'Tomato pill' improves function of blood vessels in patients with cardiovascular diseases

Micrograph of a heart with fibrosis (yellow) and amyloidosis (brown). Movat's stain. Credit: Nephron/Wikipedia

A daily supplement of an extract found in tomatoes may improve the function of blood vessels in patients with cardiovascular disease, according to new research from the University of Cambridge.

10 jun 2014--The incidence of cardiovascular disease varies worldwide, but is notably reduced in southern Europe, where a 'Mediterranean diet' consisting of a larger consumption of fruit, vegetables and olive oil predominates. Recent dietary studies suggest that this diet reduces the incidence of events related to the disease, including heart attack and stroke, in patients at high cardiovascular risk, or those who have previously had the disease.

One component of the Mediterranean diet thought to play a role in reducing this risk is lycopene, a powerful antioxidant which is ten times more potent than vitamin E. Lycopene is found in tomatoes and other fruits, and its potency appears to be enhanced when it is consumed pureed, in ketchup or in the presence of olive oil. Whilst there is strong epidemiological evidence to support the role of lycopene in reducing cardiovascular risk, the mechanism by which it does so is unclear.

In a study published in the journal PLOS One, researchers at the University of Cambridge and the Cambridge University Hospitals National Health Service Foundation Trust demonstrate one mechanism by which they believe lycopene reduces the risk.

Dr Joseph Cheriyan, consultant clinical pharmacologist & physician at Addenbrooke's Hospital and Associate Lecturer at the University of Cambridge, says: "There's a wealth of research that suggests that the Mediterranean diet – which includes lycopene found in tomatoes and other fruit as a component – is good for our cardiovascular health. But so far, it's been a mystery what the underlying mechanisms could be."

The researchers carried out a randomised, double blind, placebo controlled, interventional trial investigating the effects of lycopene a gold standard method of measuring the function of blood vessels called forearm blood flow, which is predictive of future cardiovascular risk. Thirty-six cardiovascular disease patients and thirty-six healthy volunteers were given either Ateronon (an off-the-shelf supplement containing 7mg of lycopene) or a placebo treatment. As a double blind trial, neither the study participants nor the researchers dispensing the pills were aware which treatment was being provided.

The patients with cardiovascular disease were all on statins (cholesterol-lowering drugs). However, despite this, they still had a relatively impaired function of the endothelium – the inner lining of blood vessels – compared to healthy volunteers. This function is determined by the response of blood vessels in the forearm to a naturally occurring molecule called acetylcholine. Endothelial function predicts future events, so having a healthy endothelium is an important factor in preventing the evolution of heart disease.

The researchers found that 7mg of oral lycopene supplementation improved and normalised endothelial function in the patients, but not in healthy volunteers. Lycopene improved the widening of the blood vessels by over a half (53%) compared to baseline in those taking the pill after correction for those who took the placebo; constriction of the blood vessels is one of the key factors that can lead to heart attack and stroke. However, the supplement had no effect on blood pressure, arterial stiffness or levels of lipids.

"We've shown quite clearly that lycopene improves the function of blood vessels in cardiovascular disease patients," adds Dr Cheriyan. "It reinforces the need for a healthy diet in people at risk from heart disease and stroke. A daily 'tomato pill' is not a substitute for other treatments, but may provide added benefits when taken alongside other medication. However, we cannot answer if this may reduce heart disease – this would need much larger trials to investigate outcomes more carefully."

Professor Jeremy Pearson, Associate Medical Director at the British Heart Foundation, says: "Impaired endothelial function is a known predictor of increased risk of future heart disease. Further work is needed to understand whether the beneficial effects seen in this small study translate into clinical benefit for at-risk patients."

More information: Gajendragadkar, PR et al. Effects of Oral Lycopene Supplementation on Vascular Function in Patients with Cardiovascular Disease and Healthy Volunteers: A Randomised Controlled Trial. PLoS One; 9 June 2014.

Provided by University of Cambridge

Study reveals rats show regret, a cognitive behavior once thought to be uniquely human

Hucky rat. Credit: AlexK100/Wikipedia.

