Once Just an Aging Sign, Falls Merit Complex Care

By JOHN LELAND

MEDFORD, N.J., 10 nov 2008 — Katherine Aliminosa, 93, shattered her lower leg while getting snacks for her nieces.

Susan Arnold, 87, broke her hip hanging a photograph.

In mid-July, in a nursing unit of a retirement community here, the two women were at the start of a recovery process that both hoped would return them to their previous lives.

Their progress over the next few months, and their divergent outcomes, illustrate the unpredictable impact that common falls can have on the bodies of older people.

By early autumn, Ms. Aliminosa had graduated to an independent living apartment and was able to get around with a walker. She looked like a different person: more robust, content.

Though six years younger, Ms. Arnold never recovered her strength after hip surgery. Her muscles atrophied from inactivity, and she developed pneumonia. She died on Sept. 6.

Once considered an inevitable part of aging, falls are now recognized as complex, often preventable events with multiple causes and consequences, calling for a wide range of interventions, both psychological and physiological, that many patients never receive.

Even falls that cause only minor injury “need to be taken as seriously as diabetes,” said Dr. R. Sean Morrison, a professor of geriatrics and adult development at Mount Sinai School of Medicine in New York, because “they can be a real warning sign that something serious is wrong.”

Dr. Mary E. Tinetti, a falls expert at Yale University medical school, compared falls to strokes in their harmfulness, adding that people do not always report them or seek help, for fear their families will try to put them in nursing homes. For some people, Dr. Tinetti said, admitting that they fall is tantamount to admitting that they are no longer competent to take care of themselves.

Each year, 1.8 million Americans over age 65 are injured in falls, according to the Centers for Disease Control and Prevention. Some rebound as if the injury never happened. But for some, the fall sets off a downward spiral of physical and emotional problems — including pneumonia, depression, social isolation, infection and muscle loss — that become too much for their bodies to withstand.

In 2005, the last year for which statistics are available, 433,000 people over 65 were admitted to hospitals after falling, and 15,800 died as a direct result of the fall. Less visible are the many who survive the fall but not the indirect consequences.

When first interviewed in mid-July, Ms. Aliminosa and Ms. Arnold felt vulnerable and constrained, their world diminished. Both had led accomplished professional lives — Ms. Arnold as a school psychologist, Ms. Aliminosa as a medical researcher — and had been active in the community’s independent living apartments. But neither could be confident about what the future held.

Ms. Aliminosa said she was depressed, and able to walk only in very small stretches. A small woman with a soft voice and grainy New York accent, she barely filled her chair. She seemed defeated. “Emotionally I have not been well,” she said. “It’s made me very aware of my age, and that’s hard to accept.”

Ms. Arnold, by contrast, was full of emotional energy, so angry about her broken hip that she kicked out for emphasis as she talked, turning conversation into a full-contact sport. Before her fall, she had been preparing for a vacation with her daughter at a family beach house on Long Island — the same house where she had spread her husband’s ashes. Now that plan was gone.

“It kills me, it just kills me,” she said. “This was going to be the frosting on the cake, and somebody ate it.”

Of the two women, Ms. Arnold was up against the longer odds. One in five hip-fracture patients over age 65 die within a year after surgery, according to the C.D.C.; one in four have to spend a year or more in a nursing home. When younger people fall, they tend to break their wrists catching themselves, but in older people, who have slower reactions and less upper-body strength, the weight more often falls on their hips or heads. Any underlying conditions, like heart disease or respiratory problems, increase the chances of a downward health spiral.

Ms. Arnold had a history of pulmonary disease, and had been a heavy smoker, starting after high school. “She had a boyfriend in college,” her daughter, Margery Creek, said, “and it was the lesser of evils — sex, drinking or smoking.”

But her lung problems did not keep her down. In 2006, she took a 10-day trip to Sweden. Even after she fell and fractured a hip that autumn, she lived independently and was able to drive, returning to the beach house. That day in mid-July, even as she talked about depression, she took jubilant delight in photographs of her grandchildren and great-grandchildren. “Now if that isn’t the picture of a baby,” she said. “Isn’t she a sweetie?”

If Ms. Arnold were a machine, it would be simple to draw a straight line between her lung disease, her hip surgery and her chances of recovery. Older bodies typically have several weakened systems that are dependent on one another, and rely on drugs that may or may not work well together. “If you take 70-year-olds, on average they’re taking five medications,” Dr. Tinetti said. “When you get to 10 medications” — as a patient might after a fall — “the likelihood of adverse effects is close to 100 percent.”

But psychological factors can be as devastating as the physical trauma, Dr. Tinetti said. “It’s the fear of falling, the lost confidence. Good walkers stop walking, stop going to church. They become socially isolated and depressed.”

After Ms. Arnold’s first broken hip, she had reduced feeling in one foot, which added to the likelihood that she would fall again.

On July 6 this year, it happened: Ms. Arnold turned her body without moving her foot, pulling the closet door down with her when she fell and fracturing her hip bone.

“I’m outraged,” she said a week after the fall, raising her voice and then becoming fatigued. Her breathing was interrupted by coughing spasms. She said she was determined not to end up using an electric cart. “Disappointment,” she said, accenting each syllable. “I had a very good life.”

“But your life isn’t over,” said Deanna Gray-Miceli, an adjunct assistant professor of nursing at the University of Pennsylvania and an expert in geriatric falls who was looking in on Ms. Arnold in the nursing unit.

“Well, it bloody well is,” Ms. Arnold said. “I have no strength. Let’s talk about depression.”

The period of immobility after a fall is particularly dangerous, said Dr. Gray-Miceli, whose research includes studying a group of patients after falls. “Being immobile, you’re not taking deep breaths, you’re more prone to orthostatic pneumonia, or older people can develop urinary incontinence. And that can have a whole cascade of emotional consequences as well as the physical consequences, such as skin breakdown, pressure sores, bladder infection, lung infection.

“We also see temporary confusion from infection,” she added, “And that can lead to someone’s demise.”

Dr. Gray-Miceli’s work focuses on identifying the causes of falls, which might include treatable factors like changes in gait, low blood pressure, declining vision or heart arrhythmias, as well as conditions in the home. In a study by Dr. Tinetti, simple preventive suggestions from doctors, like physical therapy and changes in medication, reduced falls by 11 percent. (The C.D.C. offers tips to reduce falls at home, like removing loose rugs and making sure stairway handrails go all the way to the bottom, at cdc.gov/ncipc/duip/preventadultfalls.htm.)

For Ms. Arnold, it was too late. Shortly after surgery she grew depressed and fatalistic, her daughter said. “One morning when my brother was here, she woke up and said, ‘I’m weary, I’m just absolutely weary,’ ” Mrs. Creek said. “And she had no muscle that came back. Her arms had really gotten down to skin and bones. You hear that term — it certainly seemed that way, no muscle.”

In August, Ms. Arnold developed pneumonia and spent three nights in the hospital. Though she responded well to the medications, Mrs. Creek said: “It was just one more nail. She said she was ready to be with Dad.”

The last time Mrs. Creek called her, in early September, Ms. Arnold could recognize her voice but not respond, Mrs. Creek said. “I think she just said, ‘I’ve had it, I’m checking out.’ ”

Down the hall, Ms. Aliminosa’s response after her leg fracture was just as unpredictable.

On April 4, she was enjoying a visit from two favorite nieces — Ms. Aliminosa never married — when she found herself on the floor of her apartment, she said. She had no memory of how she fell.

Ms. Aliminosa has osteoporosis and a history of falling, so she told her relatives not to touch her until the nurses came. She needed a metal rod in her leg and began a slow process of physical rehabilitation. She said the falls were the first thing that made her feel old. “I’d love to be able to have dinner and take a short walk, and I can’t do that,” she said.

Because she was in a full-spectrum medical facility, her care was well coordinated, said Dr. Albert Siu, a professor and chairman of geriatrics and adult development at Mount Sinai.

“For example, osteoporosis is often at root of this,” Dr. Siu said. “But in a three-day hospital stay, addressing osteoporosis is not at the top of everyone’s mind. There it’s dealing with the pain, the complications and the repair of the fractured hip.” Medications for blood pressure or pain might increase dizziness or chance of falls. In mid-July, while Ms. Arnold was angry but relatively mobile, Ms. Aliminosa seemed resigned to a loss of mobility and independence. The prospect weighed heavily on her. When asked if she had considered counseling for depression, she said she did not think she could bear talking about it. “I think as we get older it’s hard to control our emotions,” she said.

Patients’ pessimism can be self-fulfilling, because they may not walk to the extent they can. “Their stride becomes shorter,” Dr. Morrison said. “They don’t use their lungs.”

Dr. Gray-Miceli said it was important for doctors and nurses to keep the patient focused on tangible signs of progress, “so she can say: ‘Today I got up by the side of the chair and took five steps. Yesterday I only took four steps.’ ”

Ms. Aliminosa began a physical therapy regimen to build strength in her legs and upper body and improve her gait. With improvement she gained a sense of optimism and control over her body.

