday at the American Geriatrics Society annual meeting, in Washington, D.C.
In a separate Wake Forest study, published online in April in the Journal of the American Geriatrics Society, Sink found that older nursing home residents who took medicines for dementia along with anticholingerics for incontinence declined in function 50 percent faster than those only treated only for dementia.
"Over a year's time, the decline we observed would represent a resident going from requiring only limited assistance in an activity to being completely dependent, or from requiring only supervision to requiring extensive assistance in an activity," said Sink, an assistant professor of internal medicine-gerontology at Wake Forest.
The seniors in the second study had completed at least two consecutive prescriptions for cholinesterase inhibitors, a family of drugs used to treat dementia by increasing levels of acetylcholine. These include donepezil (brand name Aricept), galantamine (Razadyne), rivastigmine (Exelon) and tacrine (Cognex).
About 10 percent of those studied were also taking either oxybutynin or tolterodine, the two most commonly prescribed drugs for urinary incontinence.
"The two drugs are pharmacological opposites, which led us to hypothesize that the simultaneous treatment of dementia and incontinence could lead to reduced effectiveness of one or both drugs, Sink said.
As an estimated 33 percent of people with dementia also take a medicine to control incontinence, this finding is especially alarming.
The two studies suggest that physicians should carefully consider the implications when prescribing anticholingeric medications to older adults.
Thursday, May 01, 2008
Chilean town giving free Viagra to senior citizens
01 may 2008--A working class suburb of Chile's capital began handing out free Viagra to senior citizens on Wednesday. Lo Prado Mayor Gonzalo Navarrete said he launched the program because "an active sexuality improves the overall quality of life."
About 1,500 residents of the working-class area are eligible to receive as many as four pills of the erectile dysfunction drug each month, the mayor said. They have to be at least 60 and be registered with the municipality's health service.
"A doctor will have to certify that they suffer from erectile dysfunction and that their condition would not put them in danger of suffering cardio-respiratory side effects," Navarrete told The Associated Press by telephone.
He said he has assured about US$10,000 (euro6,400) in financing for the program through the end of the year.
Some government insurance plans in the United States and elsewhere provide Viagra, but Lo Prado hands the 50mg pills out free, with no membership in any public or private insurance plan required.
Navarrete said some other mayors in the Santiago area, which includes 34 municipalities, have told him they plan similar programs.
Navarrete said he did not know how many pills had been distributed so far.
01 may 2008--A working class suburb of Chile's capital began handing out free Viagra to senior citizens on Wednesday. Lo Prado Mayor Gonzalo Navarrete said he launched the program because "an active sexuality improves the overall quality of life."
About 1,500 residents of the working-class area are eligible to receive as many as four pills of the erectile dysfunction drug each month, the mayor said. They have to be at least 60 and be registered with the municipality's health service.
"A doctor will have to certify that they suffer from erectile dysfunction and that their condition would not put them in danger of suffering cardio-respiratory side effects," Navarrete told The Associated Press by telephone.
He said he has assured about US$10,000 (euro6,400) in financing for the program through the end of the year.
Some government insurance plans in the United States and elsewhere provide Viagra, but Lo Prado hands the 50mg pills out free, with no membership in any public or private insurance plan required.
Navarrete said some other mayors in the Santiago area, which includes 34 municipalities, have told him they plan similar programs.
Navarrete said he did not know how many pills had been distributed so far.
Nursing homes undertreat dementia patients' pain
01 may 2008--Nursing home residents with dementia appear to be less likely to receive pain medication than other residents, even though they have just as many painful health conditions, a new study suggests.
Researchers at the University of North Carolina Chapel Hill evaluated data for 551 residents of six nursing homes across the state and found that residents who were cognitively impaired were less likely to receive regular doses of pain medication or to receive pain drugs at all.
This was despite the fact that dementia patients and cognitively healthy patients had similar rates of often-painful conditions like cancer, osteoarthritis and degeneration in the spinal disks.
Pain medications are often prescribed to be taken "as needed," the researchers note. The findings suggest that more nursing home residents with dementia should be on regularly scheduled doses of pain medication, they report in the Journal of Pain and Symptom Management.
This does not mean that undertreatment stems from neglect on the part of nursing home staff, lead author Dr. Kimberly S. Reynolds and her colleagues point out in the report. Instead, it is simply more difficult to recognize pain in dementia patients, who often lack the ability to communicate their symptoms or ask for pain drugs, as cognitively healthy nursing home residents do.