09 jun 2014--New research from the Department of Neuroscience at the University of Minnesota reveals that rats show regret, a cognitive behavior once thought to be uniquely and fundamentally human.

Research findings were recently published in Nature Neuroscience.

To measure the cognitive behavior of regret, A. David Redish, Ph.D., a professor of neuroscience in the University of Minnesota Department of Neuroscience, and Adam Steiner, a graduate student in the Graduate Program in Neuroscience, who led the study, started from the definitions of regret that economists and psychologists have identified in the past.

"Regret is the recognition that you made a mistake, that if you had done something else, you would have been better off," said Redish. "The difficult part of this study was separating regret from disappointment, which is when things aren't as good as you would have hoped. The key to distinguishing between the two was letting the rats choose what to do."

Redish and Steiner developed a new task that asked rats how long they were willing to wait for certain foods. "It's like waiting in line at a restaurant," said Redish. "If the line is too long at the Chinese food restaurant, then you give up and go to the Indian food restaurant across the street."

In this task, which they named "Restaurant Row," the rat is presented with a series of food options but has limited time at each "restaurant."

Research findings show rats were willing to wait longer for certain flavors, implying they had individual preferences. Because they could measure the rats' individual preferences, Steiner and Redish could measure good deals and bad deals. Sometimes, the rats skipped a good deal and found themselves facing a bad deal.

"In humans, a part of the brain called the orbitofrontal cortex is active during regret. We found in rats that recognized they had made a mistake, indicators in the orbitofrontal cortex represented the missed opportunity. Interestingly, the rat'sorbitofrontal cortex represented what the rat should have done, not the missed reward. This makes sense because you don't regret the thing you didn't get, you regret the thing you didn't do," said Redish.

Redish adds that results from Restaurant Row allow neuroscientists to ask additional questions to better understand why humans do things the way they do. By building upon this animal model of regret, Redish believes future research could help us understand how regret affects the decisions we make.

More information: Behavioral and neurophysiological correlates of regret in rat decision-making on a neuroeconomic task, Nature Neuroscience, dx.doi.org/10.1038/nn.3740

Provided by University of Minnesota

Football for untrained 70-year-old men

It is never too late to start playing football. Football boosts physical capacity and heart health, and minimizes the risk of falls and fractures in elderly men, who have never played football before or have not played for decades. Photo: Mikal Schlosser.

08 jun 2014--Research carried out by the Copenhagen Centre for Team Sport and Health in Denmark shows that untrained elderly men get markedly fitter and healthier as a result of playing football (soccer). After only 4 months of twice-weekly 1-hour training sessions, the men achieved marked improvements in maximum oxygen uptake, muscle function and bone mineralization.

Later today, three scientific articles will be published in the Scandinavian Journal of Medicine & Science in Sports describing the fitness and health effects of football training for 63‒75-year-old untrained men. The Copenhagen researchers, led by Professor Peter Krustrup of the Copenhagen Centre for Team Sport and Health, University of Copenhagen, have a compelling case. Football is a fun, social and effective form of high-intensity interval training that is open to all.

Untrained elderly men can also play

"Our previous studies have shown that 70-year-old men with lifelong participation in football possess a postural balance and rapid muscle force that is comparable to that of 30-year-old untrained men," says Krustrup. "This time we have gone one step further by evaluating the intensity of football training as well as the health and fitness effects of football for untrained elderly men with little experience of football."

"The study revealed that inactive elderly men improved their maximum oxygen uptake by 15% and their performance during interval exercise by as much as 50% by playing football for 1 hour two times per week over 4 months. Moreover, muscle function was improved by 30% and bone mineralization in the femoral neck increased by 2%," says Krustrup.

"The results provide strong evidence that football is an intense, versatile and effective form of training, including for untrained elderly men. It is definitely never too late to start playing football. Football boosts physical capacity and heart health, and minimizes the risk of falls and fractures, including in elderly men who have never played football before or have not played for decades," says Krustrup.