She said the depression returned from time to time, as did the fear of falling again. But she said: “The thought that I’m getting better has helped a great deal. I try to think so each day, really.”

She smiled; she joked. On a recent morning, she groused amiably about her fitness program, but finished, with no sign of pain or exhaustion. “I’m walking,” she said, “I wouldn’t say to my satisfaction, because I used to be a hiker. I can’t expect that yet, but I’m hoping for it.”

Despite failures, search for anti-obesity drugs still looks golden

by Richard Ingham

PARIS, 10 nov 2008-- Designers of anti-obesity drugs have suffered three major setbacks, but the potential reward from treating the world's fat epidemic is so great that their quest is unlikely to be deterred.

After investing a sum rumoured to be in the hundreds of millions of euros (dollars), Sanofi-Aventis of France announced last Wednesday it was abandoning its drug rimonabant, which had stoked huge expectations at its launch in 2006.

Rimonabant -- brand name Acomplia -- ran into a flurry of ever-tougher warnings from European watchdogs about potential psychiatric side effects, including depression.

In October, the European Medicines Agency (EMEA) recommended that rimonabant be pulled from sale in Europe. The drug had never been able to gain approval in the all-important US market.

Also Wednesday, the US giant Pfizer put a stop to tests of a prototype in late-stage development called CP-945,598, citing regulatory hurdles.

"The risk/benefit profile in this class of drugs was lower than expected for obtaining market authorisation," said Catherine Baulac, in charge of new products with Pfizer's French subsidiary.

And on October 2, Merck of the United States pulled the plug on its own experimental obesity fighter, taranabant, because of concerns about anxiety and depression at high doses.

The main causes of obesity -- overconsumption of fatty or sugary food and a sedentary lifestyle -- are well known. But the molecular machinery that drives it is in many ways obscure and, it is now suspected, more complex than thought.

Treating obesity entails a limited basket of options, from lifestyle changes to drugs and gastric-bypass surgery.

But when it comes to that middle choice, the most promising class of new prescription medicines for treating long-term obesity has just been wiped out.

The three scratched drugs belong to a group called cannabinoid receptor antagonists.

They take on the same target in the central nervous system as marijuana. But instead of sharpening appetite -- the "munchies" associated with smoking cannabis -- they work in reverse, dulling the urge to eat.

"There are now just two drugs left, orlistat and sibutramine," Colin Waine, a doctor who is chairman of a British organisation, the National Obesity Forum, said.

Anders Sjoedin, a specialist in obesity drugs at the University of Copenhagen, Denmark, said cannabinoid receptor antagonists had now been discredited as an approach.

"Cannabinoid receptors not only regulate the appetite, they also affect mood," he said.

Orlistat, marketed as Xenical or alli, curbs absorption of fat in the intestine by blocking a pancreatic enzyme. Sibutramine, sold as Reductil or Meridia, affects levels of a brain chemical called serotonin, believed to influence feelings of hunger or satiety.

Both are "very useful," said Waine. They come, though, with a list of side effects -- including, in orlistat's case, the risk of sudden, oily faeces.

As proof of the glittering allure of the obesity market, drug engineers are exploring unusual paths.

According to the UN's World Health Organisation (WHO), around 400 million adults were obese in 2005, and the tally is expected to balloon to more than 700 million in 2015.

In the lab, at least, are potential rivals to orlistat in the field of lipase inhibitors; new neurotransmitter inhibitors that reduce appetite; and even a hydrogel pill that expands in the stomach to give a sense of fullness.

But, should these prototypes ever get the green light to go on sale, will they meet the hopes of people desperate to lose dozens of kilos in a year, rather than just a few?

Even more important, are they safe?

Eleven years ago, the search for an obesity drug ran into controversy when fenfluramine, an appetite suppressant, was banned in the United States over fears of its effect on the heart. Last week, a study published in the journal BioMed Central found fenfluramine's damage to cardiac valves was visible seven years later.

Such questions pose a dilemma for scientists much as they do for drug regulators.

Obesity is a huge and growing disease, for which people are clamouring for a quick fix. Yet it is also a complex disease, and no drug is without side effects to some degree.

Sjoedin said that researchers believed that regulators, especially in the United States, were becoming increasingly demanding about proposed obesity drugs.

Watchdogs were wanting to see more data about adverse effects from proposed drugs, as well as further proof of benefits other than weight loss, such as lower blood pressure.

"Obese people will be around, and I'm not sure that surgery is the solution for all them," said Sjoedin. "In that respect, there is a need for drugs. But no one is going to make a drug unless they can make money out of it in the end."

Depressed Patients Have Dysfunctional Pain-Processing Network

By Todd Neale
LA JOLLA, Calif.,09 nov 2008 -- Patients with major depressive disorder process pain differently in the brain than healthy individuals, researchers here found.
During exposure to a painful heat stimulus, depressed patients had decreased activity in the area of the brain responsible for pain modulation, Irina Strigo, Ph.D., of the University of California San Diego, and colleagues reported in the November issue of Archives of General Psychiatry.
When the same patients anticipated pain, they had increased activity in the right anterior insular region, dorsal anterior cingulate, and right amygdala, parts of an emotion-processing network.
"The anticipatory brain response may indicate hypervigilance to impending threat, which may lead to increased helplessness and maladaptive modulation during the experience of heat pain," the researchers said.
"This mechanism could in part explain the high comorbidity of pain and depression when these conditions become chronic," they said.
More than three-quarters of patients with depression have chronic pain and 30% to 60% of patients with chronic pain have depressive symptoms, according to the researchers.
But despite the overlap between the two conditions, they said, little is known about the neurobiological basis of how pain is processed in the brains of patients with major depressive disorder.
So they recruited 15 patients with major depressive disorder (12 females; mean age 24.5) and 15 healthy controls with no history of psychiatric disorders (10 females; mean age 24.3) to undergo functional magnetic resonance imaging before and during painful stimulation.
The depressed patients completed the Pain Catastrophizing Scale, which assesses magnification, rumination, and helplessness related to pain.
Both painful and non-painful levels of heat were applied to the participants' forearms as they viewed images that signaled the intensity of heat to come.
The temperatures did not differ significantly between the groups; the painful stimulus was 115.5° F in the depressed patients and 116.4° F for the controls (P=0.08), and the non-painful stimulus was 102.2° F for both groups (P=0.59).
Both groups reported similar subjective ratings of the unpleasantness and intensity of the painful heat.
The depressed patients rated the non-painful heat as significantly more unpleasant (P=0.04), "a finding that is consistent with our previous observations of the increased affective bias in major depressive disorder at non-painful temperatures," the researchers said.
During the anticipation of pain, the depressed patients had increased activation in the right anterior insular region, left anterior insular/inferior frontal gyrus, bilateral dorsal anterior cingulate cortex, right dorsolateral prefrontal cortex, several clusters in the left dorsolateral prefrontal cortex, clusters in the temporal and occipital lobes, and right amygdala.
The increased activity in the amygdala during anticipation was associated with greater levels of perceived helplessness toward pain (P=0.01) and rumination (P=0.02) in the depressed patients only.
During painful stimulation, the depressed patients had increased activity in the left parahippocampal gyrus and occipital cortex and the right amygdala, and decreased activity in the periaqueductal gray matter and the rostral anterior cingulate and prefrontal cortices.
The increased activity in the amygdala during painful stimulation was associated with perceived levels of helplessness (P=0.02) and rumination (P=0.03).
"These findings suggest that increased emotional reactivity during the anticipation of heat pain may lead to an impaired ability to modulate pain experience in major depressive disorder," the researchers said.
Cognitive models suggest that patients with major depressive disorder negatively bias their expectations, perceptions, and memories, which may lead to the development of passive coping styles that promote helplessness and the maintenance of depression, they said.
Past studies have shown that passive coping styles are associated with the enhanced emotional impact of chronic and experimental pain.
The current findings are in line with these models, the researchers said, and "may represent a neural correlate of hypervigilant monitoring of negative information in major depressive disorder," the researchers said.
The authors acknowledged that the study was limited by the "mixed sample of relatively modest size," and that the findings needed to be confirmed using more patients.
The study was supported by grants from the National Institute of Mental Health and by the Barrow Neurological Foundation, the National Alliance for Research in Schizophrenia and Depression, and the University of California San Diego Center of Excellence for Stress and Mental Health.
The authors reported no financial disclosures.
Primary source: Archives of General PsychiatrySource reference:Strigo I, et al "Association of major depressive disorder with altered functional brain response during anticipation and processing of heat pain"Arch Gen Psychiatry 2008; 65: 1275-1284.