Indeed, the researchers' review of residents' medical records showed that while 34 percent of those with no cognitive impairment had documented pain in the past week, this was true of only 10 percent of residents with the most severe cognitive impairment.
Severely impaired patients were also more likely to have their pain documented as "less than daily" and "mild."
It was not surprising, then, that residents with dementia received pain drugs less often, according to Reynolds' team. Overall, 80 percent of residents with no impairment received pain medication at least occasionally, versus 56 percent of those who were the most severely impaired.
Similarly, 42 percent of cognitively healthy residents were on regularly scheduled doses of pain relievers, compared with only 23 percent of residents with severe dementia.
Yet it is unlikely that dementia patients truly were in less pain than their cognitively healthy counterparts, Reynolds and her colleagues write. In both groups of patients, roughly half had medical conditions likely to cause pain.
Given that severely impaired patients may be unable to complain of pain or ask for medication, the researchers conclude, in many cases it would be "more appropriate" for them to be on scheduled doses of medication.
SOURCE: Journal of Pain and Symptom Management, April 2008.
01 may 2008--Nursing home residents with dementia appear to be less likely to receive pain medication than other residents, even though they have just as many painful health conditions, a new study suggests.
Researchers at the University of North Carolina Chapel Hill evaluated data for 551 residents of six nursing homes across the state and found that residents who were cognitively impaired were less likely to receive regular doses of pain medication or to receive pain drugs at all.
This was despite the fact that dementia patients and cognitively healthy patients had similar rates of often-painful conditions like cancer, osteoarthritis and degeneration in the spinal disks.
Pain medications are often prescribed to be taken "as needed," the researchers note. The findings suggest that more nursing home residents with dementia should be on regularly scheduled doses of pain medication, they report in the Journal of Pain and Symptom Management.
This does not mean that undertreatment stems from neglect on the part of nursing home staff, lead author Dr. Kimberly S. Reynolds and her colleagues point out in the report. Instead, it is simply more difficult to recognize pain in dementia patients, who often lack the ability to communicate their symptoms or ask for pain drugs, as cognitively healthy nursing home residents do.
Indeed, the researchers' review of residents' medical records showed that while 34 percent of those with no cognitive impairment had documented pain in the past week, this was true of only 10 percent of residents with the most severe cognitive impairment.
Severely impaired patients were also more likely to have their pain documented as "less than daily" and "mild."
It was not surprising, then, that residents with dementia received pain drugs less often, according to Reynolds' team. Overall, 80 percent of residents with no impairment received pain medication at least occasionally, versus 56 percent of those who were the most severely impaired.
Similarly, 42 percent of cognitively healthy residents were on regularly scheduled doses of pain relievers, compared with only 23 percent of residents with severe dementia.
Yet it is unlikely that dementia patients truly were in less pain than their cognitively healthy counterparts, Reynolds and her colleagues write. In both groups of patients, roughly half had medical conditions likely to cause pain.
Given that severely impaired patients may be unable to complain of pain or ask for medication, the researchers conclude, in many cases it would be "more appropriate" for them to be on scheduled doses of medication.
SOURCE: Journal of Pain and Symptom Management, April 2008.
Global researchers join hands to fight cancer
01 may 2008--Scientists across the globe are stepping up the fight against cancer, joining forces to create a first-of-a-kind database of genetic factors, research institutions said Wednesday.
The International Cancer Genome Consortium was formed by research bodies in nine countries and the European Commission for efforts projected to take up to a decade.
"This is the first large international cooperation" on cancer research at the genetic level, said Takuya Okamoto, a research promotion official at Japan's state-backed Riken institution, which is involved in the project.
The consortium will allow research to be conducted internationally without duplication, he said.
"We didn't have a good tool to fight cancer before but now we're seeing the light in revealing its mechanisms at the level of genes," he said.
The project was initiated by Canada's Ontario Institute for Cancer Research and the US National Institutes of Health, he said. Its secretariat will be housed at the Canadian institute in Toronto.
Once thought of as a single disease, cancer is now understood to consist of a large number of different conditions, the consortium noted in a statement.
In almost all forms, however, cancer changes the genetic blueprint, or genomes, of cells, and causes disruptions within normal biological pathways, leading to uncontrolled cell growth, it said.
Each participating institution will take up one type or subtype of cancer and find data on it at its own cost. Each batch of research is estimated to cost 20 million dollars.