Sky-high intensity

"The players had heart rates that were sky high and corresponded to the values obtained during elite football games," says Associate Professor Eva Wulff Helge of the Department of Nutrition, Exercise and Sports, University of Copenhagen.

"GPS measurements and video analyses also showed that there are many fast runs, stops, turns, dribbles, passes and shots, providing strong stimuli for muscle and bone adaptations. The fast runs, intense actions and unorthodox movements may well be the cause of a large increase in bone mineralization in the femur bone and femoral neck after only 4 months and of the further 3% improvement from 4 to 12 months of training," says Helge.

An active everyday life and better health

"Our study shows that intense training such as football can change the lives of elderly men," says Krustrup.

"The remarkable improvements in aerobic fitness and muscle strength make it easier for the players to live an active life and overcome the physical challenges of everyday life such as climbing stairs, shopping, cycling and gardening. This benefits not only the players themselves, but also their families and friends," says Krustrup.

The scientific study

The researchers at the Copenhagen Centre for Team Sport and Health have conducted numerous randomized controlled training studies involving football and other team sports.

In the present study, a total of 27 untrained men aged 63 to 75 were recruited, tested and randomized into a football group, a strength training group and an inactive control group. The two training groups exercised for 1 hour twice a week for a year. A comprehensive testing battery was used at baseline, after 4 months and after 12 months. The research team, comprising 20 researchers from the Copenhagen Centre for Team Sport and Health, the University of Southern Denmark, Gentofte University Hospital and the National Research Centre for the Working Environment, was led by Professor Peter Krustrup, who has studied fitness and health effects for more than 10 years and published 55 articles in the area over the last 5 years.

More information: More information about the three new publications Schmidt et al. 2014, Helge et al. 2014 and Andersen et al. 2014: www.holdspil.ku.dk/english/news/2014/granddad-football/

Provided by University of Copenhagen

Top 5 myths about gluten

Gluten is a protein composite found in wheat and other grains. Gluten gives elasticity to dough, helping it rise and keep its shape.

07 jun 2014--In the past few years there has been a surge in gluten-free diets and products that claim giving up the protein can lead to healthier lifestyles. A New York Times article recently cited Mintel, a market research company, noting "sales of gluten-free products were expected to total $10.5 billion last year…[and] estimates the category will produce more than $15 billion in annual sales in 2016." Even the Girl Scouts have jumped on the proverbial bandwagon, introducing a gluten-free chocolate chip shortbread cookie into their lineup. But is gluten truly bad for you or has it gained a big market based on a bad reputation?

FIU News consulted with Student Health Services Registered Dietitian Christine Tellez to debunk the top 5 myths about gluten.

1. Gluten is bad for everyone.

"Gluten is a mixture of two proteins found in foods like cereal grains and wheat products," says Tellez. "Most people probably don't even know when they are eating gluten since adverse reactions generally only affect people who have celiac disease or those with a gluten sensitivity." A doctor can test you for a gluten intolerance through a blood test.

2. Gluten makes you fat.

"Gluten itself cannot make you fat," she says. "Gluten is naturally found in wheat grains, including barley and rye, even beer and soy sauce. Wheat gluten is also added to imitation meats sometimes to improve the texture of the product." Overeating, an unbalanced diet and lack of exercise are still the leading causes of weight gain. In fact, Tellez says gluten-free pastas and breads may actually have more calories and lower fiber, vitamins and minerals than gluten-containing products. "Gluten-free diets really only benefit you if you have a true gluten intolerance or celiac disease."

3. Not eating gluten will improve your skin.

"Most people probably wouldn't notice a difference," says Tellez. "On average, one in 133 people in the U.S. have celiac disease which present severe symptoms, including recurring abdominal pain and bad acne, when consuming gluten." If you want to improve your skin, she says, eat a balanced diet with high fruit and vegetable intake to ensure your body is getting the full spectrum of vitamins and nutrients.