FDA Approves Drug Treatment for Overactive Bladder

09 nov 2008--The FDA has approved Toviaz (fesoterodine), an anticholinergic agent, to treat overactive bladder in adults. The drug relaxes smooth muscle in the bladder, thereby reducing urinary frequency, urgency, and incontinence. Available doses are 4 and 8 mg daily.
Contraindications include severely reduced kidney function, urinary or gastric retention, uncontrolled narrow-angle glaucoma, severe liver impairment, and use of medications (e.g., ketoconazole) that block fesoterodine metabolism. The FDA also recommends caution in prescribing fesoterodine for patients with decreased gastric motility.
LINK(S):
FDA announcement (Free)

Age Determines Clinical Characteristics of Infective Endocarditis

09 nov 2008--Increasing age is a determinant of the clinical characteristics of infective endocarditis, according to an international prospective cohort study in Archives of Internal Medicine.
Researchers studied 2800 patients with infective endocarditis (1700 were under age 65, 1100 were 65 or older). Older patients were less likely to have vegetations and more likely to have abscesses than younger patients; they were also less likely to experience vascular manifestations of the disease, such as embolic events. Diabetes and cancers of the genitourinary or gastrointestinal tract were major predisposing factors in the older group.
After exclusion of patients with prosthetic- or healthcare-related endocarditis, mortality in older patients was still about twice that of younger patients.
The proportion of cases associated with healthcare procedures increased with age. Along with a high index of suspicion, the authors recommend appropriate antibiotic prophylaxis and greater adherence to aseptic practices when dealing with frail, older patients.
LINK(S):
Archives of Internal Medicine article (Free abstract; full text requires subscription)

CHEST: Statins May Cut Risk of Deep Vein Thrombosis in Cancer Patients

By John Gever
PHILADELPHIA, 09 nov 2008-- Statin treatment appeared to lower the rate of venous thromboembolism by two-thirds in cancer patients at risk for the condition, a researcher said here.About 8% of patients who had been taking statins for at least two months to control cholesterol before hospitalization with a solid-tumor later suffered venous thromboembolism, compared with 21% of those with short-term or no previous statin treatment (OR 0.33, 95% CI 0.19 to 0.59), reported Danai Khemasuwan, M.D., of Albert Einstein Medical Center here.The findings reflected adjustments for smoking status, metastatic disease, current use of chemotherapy, aspirin, and immobilization, he said at the American College of Chest Physicians meeting.Dr. Khemasuwan said the mechanism underlying the apparent effect remained unclear.
"It could be either the lipid-lowering effect … or it could be anti-inflammatory or anti-thrombolytic," he said, calling for a prospective, randomized trial to confirm the finding.
His study involved a review of 740 consecutive patients with a variety of solid tumors, prompted by suggestions in earlier studies that statins may reduce the DVT risk in other patient groups.
Most patients in the study had lung, breast, or prostate cancer. Other malignancies included tumors of the ovaries, stomach, colon, brain, kidney, esophagus, and pancreas.
Mean patient age was 65 and three-quarters were African-American. Patients were excluded if they had received anticoagulant therapies such as warfarin or heparin prior to admission.
About 31% of the sample had dyslipidemia at admission, and 26% were on statins.
He noted previous research indicating that statins decrease serum markers of inflammation, which in turn alters blood coagulation thresholds.
Patients in the study received simvastatin (Zocor), atorvastatin (Lipitor), or rosuvastatin (Crestor). The study did not attempt to determine whether one agent was more or less effective than the others in reducing venous thromboembolism risk, nor did it examine dosing.
A limitation of the study was that it did not measure serum lipids in patients. Differences between the statin-treated and control groups in lipid levels were a potential confounding factor.
Despite these limitations, David Gutterman, M.D., of the Medical College of Wisconsin in Milwaukee, said the findings were important.
"It's very logical," said Dr. Gutterman, who was not involved with the research. "I think it makes a lot of sense, particularly with regard to the pleiotropic effects of statins."
He said those effects "may not have so much to do with cholesterol, but may still have to do with inhibition of the HMG-co-reductase pathway," the main target of the statin class.
He noted that statins are well known to improve arterial endothelial function, which would be expected to have a favorable impact on thrombosis risk.
"The interesting thing about this study is that it suggests maybe the same kind of improvement is occurring on the venous side of the circulation," Dr. Gutterman said.
The study had no external funding. Dr. Khemasuwan and Dr. Gutterman reported no potential conflicts of interest.
Primary source: CHEST 2008Source reference:Khemasuwan D, et al "Statins decrease the incidence of venous thromboembolism: retrospective study in patients with solid organ tumor" CHEST 2008; 134: 8003S.Complete CHEST Coverage

Elective Surgery Is One Thing, Elective Politics Another

Why the Presidential Race Should Skirt The Doctor's Office

By Manoj Jain
09 nov 2008--A few weeks ago, as I was making rounds on the oncology floor, one of my patients asked, out of the blue, "Hey, Doc, who you gonna vote for?"
I would have expected this patient to have other questions on his mind. He's a 32-year-old writer whose leukemia had failed to remit after two rounds of chemotherapy. Now a third, more powerful regimen had dropped his white blood cell count to near zero, making him vulnerable to life-threatening infections.
Chuckling politely, I asked him why he wanted to know. "I'm curious, Doc," he said. "It tells me your worldview." He said that if we agreed on who should be the next president, it would strengthen our doctor-patient relationship. I asked what would happen if we didn't agree. He said, "That would be okay."
I'm not so sure. I have strong political opinions, but I am edgy about disclosing them to my patients for several reasons. For one, I'm in an authoritative position: When I talk about antibiotics, my patients listen and usually do as I advise. As a result, they might give inappropriate weight to my political pronouncements. For another, I fear that no matter how carefully I tread in these conversations, a disagreement could leave a dead zone in our relationship; that would be damaging because doctors and patients have to work as a team.
Later, looking up lab tests on the computer in the doctors lounge, I asked a cardiologist what he would have said to my leukemia patient. "I clearly avoid political conversations in the examination room," he said emphatically. "It raises the patients' stress level, and they're already stressed-out being in the office."
Another colleague, an orthopedic surgeon, also refuses to talk politics, but his reason was purely practical: "Who has the time to chitchat?" That's a good point. As a 2006 study showed, the average primary care visit is 17.4 minutes long and includes discussion of 6.5 topics. Often, I barely have time to spell out the potential side effects of my patients' medications. A political discussion should include more than sound bites.
These colleagues reflected what I think is the norm: that even in this unusually strident election year, medical professionals prefer to keep politics out of the examining room. At our hospital, even wearing a political button is considered unprofessional conduct. (Remember when Ronald Reagan was shot in 1981? He quipped to the doctor who was going to operate on him, "I hope you're a Republican." The doctor replied, "Today, Mr. President, we're all Republicans." That would have been less convincing from someone wearing a Carter-Mondale pin.)
This fall I ran into an oncology nurse wearing a McCain button, and I asked him how his patients felt about it. "I don't know," he shrugged. "Once all the patient's family had big Obama T-shirts on, so I just covered my button with my name tag."
Not all patients are open to political discussion. My editor tells me she deeply resented it when her dentist, drill in hand, began an opinionated conversation about the Middle East, knowing full well she works for a newspaper. So one morning recently I polled my recovering patients (not anybody who was critically ill) on the subject. One man with a heart transplant and an infection where part of his right leg had been amputated had the same reaction as my orthopedic colleague. "It's not a taboo, but I don't want to take up the doctor's time," he said. "I want him to treat my stump."
Since another patient, recovering from a case of severe encephalitis, had short-term memory loss, I added my polling question to the list of simple queries we had him answer every day. This time he knew his name, stumbled on the year ("1998 . . . no, no . . . 2008") and couldn't quite recall the president ("It's a four-letter word, but not Gore.") As for who the next president was likely to be, he was uncertain, and he didn't care if his doctor discussed politics or not.
Another patient told me he feared that patients would be hurt if the doctor did not agree with their views, then went on to tell me how the Republicans had screwed up the economy over the past eight years. Another said it was "okay to talk" and demonstrated his conviction by telling me how he thought the Bush administration should freeze the assets of all the investment bank CEOs and leave them with just $500 apiece.
Back in the doctors lounge (where the TV usually broadcasts Fox News, and conversations tend to be weighted to the right) I'm more willing to talk about the election. And when an ICU nurse paused at the nursing station to ask what I thought of the Democratic and Republican conventions, I gave a 20-minute response, my assistant waiting impatiently for me to finish with the chart of a heart transplant patient with MRSA pneumonia.
Not every doctor would do that. One gastroenterologist I know says: "I'm a blue doctor in a red state. I don't want to anger my referral base for consults, so I just stay quiet [about politics] or avoid going to the doctors lounge."
But this must go on in every office. Employees test the waters or tiptoe around conversations when the colleague, the client or the boss has a differing political view.
I'm a little uncertain how I feel on a related subject: whether I should advise patients on health issues that have political implications. Not abortion rights -- that's way too provocative. But take the case of stem cell research. Evidence shows that this research is a likely source of information that could one day help cure cerebral palsy, muscular dystrophy and other diseases. In the 2004 election, a friend changed her vote solely based on the topic, because her child had been given a diagnosis of muscular dystrophy. Should I inform parents, "Your child's illness might one day be treated if we can speed up stem cell research?" Do I make them aware of each party's platform stance?
One conversation that is germane to nearly every doctor visit, yet does not happen often enough, is about health insurance. One in five of my patients is uninsured or under-insured. Lack of adequate insurance is a proven risk factor for becoming ill and dying -- no different from smoking, excessive alcohol intake or high blood pressure. Should I discuss these facts with patients? Should I tell them which party's plan I believe would be more helpful for their particular condition?
So far, I talk about stem cells only if the patient brings it up. As for health insurance, I encourage patients to get it, and if there's time for a longer conversation, I will share my opinion on which candidate has the better plan.
I can't be sure how most doctors feel about all this. Of the millions of medical articles published, I can find only one that posed the question "Do physicians discuss political issues with their patients?" It described how 36 primary care physicians in the Philadelphia area were surveyed in 2004 after the voter registration deadline and before Election Day. Nearly half of them said they had initiated a discussion about a politically oriented health issue in the past decade, and 63 percent said they were willing to offer voter registration in their office. Interestingly, the male respondents were much more likely to initiate political discussion than the women.
The American Medical Association code of ethics notes: "It is natural that in fulfilling . . . political responsibilities, physicians will express their views to patients or their families. However, communications . . . about political matters must be conducted with the utmost sensitivity to patients' vulnerability and desire for privacy."
So even though the presidential candidates have different positions on certain health-care issues, and even though my leukemia patient assured me that my opinion would not influence his, I didn't tell him how I'll vote.
And I'm not disclosing it here, either.