Eventually, a genetic catalogue would allow doctors to warn patients of risks by analysing their genes, Okamoto said.
"Because genetic mutations are often specific to a particular type of cancer, having a catalogue of them would make it clear for researchers what they should target and how they should fight," Okamoto said.
Worldwide, more than 7.5 million people died of cancer and more than 12 million new cases were diagnosed in 2007, according to institutions involved in the project.
Unless medical progress is made, those numbers are expected to rise to 17.5 million deaths and 27 million new cases in 2050, they said.
Countries involved in the project are Australia, Britain, Canada, China, France, India, Japan, Singapore and the United States.
The consortium said it would extend an invitation to all nations to participate and will make its data freely available.
01 may 2008--Scientists across the globe are stepping up the fight against cancer, joining forces to create a first-of-a-kind database of genetic factors, research institutions said Wednesday.
The International Cancer Genome Consortium was formed by research bodies in nine countries and the European Commission for efforts projected to take up to a decade.
"This is the first large international cooperation" on cancer research at the genetic level, said Takuya Okamoto, a research promotion official at Japan's state-backed Riken institution, which is involved in the project.
The consortium will allow research to be conducted internationally without duplication, he said.
"We didn't have a good tool to fight cancer before but now we're seeing the light in revealing its mechanisms at the level of genes," he said.
The project was initiated by Canada's Ontario Institute for Cancer Research and the US National Institutes of Health, he said. Its secretariat will be housed at the Canadian institute in Toronto.
Once thought of as a single disease, cancer is now understood to consist of a large number of different conditions, the consortium noted in a statement.
In almost all forms, however, cancer changes the genetic blueprint, or genomes, of cells, and causes disruptions within normal biological pathways, leading to uncontrolled cell growth, it said.
Each participating institution will take up one type or subtype of cancer and find data on it at its own cost. Each batch of research is estimated to cost 20 million dollars.
Eventually, a genetic catalogue would allow doctors to warn patients of risks by analysing their genes, Okamoto said.
"Because genetic mutations are often specific to a particular type of cancer, having a catalogue of them would make it clear for researchers what they should target and how they should fight," Okamoto said.
Worldwide, more than 7.5 million people died of cancer and more than 12 million new cases were diagnosed in 2007, according to institutions involved in the project.
Unless medical progress is made, those numbers are expected to rise to 17.5 million deaths and 27 million new cases in 2050, they said.
Countries involved in the project are Australia, Britain, Canada, China, France, India, Japan, Singapore and the United States.
The consortium said it would extend an invitation to all nations to participate and will make its data freely available.
New rheumatoid arthritis drugs equally effective
01 may 2008--Three available drugs that belong to the newest class of drugs for treating rheumatoid arthritis -- the tumor necrosis factor (TNF)-alpha blockers -- are equally effective in treating this common joint disease, according to an analysis of several prior studies.
Still, the results suggest that it is generally best to start with an older drug like methotrexate and then add the newer agents if the treatment response is poor.
Although the three drugs - Remicade (infliximab), Enbrel (etanercept), and Humira (adalimumab) -- were approved by the US Food and Drug Administration for treatment of rheumatoid arthritis between 1998 and 2003, there are no published "head-to-head" comparative studies, Spanish researchers point out in the journal BMC Musculoskeletal Disorders.
Led by Dr. Alberto Alonso-Ruiz at Cruces Hospital in Barakaldo, the research team conducted an analysis of 13 trials lasting at least 6 months involving 7,087 patients with rheumatoid arthritis. Comparison subjects were given either methotrexate, a standard treatment for the disease, or an inactive "placebo."
The TNF-alpha blockers were generally comparable in their ability to control the signs and symptoms of rheumatoid arthritis, the findings indicate.
The TNF-alpha blockers provided the greatest benefit when added to the treatment regimen of patients who had a poor response to methotrexate. The drugs offered little added benefit if methotrexate was already working, and they were also more likely to cause side effects.
"Therefore," Alonso-Ruiz and his associates conclude, "we advise against starting treatment with (TNF-alpha blockers) until a lack of adequate response to methotrexate is clearly documented."
SOURCE: BMC Musculoskeletal Disorders, April 17, 2008.
01 may 2008--Three available drugs that belong to the newest class of drugs for treating rheumatoid arthritis -- the tumor necrosis factor (TNF)-alpha blockers -- are equally effective in treating this common joint disease, according to an analysis of several prior studies.