4. Gluten causes allergies.

"Some celebrities have claimed that gluten free diets have improved autism symptoms or autoimmune disorders, but research doesn't support these claims at all," she says. "Gluten isn't like fat. You can't just assume that less is better."

5. Not eating gluten makes you healthier.

"Not eating gluten can actually be bad for you," says Tellez. "Since gluten is present in many of today's staple foods, cutting it out altogether could mean you miss important nutrients." Tellez advises to consult with your doctor if you think you have a gluten intolerance to determine the best course of action.

Provided by Florida International University

Doctors reluctant to discuss end-of-life care with heart failure patients

Healthcare providers are reluctant to discuss end-of-life care with heart failure patients and their families because they feel uncomfortable broaching the topic or lack time, according to a new study presented at the Quality of Care and Outcomes Research 2014 Scientific Sessions.

06 jun 2014--Researchers surveyed 50 physicians and 45 nurse practitioners or physician assistants at three practices at the Mayo Clinic in Rochester, Minnesota and the Mayo Clinic Health System. Ninety-five clinicians completed the survey.

Among the findings:

• Only 12 percent of the healthcare providers reported having routine yearly discussions about end-of-life care as advocated by the American Heart Association.
• Thirty percent of the group reported having little confidence in discussing or providing end-of-life care.
• Among the 52 percent who said they felt hesitant mentioning end-of-life-care, 21 percent cited their perceptions that patients weren't ready to talk about the issue; 11 percent said they felt uncomfortable bringing it up; 9 percent said they worried about destroying a sense of hope; and 8 percent said they lacked time.

Healthcare providers were often unsure about who should bring up end-of-life care: 63 percent of heart failure specialists and 58 percent of community cardiology clinicians thought end-of-life care discussions were the responsibility of heart failure cardiologists, while 66 percent of primary care providers felt it was their responsibility.

Despite these perceptions, heart failure specialists and community cardiology clinicians were far more likely to have referred heart failure patients to palliative care within the past year than primary care physicians (89 percent versus 21 percent).

"Providers did express an interest in receiving additional training to develop the skills and confidence to talk about end-of-life care with their patients with heart failure," said Shannon Dunlay, M.D., M.S., the study's lead researcher and a cardiologist at the Mayo Clinic in Rochester, Minnesota.

There is no evidence that bringing up end-of-life care ruins hope, and it may ease anxiety for some patients and families, Dunlay said.

About 5.1 million Americans have heart failure and about half of those die within five years of their diagnosis, according to American Heart Association statistics.

"Communication is key but in many hospitals and health systems this can be difficult as patients often have multiple healthcare providers," Dunlay said. "Sometimes it's helpful to pick up the phone and have a provider-to-provider conversation so that everybody is on the same page. Incorporating end-of-life conversations into the ongoing, routine care of the patient is important as goals and preferences can change over time and patients and their families can feel more comfortable and confident in relaying their wishes to multiple providers."

Provided by American Heart Association

New health services needed for rise in 100-year-olds

Over 35,000 people lived to 100 years or more in England over the last ten years, with a large proportion subsequently dying from frailty exacerbated by pneumonia, according to a new study by King's College London. With the number of centenarians set to grow, end-of-life care needs to be tailored to the increasing frailty in this age group, warn the King's palliative care researchers. Boosting care home capacity and planning health services for the rise in centenarians could help to reduce reliance on hospital admission at the end of life and ensure a better quality of end-of-life.

05 jun 2014--Centenarians – people aged 100 years or over - are a rapidly growing demographic group worldwide. In 2011, centenarians globally numbered over 300,000. They are projected to reach three million worldwide by 2050, and 17 million at the end of the century. In the UK, this group has steadily increased since 1956 with numbers roughly doubling every 10 years. The latest Office of National Statistics figures indicate that 13,350 centenarians were living in the UK in 2012. Over half a million are expected to be living in the UK by 2066.