Exercise may improve function in dementia patients

NEW YORK 08 nov 2008– Organized exercise designed to increase strength, flexibility, mobility and coordination may improve overall physical function among nursing home patients with Alzheimer's disease, researchers report.
Alzheimer's disease patients who have physically deteriorated are less able to perform activities of daily life, which, in turn, affects their quality of life. Despite the well-known physical benefits obtained from exercise, Professor Alejandro Lucia and colleagues in Spain found comparatively little research has focused on exercise training among patients with Alzheimer's disease.
To address this, Lucia, of the Universidad Europea De Madrid, and collaborators compared the outcomes of 16 Alzheimer's disease patients who were randomly assigned to receive normal care involving no programed exercise or to a12-week exercise program as part of their nursing home care.
Each group consisted of five women and three men of similar functional capacity at the start of the study. Participants' average age was 73 years in the normal care group and 76 years in the exercise group, the investigators report in the International Journal of Sports Medicine.
Exercise sessions, held 3 days each week, included 75 minutes of warm-up and cool-down stretching, inside walking, joint mobility activities, elastic exercise-band resistance training, and coordination exercises using foam balls.
Lucia's team reports the exercise group had significant improvements in measures of upper and lower body strength and flexibility; agility and balance; walking abilities; and endurance. Exercise participants also showed greater ability to independently perform activities of daily living such as rising from a chair, transferring from bed to chair, bathing, or dressing.
By contrast, the normal care group showed no changes over the 12-week period.
These findings show that shorter duration exercise programs "are sufficient to induce significant improvements in patients' functional performance and independence," the investigators state. Adherence to the training program was nearly 100 percent, they add.
While more evidence of efficacy is needed from larger study populations, Lucia and colleagues suggest similar programs could be included in the overall nursing home care of Alzheimer's disease patients.
SOURCE: International Journal of Sports Medicine, October 2008.

Drug Boosts Natural Growth Hormone in Seniors

By Alan Mozes
08 nov 2008 -- An experimental drug can restore the amounts of muscle-linked growth hormone in seniors to youthful levels, a new study shows.
Those on the therapy also gained muscle mass over the two-year trial, scientists say. However, there's no clear indication that this led to significant improvements in their strength or function.
Still, it does raise the hope that by increasing natural growth hormone Americans might be able to beat back the ravages of age.
"As we all get older, our body composition changes," explained study author Dr. Michael O. Thorner, a teaching professor of internal medicine at the University of Virginia in Charlottesville. "So, people in their 80s and 90s all look the same: their fat is distributed in the center and the abdomen, and they lose a lot of muscle mass."
"This has become an increasing problem as life expectancy has increased from 45 at the turn of the century to now over 80," he continued. "Obviously people would like to remain independent and functional as long as possible, but these changes work against them."
The challenge is to stop or at least slow down those changes.
"Because this age-related reduction in muscle mass is associated with a decrease in growth hormone secretion, the rationale for the therapy we're studying is to try and address the problem by boosting the normal secretion of this hormone," Thorner said.
His team reported its findings in the Nov. 3 issue of the Annals of Internal Medicine.
Human growth hormone, produced naturally by the body's pituitary gland, is essential to healthy development and the maintenance of tissues and organs. But as people enter their 30s and 40s, levels of the hormone start to decline. The use of synthetic versions of human growth hormone has also become the focus of "sports doping" headlines, with well-known athletes allegedly turning to the drug for its reputed performance-enhancing properties.
Aging Americans are also showing an interest in synthetic human growth hormone as a hoped-for "elixir of youth." According to the American College of Physicians, it's estimated that some patients spend as much as $1,000 to $2,000 per month on the drug for anti-aging purposes.
But what if there were a way to jumpstart the aging body's natural supply of growth hormone?
In the current work, the authors had 65 healthy adults between the ages of 60 and 81 receive either a placebo or a so-called "oral ghrelin mimetic" called MK-677, over the course of one year. MK-677 is an experimental medication that prompts the body to release naturally produced growth hormone. The drug was ingested once daily in pill form.
After the end of the year, those who had been taking a placebo were switched to MK-677. At the same time, the group who had already been taking the drug either continued to take the medication or were taken off it.
Thorner's team found that patients who had received the therapy experienced an increase in growth hormone levels equivalent to levels seen among healthy young adults. Their lean, fat-free muscle mass also increased, as did overall body weight and the amount of fat distributed to the arms and legs.
"Whereas those who didn't get the growth-hormone boosting therapy lost about one pound of muscle in a year, those who got [the drug] gained about two pounds of muscle mass and experienced appetite stimulation," Thorner added. "Although fat increase was the same between the two groups, there was a difference in [fat] distribution, so that among those treated with the drug 50 percent of it was distributed to the limbs, rather than all to the center, as usual."
Patients who had been on MK-677 and then were taken off the medication saw all of the drug's beneficial effects dissipate, the authors reported. In contrast, those who stayed on the regimen maintained their gains throughout the total two-year period.
Insulin sensitivity decreased among those taking MK-677, while their blood sugar increased. The therapy did not have any observable effect on the muscularity of the thigh area -- a key source of mobility strength -- nor did it have any impact on overall muscle strength or activity function, the team noted.
"But the patients we studied were healthy to begin with," Thorner stressed. "So, we believe that we now need a longer-term study with possibly more frail individuals, to see if we can demonstrate any possible change or improvement in function as a result of the therapy."
Thorner noted that a person's growth hormone levels are highest during mid-puberty, but have dropped by about half by the time men and women turn 30. The decline continues with age, with levels diminishing at a rate of about 50 percent every 7 years.
Dr. Todd Schlifstein, an assistant professor of rehabilitation medicine at the New York University School of Medicine in New York City, called the study "very interesting" but agreed that more research is needed.
"I think it certainly enlightens an area where there certainly seems like there is a potential for a benefit for elderly patients," he said. "But now it needs to be looked at further in a functionality type of way, to see how an increase in appetite, body energy, and lean muscle mass actually

'Prescription Switching' Would Make Most Patients Unhappy

By Amanda Gardner
08 nov 2008-- Most prescription drug users would be unhappy if one of their medications was switched to another in the same class without their knowledge or their doctor's approval, a new survey shows.
The practice, known as therapeutic substitution, is usually done as a cost-saving measure.
"People may not know about it, but it's happening, and if it is happening, it should be happening with full transparency, and patients and doctors should be in on this," said Sally Greenberg, executive director of the National Consumers League. "It's not necessarily something that we're condemning."
But others feel the practice is not unduly widespread and, even when it is used, that doctors and patients rarely go uninformed.
"I think they're making much ado about nothing. I can't imagine this goes on without the doctor's or patient's knowledge," said Robert Freeman, a professor of pharmaceutical sciences at Texas A&M Health Science Center Irma Lerma Rangel College of Pharmacy in Kingsville. "It would be insane to do this without informing the patient or without the physician knowing. Just think about the tort ramifications."
Curtis Haas, director of pharmacy at the University of Rochester Medical Center, said the practice is "not uncommon," but added that, "it's hard to believe pharmacists would change patient medications and not talk to them about it."
In New York, where Haas practices, a pharmacist would have to communicate directly with the doctor to get a new prescription authorized before another medication could be dispensed.
Prescription switching is the practice of dispensing a different drug, albeit one still in the same class of medications, as the drug originally prescribed.
According to Greenberg, exact numbers on the practice are elusive, but financial concerns are usually the reason for the switch.
"It's the 80/20 rule, the idea being that if the vast majority of people are using one drug versus the other that when you apply this to a large population, that drug will be the most cost-effective with no compromise in quality," Haas said.
The cholesterol-lowering drugs known as statins have been targeted for therapeutic substitution, as have proton pump inhibitors, which are used to treat acid reflux. "To most people's knowledge, there are no important differences if given in equivalent doses," said Haas.
Pfizer, which makes Lipitor (atorvastatin), funded this survey.
These surveyors contacted 1,387 adults who had filled a prescription in the past year. Two-thirds had never heard of therapeutic substitution, while 10 percent reported they had personally experienced the practice in the past two years.
Among the survey's other findings:
Seventy percent of respondents said they would be "very" or "extremely" concerned if their prescription had been switched without their doctor's knowledge; 77 percent oppose the practice without doctor or patient consent.
One-third of those who said they or a family member had experienced therapeutic substitution said the doctor had not been consulted beforehand, while two-thirds said the family member was not consulted.