Still, the results suggest that it is generally best to start with an older drug like methotrexate and then add the newer agents if the treatment response is poor.
Although the three drugs - Remicade (infliximab), Enbrel (etanercept), and Humira (adalimumab) -- were approved by the US Food and Drug Administration for treatment of rheumatoid arthritis between 1998 and 2003, there are no published "head-to-head" comparative studies, Spanish researchers point out in the journal BMC Musculoskeletal Disorders.
Led by Dr. Alberto Alonso-Ruiz at Cruces Hospital in Barakaldo, the research team conducted an analysis of 13 trials lasting at least 6 months involving 7,087 patients with rheumatoid arthritis. Comparison subjects were given either methotrexate, a standard treatment for the disease, or an inactive "placebo."
The TNF-alpha blockers were generally comparable in their ability to control the signs and symptoms of rheumatoid arthritis, the findings indicate.
The TNF-alpha blockers provided the greatest benefit when added to the treatment regimen of patients who had a poor response to methotrexate. The drugs offered little added benefit if methotrexate was already working, and they were also more likely to cause side effects.
"Therefore," Alonso-Ruiz and his associates conclude, "we advise against starting treatment with (TNF-alpha blockers) until a lack of adequate response to methotrexate is clearly documented."
SOURCE: BMC Musculoskeletal Disorders, April 17, 2008.
FDA Approves Lubiprostone (Amitiza) for Women with IBS with Constipation
By Peggy Peck
ROCKVILLE, 01 may 2008-- The FDA has approved lubiprostone (Amitiza) for women 18 or older with irritable bowel syndrome with constipation (IBS-C).
Lubiprostone, already approved for chronic idiopathic constipation, becomes the only prescription drug approved for IBS-C. The FDA said the drug should be taken twice a day in 8 mcg doses with food and water.
Tegaserod (Zelnorm), the IBS-C drug pulled from the market a year ago, is no longer available under an investigational new drug protocol plan that permitted its use in symptomatic women younger than 55 in "critical need" . The program was suspended in March.
In two lubiprostone clinical trials with 1,154 IBS-C patients, 12 weeks of the agent at 8 mcg bid was associated with moderate to significant improvement in symptoms compared with placebo, the FDA said. Only 8% of the patients in the trials were men and the FDA said that efficacy was not demonstrated in men.
Common side effects of lubiprostone included nausea, diarrhea, and abdominal pain. Other rare side effects include urinary tract infections, dry mouth, syncope, peripheral edema, dyspnea, and heart palpitations.
Lubiprostone is not approved for use in children and men. It is not to be given to patients with severe diarrhea or known or suspected bowel obstructions. Its safety and efficacy has not been established in patients with renal or hepatic impairment, women who are pregnant, or nursing mothers.
Amitiza is manufactured by Sucampo Pharmaceuticals, Bethesda, Md., and Takeda Pharmaceuticals America, Inc., Deerfield, Ill.
By Peggy Peck
ROCKVILLE, 01 may 2008-- The FDA has approved lubiprostone (Amitiza) for women 18 or older with irritable bowel syndrome with constipation (IBS-C).
Lubiprostone, already approved for chronic idiopathic constipation, becomes the only prescription drug approved for IBS-C. The FDA said the drug should be taken twice a day in 8 mcg doses with food and water.
Tegaserod (Zelnorm), the IBS-C drug pulled from the market a year ago, is no longer available under an investigational new drug protocol plan that permitted its use in symptomatic women younger than 55 in "critical need" . The program was suspended in March.
In two lubiprostone clinical trials with 1,154 IBS-C patients, 12 weeks of the agent at 8 mcg bid was associated with moderate to significant improvement in symptoms compared with placebo, the FDA said. Only 8% of the patients in the trials were men and the FDA said that efficacy was not demonstrated in men.
Common side effects of lubiprostone included nausea, diarrhea, and abdominal pain. Other rare side effects include urinary tract infections, dry mouth, syncope, peripheral edema, dyspnea, and heart palpitations.
Lubiprostone is not approved for use in children and men. It is not to be given to patients with severe diarrhea or known or suspected bowel obstructions. Its safety and efficacy has not been established in patients with renal or hepatic impairment, women who are pregnant, or nursing mothers.
Amitiza is manufactured by Sucampo Pharmaceuticals, Bethesda, Md., and Takeda Pharmaceuticals America, Inc., Deerfield, Ill.
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