Overnight hemodialysis dramatically improves survival

Erkan Ok.
08 nov 2008--For hemodialysis patients, undergoing dialysis for eight hours overnight, three times weekly, reduces the risk of death by nearly 80 percent, compared to conventional, four-hour dialysis, according to research being presented at the American Society of Nephrology's 41st Annual Meeting and Scientific Exposition in Philadelphia, Pennsylvania.
In a study led by Ercan Ok, MD, of Ege University in Izmir, Turkey, 224 dialysis patients were switched to overnight dialysis. The patients spent three nights a week at the dialysis center where they underwent eight hours of continuous hemodialysis. The patients adjusted well to overnight hemodialysis. "After an adaptation period of a month, all patients slept during the night without any complaint," says Dr. Ok.
The patients remained on overnight hemodialysis for about one year. Their outcomes were compared with those of a similar group of patients who continued on conventional dialysis: four hours, three days per week.
Overnight dialysis led to improvements in a wide range of outcomes. "The hospitalization rate during follow-up was one-fourth of that observed in patients treated with four-hour conventional hemodialysis," comments Dr. Ok. "Most importantly, our results confirmed that longer dialysis produces significantly better patient outcomes, with a 78 percent reduction in mortality rate."
Patients receiving overnight hemodialysis had better blood pressure control, leading to a two-thirds reduction in blood pressure medications. They were also at lower risk of blood pressure drops during dialysis, a common problem with conventional hemodialysis. Levels of the mineral phosphate decreased toward normal, despite a 72 percent reduction in medications used to lessen phosphate absorption.
The need for other medications decreased as well. All of these outcomes either did not change or deteriorated in patients on four-hour conventional dialysis.
Most patients in the overnight hemodialysis group mentioned an increase in appetite. They gained weight, and their serum protein (albumin) levels increased. Many patients were able to return to work, reporting improved job performance and better mental (cognitive) functioning.
More frequent and/or longer dialysis regimens are a promising alternative to addressing the "unacceptably high" risk of death among dialysis patients, according to Dr. Ok. Although home dialysis is may be the best approach (aside from kidney transplantation), it is not an option for most patients.
Previous studies of overnight, thrice-weekly hemodialysis have shown impressive results, with ten-year survival rates as high as 75 percent. The new trial is the first prospective, controlled study to compare the results of eight-hour versus four-hour hemodialysis, performed in the dialysis center.
The study has some important limitations, including the fact that patients were not randomly assigned to the two dialysis strategies. With an average age of 45, the patients were younger than the general population of dialysis patients—few older patients were willing to switch to overnight hemodialysis. In addition, the follow-up period was relatively short.
However, given the clear superiority of eight-hour dialysis, the researchers do not think the results would be changed with long-term observation. Dr. Ok adds, "We expect that these data would be convincing to the whole of society—including physicians, patients, health authorities, and social security institutions—for the necessity of longer hemodialysis in order to improve high mortality and morbidity."
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The study was supported by a grant from the European Nephrology Dialysis Institution. The study was conducted in Fresenius Medical Care (FMC) Turkey clinics. Ercan Ok, MD and Ali Basci, MD are members of the Scientific Advisory Board of FMC Turkey; Siddig Momin Adam, MD, is a nephrologist in a FMC Turkey Clinic.

New equation provides more accurate estimates of kidney function

Andrew S. Levey
08 nov 2008--A newly developed equation produces more accurate estimates of the glomerular filtration rate (GFR)—a key indicator of kidney function in patients with chronic kidney disease (CKD), according to research being presented at the American Society of Nephrology's 41st Annual Meeting and Scientific Exposition in Philadelphia, Pennsylvania.
"Equations to estimate GFR are routinely used to assess kidney function and to detect, evaluate, and manage CKD," comments Andrew S. Levey, MD, of Tufts Medical Center in Boston, Massachusetts, on behalf of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). "Our new estimating equation, developed from pooled databases, is more accurate than the widely used Modification of Diet in Renal Disease (MDRD) Study equation."
The MDRD and similar equations use information on age, race sex, and the level of creatinine—a waste product normally removed from the blood by kidneys—to estimate the GFR. (Although there is a test to measure the actual GFR, it is time consuming and impractical for routine use.)
However, the MDRD equation has some important limitations: it is relatively imprecise and tends to underestimate GFR, especially at higher (closer to normal) levels. The MDRD was developed using data on about 1,600 patients from a single study.
In an attempt to improve on the MDRD, the CKD-EPI researchers developed a new equation based on pooled databases. Initial development used data on more than 8,000 patients from 10 studies; the equation was then validated (confirmed) using data on nearly 4,000 patients from 16 studies.
Compared to actual GFR measurements, the resulting CKD-EPI equation was more accurate than the MDRD equation. The CKD-EPI equation was more accurate at all levels of kidney function, although the difference was greatest at higher GFR levels. When the two equations were applied to a nationally representative sample of 16,000 Americans, the estimated prevalence of CKD in the population was 12.2 % with the CKD-EPI equation, compared to 13.3 % with the MDRD equation.
The National Kidney Foundation estimates that 26 million U.S. adults have CKD, while another 20 million are at increased risk. Early detection and treatment are needed to reduce the risk of worsening kidney disease. Estimating equations like the MDRD equation play an important role in CKD diagnosis and treatment.
The CKD-EPI equation, developed in pooled databases including thousands of patients, appears to offer some important advantages over the MDRD equation. "The CKD-EPI equation has lower bias, especially at higher estimated GFR," says Dr. Levey. "Although its precision remains limited, the CKD-EPI equation could replace the MDRD equation for routine clinical use."
The researchers emphasize that a single equation may not be accurate in all populations of patients with CKD. The CKD-EPI equation was developed from pooled databases, not a representative population. As with the MDRD equation, the CKD-EPI estimates of GFR are not as accurate as actual GFR measurements.
The CKD-EPI collaboration was funded by research grants from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
The study abstract, "A New Equation to Estimate GFR from Serum Creatinine: Improved Accuracy and Updated Estimates of Prevalence of Chronic Kidney Disease in the United States," (F-FC160) will be presented as part of a Free Communications session on the topic of "Effects of Traditional and Nontraditional Risk Factors on Cardiovascular Risk in Chronic Kidney Disease and End Stage Renal Disease" on Friday, November 7 at 1:30 p.m. in Room 102 of the Pennsylvania Convention Center in Philadelphia, PA.
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ASN is a not-for-profit organization of 11,000 physicians and scientists dedicated to the study of nephrology and committed to providing a forum for the promulgation of information regarding the latest research and clinical findings on kidney disease. ASN Renal Week 2008, the largest nephrology meeting of its kind, will provide a forum for 11,000 nephrologists to discuss the latest findings in renal research and engage in educational sessions related to advances in the care of patients with kidney and related disorders. Renal Week 2008 will take place November 4 – November 9 at the Pennsylvania Convention Center in Philadelphia, PA.

Age is not a key factor in cancer survival, but clinical trials exclude older patients

60 percent of cancer patients are older, but they are 'systematically excluded' from clinical trials

07 nov 2008--Age is not an independent factor in cancer survival rates and should not influence decisions about how to treat older patients, according to a study in the November issue of IJCP, the Independent Journal of Clinical Practice.
A team of hospital and University-based researchers from Barcelona, Spain, carried out a detailed study of more than 200 patients diagnosed with cancer.
"We found that there were a number of factors that influence survival rates – including physical quality of life and how far the cancer had spread – but age was not one of them" says lead researcher Dr Eva Domingo from Hospital Vall d'Hebron.
"Despite this fact, and the challenges that clinicians face from an ageing population, there has been little research into how to treat older cancer patients, who often have complex medical needs because of other health issues.
"They have been systematically excluded from clinical trials for cancer treatments. Although 60 per cent of cancers occur in patients over 65, their participation in clinical trials does not exceed 25 per cent.
"This has made it difficult to predict how older patients will tolerate and respond to the latest cancer treatments and has provided an obstacle to making evidence-based clinical decisions."
Dr Domingo and her colleagues teamed up with researchers from the University of Barcelona to look at 224 patients diagnosed with cancerous tumours.
The patients ranged from 32 to 92 years of age and three-quarters of them were male. Thirty-nine per cent of the patients were under 65 and 61 per cent were 65 or over.
The most common tumours were respiratory (43 per cent) and gastrointestinal (29 per cent). 42 per cent of the patients had a localised tumour.
Just under two-thirds of the patients (62 per cent) died during the one-year follow-up period.
The data from each patient, which included body mass index and quality of life scores as well as various clinical tests, was subjected to a detailed analysis.
This showed that there were four independent factors that played a significant role in predicting whether a patient survived. These were:
• Metastatic dissemination, which measures how widely the cancer has spread. • The level of functional impairment the patient experienced, as measured by the Karnofsky Perfomance Status Scale. • The patient's physical quality of life, as measured by the eight criteria on the Short Form 36 questionnaire. • Serum albumin levels, a major protein that is produced in the liver and is essential for maintaining pressure in the vascular system.
Patients had better survival rates if they had a good physical quality of life and fewer problems with functional impairment. High serum albumin levels were also important, as were a lack of metastatic dissemination.
"The patient's age was not an independent factor that predicted how likely they were to survive cancer" stresses Dr Domingo. "Because of this, age, in itself, should not be used to limit diagnostic or therapeutic decisions."
The number of older cancer patients is rising as the worldwide population ages. But not enough it being done to meet their needs, argue the authors.
"Consciously or unconsciously, age often becomes a decisive element when diagnostic or therapeutic strategies are designed" says Dr Domingo.
"Older people tend to have more complex health needs, such as other illnesses, and that is one of the reasons that has frequently been put forward for not treating their cancers aggressively. However our study found that comorbidity, like age, was much less significant than factors like physical quality of life.
"Other reasons given include the limited long-term benefits, compared with younger patients, and the lack of financial, logistical and social support."
The authors hope that their research will reduce the focus that other clinicians put on age when they treat older patients with cancer.
"We would like to see less decisions taken on the basis of age and more research that explores the complex needs of older people, so that they can be treated more effectively and enjoy a better quality of life" concludes Dr Domingo.
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Notes to editors
Prognostic factors in the diagnostic work-up of cancer patients in an internal medicine department: does age matter? Domingo et al. IJCP, the International Journal of Clinical Practice. 62.11, p1723-1729. (November 2008).

A Positive Approach to Doctors-in-Training

By PAULINE W. CHEN, M.D.
07 nov 2008--At the core of every doctor’s training is the internship, that first year of residency that begins just a few weeks after all the pomp and circumstance and lighthearted celebration of medical school graduation. Sometimes referred to as simply the first year of residency, internship is the first step in a professional journey that could include several more years of residency training, a year or two of subspecialty fellowship, and another year or two of research before one ever reaches the goal of becoming a fully trained doctor, an attending physician.
I began my internship as part of a class of five, two women and three men who had all done reasonably well in medical school. By the end of our second year, however, three had left. None of us had ever expected such an attrition rate; our teachers, the attending surgeons, had not intended, as some residency programs did at the time, to fire two of my peers. None guessed that a third would simply up and quit.
The two of us left standing knew that the official reasons were poor judgment and “unprofessional behavior” — we had heard that one of our classmates had repeatedly violated patient confidentiality, and the other had made a decision that put a young child’s life in danger. But after their departure, the two of us remaining became fast friends.
We had to be, given the stark facts: we were working well over 100 hours a week with the possibility — the sheer fear, really — that we could be next in line to be fired and would lose all we had worked for until that point. Our dismissed classmates had struggled to find work after leaving; one had begun training all over again in a different specialty, and the other eventually left medicine altogether. Without the support of the other remaining intern, my best friend, I could not have survived.
We did make it through residency, and we learned during our internship and our second year to stay as far away from trouble as we could. “Remember,” the two of us often warned one another, “you’re only one slip-up away from one of those guys.”
Negative reinforcement during those early years taught me to be a cautious and conscientious doctor. Our teachers rarely praised us for good work and never allowed us to forget our errors. But sometimes the lessons had little to do with learning how to care for patients.
One night during my internship, for example, a powerful senior attending called to chew me out for putting his V.I.P. patient in a double room. His voice was so loud I can still remember holding the phone away from my ear. “Do you know I can get you fired for this?” he roared.
“Yes, sir,” I responded meekly. I was too scared to tell him the truth, which was that the head nurse, not the intern, assigned patient rooms.
Those early lessons were so effective that even today whenever I hear anyone say the words, “I need to talk to you,” my first response is: Did I do something wrong?
I believe strongly that we need to train young doctors to be competent, caring and conscientious. And I would also say that most individuals in my profession feel the same way, judging by the degree of interest in journals and professional societies in cultivating “professionalism,” the buzzword used to encompass all those desired qualities. “Placing the interests of patients above those of the physician, setting and maintaining expert standards of competence and integrity, and providing expert advice to society on matters of health” is how one international gathering of medical groups summed up the goals of “professionalism.”
I just wonder, though, if emphasizing the negatives — what not to do and the terrible personal repercussions — is necessarily the best way to go about teaching professionalism.
Recently while reading The Journal of the American Medical Association, I came across a study on professionalism that addresses positive reinforcement. Using observation-based evaluations, Dr. Darcy A. Reed and her colleagues at the Mayo Clinic in Rochester, Minn., assessed aspects of professionalism like compassion, competence and integrity among 148 residents and then examined the specific behaviors of the most outstanding among them.
I read through Dr. Reed’s paper once and had difficulty understanding her premise; there was little mention of the negative behaviors young doctors needed to avoid. I read through the paper again and this time noticed that even the so-called “average” residents in her study behaved in a very “professional” way. The differences in professionalism between the outstanding residents and those who were average were not that disparate.
In other words, most residents were trying their best to be good doctors.
I called Dr. Reed.
“People have a natural desire to do good, physicians especially,” she said. “But the problem,” she continued, “may be a training system that encourages not how I can improve but how I can survive.”
Doctors-in-training, Dr. Reed maintained, want to know how to improve. But many of their teachers, individuals like myself who were exposed early on in their training to negative reinforcement, might not necessarily understand how encouraging rather than ignoring or discouraging might work in residency. Moreover, even for those educators who are comfortable with positive reinforcement, it is still not entirely clear which behaviors correlate best with professionalism and are thus most important to encourage.
Which is the reason why Dr. Reed and her colleagues chose to focus on only the most highly-rated residents in their study. “What is it about outstanding residents? And how can we all emulate and encourage that behavior?” she asked me on the phone. “We want to encourage residents and the behaviors that we know are associated with outstanding professionalism.”
Dr. Reed paused and then added, “Negative reinforcement is so defeating. There are far fewer people who need negative reinforcement than those who need the positive.”
I got off the phone that morning feeling a little unbalanced, as if I had been handed a new pair of glasses to wear. Maybe I did not need all that early negative reinforcement to have become a conscientious doctor. Maybe all those fears my best friend and I shouldered during our internship and second year of training were unnecessary.
I read Dr. Reed’s paper yet again and suddenly remembered her answer to a question I include in all my interviews: What was it personally that got you interested in this topic?
Dr. Reed had, I noticed, answered without a moment’s hesitation. “I became interested in educational research through interest in teaching. I was impressed by excellent teachers and wanted to emulate them.”
She had learned, I now understood, through positive reinforcement.

Age, race are among factors that influence carotid-surgery success

Dr. Ethan Halm, new chief of the William T. and Gay F. Solomon Division of General Internal Medicine, helped identify several factors that can affect whether a patient dies or...

DALLAS ,07 nov 2008– Advanced age and race are among the factors that can affect whether a patient dies or suffers a stroke after carotid-artery surgery, a UT Southwestern physician involved in a multicenter study has found.
"This study identified 11 readily available, clinical risk factors that can help referring physicians, neurologists, surgeons and anesthesiologists better weigh the risks and benefits of carotid surgery for an individual patient," said Dr. Ethan Halm, new chief of the William T. and Gay F. Solomon Division of General Internal Medicine at UT Southwestern and the study's lead author. "You don't want to cause a stroke to prevent a stroke."
The new findings appear in the current online version of the journal Stroke.
Dr. Halm and colleagues used data from the New York Carotid Artery Surgery (NYCAS) study, which evaluated the outcomes of 9,308 carotid surgeries performed on elderly patients by 482 surgeons in 167 hospitals in New York state. It is the largest study of its kind to use clinically detailed data on a population-based study of carotid-surgery outcomes and risk factors in community practice. Dr. Halm recently left Mt. Sinai School of Medicine in New York to lead UT Southwestern's general internal medicine division.
Carotid-artery surgery, one of the most common types of vascular surgeries performed in the U.S., involves opening the carotid artery in the neck and removing harmful plaque to restore blood flow to the brain. Although previous controlled trials have shown carotid surgery reduces the long-term risk of death or stroke in some patients, there is a chance the procedure could cause death or stroke.
The NYCAS study found that the overall risk of death or stroke in the first 30 days after surgery varied greatly according to a patient's age, race, number of serious medical conditions, severity of carotid disease and acuity of neurological symptoms.
The statistical findings included:
Advanced age (defined in the NYCAS study as 80 years or older) increased the risk-adjusted odds of death or stroke by 30 percent;
Non-white patients were 83 percent more likely to have a negative outcome within 30 days;
Having coronary artery disease increased the odds of death or stroke by 51 percent; and
Having diabetes treated with insulin increased the odds of death or stroke by 55 percent.
In addition, the more serious the neurological symptoms a patient had from the blockage of the carotid artery, the higher the risk of negative outcomes. Patients who suffered a stroke or temporary stroke in the year before carotid surgery also had increased risks.
"Having one risk factor would not necessarily be a reason not to have the surgery, but having multiple risk factors, like being over the age of 80 with heart disease and diabetes, might tip the balance for many patients in favor of medical management," Dr. Halm said.
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The NYCAS study was supported by the Agency for Healthcare Research and Quality, Centers for Medicare & Medicaid Services, the Robert Wood Johnson Foundation and the National Institute of Neurological Disorders and Stroke.

How women can improve their quality of life after breast cancer treatment

Women need to be well-informed about options for minimising harm from breast cancer treatment / Acting early could avoid long-term problems like lymphedema


07 nov 2008--Opting for less damaging treatments, staying active and learning about the warning signs of lymphedema: that's how women with breast cancer can avoid developing chronic lymphedema, according to the German Institute for Quality and Efficiency in Health Care (IQWiG). Women can learn more about how to protect themselves from this common and distressing adverse effect of treatment as well as handle the condition at the Institute's website, www.informedhealthonline.org.
Protecting women's lymph systems
Breast cancer treatment is becoming more effective, with a survival rate of more than 80% for this disease in Germany. As the survival rate goes up, quality of life for survivors assumes even more importance, according to the German Institute. Lymphedema is an adverse effect of breast cancer treatment caused by damage to the lymph system. When the lymph system cannot properly remove fluids from around the breast and arm, the fluid gathers and the arm swells. This causes pain and restricts movement. It could become a chronic problem that is hard to treat.
The more aggressive breast cancer treatment is, the higher the risk of lymphedema. Researchers estimate around 400,000 women in Germany alone have lymphoedema caused by breast cancer treatment.
"Even with many women having less aggressive breast cancer treatments, around 10 to 20% will develop lymphedema," according to Professor Peter Sawicki, the Institute's Director. "We doctors still underestimate the impact on patients' quality of life of treatment adverse effects like lymphedema. The first step to prevention is using therapies that limit the damage to the woman's lymph system."
Better quality of life after breast cancer
The second step to better quality of life is to stay active. For years, there were many warnings to women to limit the use of the arm and be careful about being too active after breast cancer treatment. But Professor Sawicki said, "While women who are developing lymphedema have to protect their arms more, the blanket warnings from the past to all women with breast cancer were never based on strong scientific evidence. In fact, trials of exercise in women with breast cancer have shown that it can improve quality of life without increasing the risk of lymphedema."
However women need to learn about the warning signs of lymphedema and act early. "A feeling of heaviness, heat and swelling in the arm - women need to take action early when this happens in the years after breast cancer treatment," Professor Sawicki said. "Lymphedema is easier to treat effectively in the early stages."
The treatment shown to be effective in trials is compression therapy with bandages or compression sleeves. A special massage technique called lymphatic drainage as well as physiotherapy might be able to help, but this has not been so well-studied. Women can learn more about the condition and what could help at www.informedhealthonline.org.
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The Institute's website, www.informedhealthonline.org, provides the public with easy-to-understand information about current medical developments and research on important health issues. If you would like to be kept up-to-date with the latest publications on the independent health information website, you can subscribe to the informedhealthonline.org newsletter.

Kidney transplantation provides cognitive benefits for patients with kidney disease

Kidney transplantation can improve mental performance

07 nov 2008--Individuals with kidney disease often suffer from cognitive impairment, but kidney transplantation can improve their mental performance, according to a paper being presented at the American Society of Nephrology's 41st Annual Meeting and Scientific Exposition in Philadelphia, Pennsylvania.
While researchers and clinicians consider cognitive decline to be a common occurrence in patients with chronic kidney disease, it is unclear if this impairment is due to patients' advanced age, their chronic health conditions, or potential treatment-related factors. In addition, the effects of surgery and immunosuppressant medications on memory and overall cognitive performance have been poorly studied, but previous research suggests that kidney transplantation may have a beneficial effect on patients' mental function.
To investigate this further, Mark Unruh, MD, and his colleagues at the University of Pittsburgh in Pittsburg, Pennsylvania, assessed kidney disease patients' cognitive performance before and after kidney transplantation. They did so by using neuropsychological tests related to language, learning and memory, attention, and other brain processes involved with thought and behavior.
The researchers compared test scores of 37 patients before and after they received transplants. A control group of 13 patients who did not receive kidney transplants but received dialysis was also followed over the same period of time.
Dr. Unruh and his team found a statistically significant improvement in performance on tests of verbal learning and memory, attention, and language after patients received kidney transplants. They found no such improvement in patients not undergoing this surgical procedure. In fact, test scores declined in these patients over time.
When comparing the differences of scores between the two groups adjusted to their original scores, transplanted patients performed particularly well on tests of learning and memory compared with dialysis patients.
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The study abstract, "Cognitive Performance Following Kidney Transplantation," (TH-PO531) will be presented as a poster on Thursday, November 6, from 10:00 a.m.- 12:00 p.m. in Exhibit Halls A and B of the Pennsylvania Convention Center in Philadelphia, PA.

Male hormone patch increases libido in women

NEW YORK, 06 nov 2008– Postmenopausal women with low sexual desire levels reported improved sexual function after they were treated with a patch in which the male hormone testosterone was applied through the skin, a clinical study has found. However, more studies are needed to confirm the safety of this treatment.
"Many postmenopausal women continue to be sexually active despite a high level of sexual dissatisfaction, engaging in sexual activity to please their partner and maintain domestic harmony," lead author Dr. Susan R. Davis, at Monash University in Prahran, Australia, and fellow researchers note.
While testosterone has proved effective for increasing libido among postmenopausal women who are on hormone replacement therapy, the effectiveness of this approach in women who are not taking estrogen is unknown.
There has also been some concern that testosterone administered without being tempered by another hormone may adversely affect circulating lipid (fat) levels, glucose (sugar) metabolism or breast tissue.
The APHRODITE trial (A Phase III Research Study of Female Sexual Dysfunction in Women on Testosterone Patch without Estrogen), conducted at 65 centers in Australia, Europe, and North America, included postmenopausal women who reported significant loss of sexual desire that was causing personal distress.
In this study, 267 women were assigned to receive transdermal testosterone at 150 g/day, 267 were treated with the patch testosterone at 300 g/day, and a third group of 277 women received placebo. The patches (Intrinsa, Procter & Gamble) were applied to the abdomen twice a week. The group assignments were all random and neither the patients nor the clinicians knew what each group was given.
At 24 weeks, an increase in the frequency of satisfying sexual episodes was significantly greater in the group receiving the 300 g testosterone dose than the placebo group, but not significantly greater in the group that received the lower dose of testosterone.
Both testosterone groups also had significantly increased scores for sexual desire and decreases in personal distress.
"The increase in the frequency of satisfying sexual episodes was modest but appeared to be clinically meaningful," the authors comment.
The most common hormone side effect was an increase in unwanted hair growth in the higher-dose group. The frequency and severity of other side effects events -- acne, baldness, and voice deepening -- did not differ between the treatment groups. There were no clinically relevant changes in blood lipid levels, glucose metabolism or liver function in any of the groups.
Of concern was the diagnosis of breast cancer in four women in the testosterone groups. The authors note that one of the subjects was symptomatic, with a bloody nipple discharge prior to study entry, and another was diagnosed after 4 months of treatment. The other two were diagnosed after 52 weeks and 104 weeks of treatment.
"Additional data are needed to assess the long-term safety of testosterone use in women with estrogen depletion," the researchers conclude.
SOURCE: The New England Journal of Medicine, November 6, 2008.

Mitochondria could be a target for therapeutic strategy for Alzheimer's disease patients

New York, 06 nov 2008 — A study in the Sept. 21 on-line edition of Nature Medicine describes the function and interaction of a critical molecule involved in cell death in Alzheimer's disease patients. These new findings reveal that blocking this molecule, called Cyclophilin D (CypD), and development of surrounding mitochondrial targets may be viable therapeutic strategies for the prevention and treatment of Alzheimer's disease, according to Shi Du Yan, Ph.D., professor of clinical pathology in the Department's of Pathology and Surgery and in the Taub Institute for Research on Alzheimer's Disease and the Aging Brain at Columbia University Medical Center, who led the multi-center research.
This paper strengthens the concept that mitochondrial permeability pores may be central in mitochondrial and neuronal malfunction relevant to Alzheimer disease. Dr. Yan and her colleagues offer new insights into the mechanism underlying amyloid beta (Aβ)-mediated mitochondrial stress through an interaction with CypD, which is linked to synaptic plasticity and learning/memory. Importantly, these findings may help explain the mechanism of action of a medication already in use in clinical trials.
Mitochondria, the microscopic parts found outside the nucleus of the cell that produce a cell's energy, are central players in mediating neuronal stress relevant to the pathogenesis or development of neurodegenerative diseases such as Alzheimer's disease. Mitochondrial dysfunction, or a problem with the cellular exchange of energy, is an early event observed in Alzheimer's disease. Recent studies have provided substantial evidence that mitochondria serve as direct targets for amyloid beta (Aβ) protein mediated neuronal toxicity. The observations that Aβ progressively accumulates in cortical mitochondria from Alzheimer's disease patients and in brains from transgenic Alzheimer's disease type mouse models suggest the role of mitochondrial Aβ in the pathogenesis or development of the disease. This Nature Medicine study describes how this mitochondrial process may be linked to synaptic failure in Alzheimer's disease.
The study provides new insights into the mechanism underlying mitochondrial Aβ-mediated and synaptic stress that links to the mitochondrial permeability transition pore (mPTP), an opening that leads to cell death for those with Alzheimer's. Mitochondrial permeability transition pore causes mitochondrial swelling, outer membrane rupture and release of cell death mediators and enhances production of reactive oxygen species (ROS). Cyclophilin D (CypD), a type of enzyme called a prolyl isomerase that is located within the mitochondrial matrix, is an integral part in the formation of the mitochondrial permeability transition pore (mPTP), leading to cell death. Up until now, however, the role of CypD in Alzheimer's disease has not been elucidated.
In this paper, Dr. Yan and colleagues demonstrate that CypD interacts with Aβ peptide within the mitochondria of Alzheimer's disease patients and a transgenic mouse model of Alzheimer's disease. The cortical mitochondria isolated from Alzheimer's disease mice lacking CypD are resistant to Aβ- and Ca2+-induced mitochondria swelling and permeability transition, increase calcium buffering capacity, and attenuate generation of mitochondrial ROS. Furthermore, CypD-deficient neurons protect against Aβ- and oxidative stress-induced cell death. Importantly, deficiency of CycD greatly improved the learning, memory, and synaptic function of an Alzheimer's disease mouse model and alleviated Aβ-mediated reduction of long term potentiation (LTP). Thus, the CypD/Aβ-mediated mitochondrial permeability transition pore directly links to the cellular and synaptic perturbation relevant to the pathogenesis of Alzheimer's disease.
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The Taub Institute for Research on Alzheimer's Disease and the Aging Brain at Columbia University Medical Center is a multidisciplinary group that has forged links between researchers and clinicians to uncover the causes of Alzheimer's, Parkinson's and other age-related brain diseases and discover ways to prevent and cure these diseases. It has partnered with the Gertrude H. Sergievsky Center at Columbia University Medical Center which was established by an endowment in 1977 to focus on diseases of the nervous system. The Center integrates traditional epidemiology with genetic analysis and clinical investigation to explore all phases of diseases of the nervous system. For more information about these centers visit: http://www.cumc.columbia.edu/dept/taub/ http://www.cumc.columbia.edu/dept/sergievsky/

Other illnesses affect Alzheimer's disease survival

NEW YORK, 06 nov 2008– Once elderly patients are diagnosed with Alzheimer's disease, the presence of other illnesses and the patients' ethnic background appear to affect their length of survival, investigators report in the medical journal Neurology.
Led by Dr. Yaakov Stern, the research team at Columbia University Medical Center identified 323 cases of Alzheimer's disease from a group of approximately 4300 Medicare recipients who were enrolled in the Washington Heights Inwood Columbia Aging Project in New York.
More than half of the subjects were Hispanic, one third were African American and about 10 percent were white. Stern's group followed these patients for an average of 4 years, to a maximum of about 13 years.
Although overall the overall average lifespan (92 years) and age at diagnosis (83 years) did not differ by racial or ethnic group, the average length of survival after Alzheimer's disease was diagnosed was 8 years among Hispanics, significantly longer than among whites (4 years) and African Americans (5 years).
A history of diabetes and high blood pressure both independently shortened survival. Closer analysis of the data revealed that the mortality risk was increased by 2.6-fold among Alzheimer's disease patients with high blood pressure, and by 2-fold among patients who also had diabetes, both statistically significant differences.
Age was also a significant predictor of shortened survival time, with an average post-diagnosis survival of 10 years among those between 67 and 74 years old; 7 years among those between 75 and 84 years; and 4 years among those between 85 and 100 years old, all statistically significant differences.
In contrast to most other studies, the team did not detect any association between survival duration and gender, history of heart disease or malignancy, or the presence of APOE-epsilon-4 alleles - the gene associated with Alzheimer's disease that is detected in some but not all who develop this type of dementia.
The lack of any apparent association with the APOE gene, Stern's group suggests, "may reflect a differential effect of epsilon-4 in the earlier stages of disease that is eclipsed by other factors (medical, social, or disease-related factors) later in the disease course."
SOURCE: Neurology 2008.

Researchers ID Genetic Markers for Esophageal Cancer

06 nov 2008-- Eleven genetic variations believed to be predictors of esophageal cancer have been identified by U.S. researchers.
The University of Texas M. D. Anderson Cancer Center team pinpointed 11 single-nucleotide polymorphisms (SNPs) in microRNA-related genes that showed an association with esophageal cancer.
Each of these unfavorable genotypes was linked with an increased risk of cancer. People with more than four of the 11 genotypes had a more than threefold increased risk of esophageal cancer, according to the study, published in the November issue of Cancer Prevention Research.
"Our ultimate goal is to construct a quantitative cancer risk prediction model based on an individual's epidemiological profile, environment exposure and genetic makeup. This risk prediction model can evaluate each person's relative risk and absolute risk of developing esophageal cancer within a certain time period," study author Dr. Xifeng Wu, a professor in the department of epidemiology, said in an American Association for Cancer Research news release.
Esophageal cancer is the fastest growing cancer in the United States, and the majority of patients are diagnosed at an advanced stage. Being able to identify people at high risk for the disease may improve screening, monitoring and prevention.
"Considering the dramatic increase in incidence, difficulty of early diagnosis, the poor survival rate for esophageal cancer, and the limited knowledge of the natural history of the tumor, we need a greater understanding of the etiology of esophageal cancer for improvement of diagnosis and hopefully a better prognosis," Wu said.
Along with genetics, other risk factors for esophageal cancer include obesity, smoking and gastrointestinal reflux disease.

Study reveals continued damage from banned obesity drug

06 nov 2008--Fenfluramine, the appetite suppressant drug banned in the US in 1997 due to fears over its links to heart conditions, has been shown to have serious long-term effects. In a report published today in the open access journal BMC Medicine, researchers have shown that people who stopped using fenfluramine eleven years ago had damaged heart valves up to seven years later.
Fenfluramine (and the closely related dexfenfluramine) were widely prescribed as half of a so-called 'fen/phen' drug combination used to combat obesity. Since its withdrawal, there have been reports that tens of thousands of lawsuits have been filed against the drug's manufacturers over damage caused. In this study, Charles Dahl from the Central Utah Clinic led a team of researchers who studied the heart condition of 5743 former fenfluramine users. He said, "Valve problems were common in individuals exposed to fenfluramines, more frequent in females and associated with duration of drug use in all valves assessed".
Heart valves, such as the aortic, mitral and tricuspid valves, ensure that blood flows in the correct direction around the heart. When they fail, blood back-flows (termed regurgitation). If the regurgitation is severe enough, congestive heart failure and/or the need for heart valve surgery may occur. Dahl said, "We found clear evidence for a strong, graded association between duration of exposure to fenfluramines and prevalence of aortic regurgitation and for mild or greater mitral and tricuspid regurgitation".
This is the largest study to examine duration of exposure to the drug and the first to estimate the incidence of valvular surgery among prior users. The authors found that 0.44% of former fenfluramine users in this group had valve surgery as a result of the use of fenfluramines. This risk for valve surgery was increased approximately seven fold. They write, "This is probably a conservative estimate, as another study has shown that there exists a 17- to 34-fold excess of clinically apparent (presumably severe), valvular disease in persons who had used fenfluramines for four months or longer".