Few studies have looked at the health and social care needs of centenarians compared to younger cohorts of older people, or the implications of extreme longevity for health policy and services. The King's study, funded by the National Institute for Health Research Health Services and Delivery Research (HS&DR) Programme and published in the journal PLOS Medicine, examined the cause and place of death in 35,867 centenarians in England between 2001 and 2010, and compared these findings with those of people who died in their 80s to 90s. The study also looked at factors such as the effect of socioeconomic deprivation on place of death.

The 35,867 people in the study spanned the age range 100-115 years (average age 101), and mainly comprised women (87%) and widowed people (85%). The number of centenarian deaths per year in England increased from 2,800 in 2001 to nearly 4,400 in 2010. Areas of highest deprivation in the UK had the lowest proportion of centenarian deaths, with dying more likely to occur in hospital than in a community setting. The North East of England had the lowest overall proportion of centenarian deaths (4%).

Over the ten-year period, around 60 per cent of centenarians died in a residential or nursing care home, a quarter died in hospital, a tenth died at home and a small number (0.2%) in a hospice.

'Old age' was the most common cause of certifying death (28%), followed by pneumonia (18%) and other respiratory diseases (6%); stroke (10%); heart disease (9%) and other circulatory diseases (10%); dementia and Alzheimer's disease (6%); and cancer (4%). Pneumonia accounted for the largest group of hospital deaths, while across non-hospital settings 'old age' formed the largest category followed by pneumonia. Overall, three-quarters of centenarian death certificates stated 'old age' as either an underlying cause (28%) or contributing cause (47%).

The main causes of death changed with increasing age. In the group aged 80-85 years, heart disease was stated on 19% of death certificates, with 'old age' on only one per cent of certificates.

Dr Catherine Evans, Clinical Lecturer in Palliative Care at the Cicely Saunders Institute, King's College London said: "Centenarians have outlived death from chronic illness, but they are a group living with increasing frailty and vulnerability to pneumonia and other poor health outcomes. We need to plan for health care services that meet the 'hidden needs' of this group, who may decline rapidly if they succumb to an infection or pneumonia. We need to boost high quality care home capacity and responsive primary and community health services to enable people to remain in a comfortable, familiar environment in their last months of life.

"Compared to other European countries the proportion of people aged 90 years and over dying in hospital in England is high, and the number dying in care homes is low. For example, in the Netherlands and Finland more than three-quarters of people aged over 90 die in a long-term care setting such as a nursing home; far fewer die in hospital.

"Hospital admission in the last weeks of life accounts for a third of the total cost of end-of-life care per patient. Increasing the number of care home beds could reduce the reliance on hospital care, but we need to ensure caliber services are provided by GPs, community nurses and other healthcare working with social care providers to enable people to remain in their usual residence at the end of life if they choose."

More information: Evans CJ, Ho Y, Daveson BA, Hall S, Higginson IJ, et al. (2014) Place and Cause of Death in Centenarians: A Population-Based Observational Study in England, 2001 to 2010. PLoS Med 11(6): e1001653. doi:10.1371/journal.pmed.1001653 . www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001653

Provided by King's College London

Locked, loaded and feeling low: Dangers of gun ownership in the elderly

In the United States the debate around gun ownership often focuses on teenagers; however, research shows that elderly Americans are the most likely to own a gun and that presents both medical and legal problems for physicians and carers.

04 jun 2014--Writing in the Journal of the American Geriatrics Society, Dr. Ellen Pinholt explores these issues and proposes a series of 'red flag' questions which caregivers must ask.

While there is no upper age limit on owning a firearm, Americans aged over 65 have the highest prevalence of dementia, depression and suicide. Federal law prohibits mentally incompetent persons from possessing a gun; however, this only applies to a formal finding by a court and not necessarily to a physician's diagnosis of dementia.

Using a series of case studies to explore the medical and legal dimensions of the issue, Dr Pinholt suggests '5 L's', questions about gun ownership which should be asked as routinely as questions about driving.

If there is a gun present is it Locked? Is it Loaded? Are Little children present? Does the gun owner feel Low? Is the gun owner Learned?

More information: Ellen M. Pinholt, Joshua D. Mitchell, Jane H. Butler, Harjinder Kumar, "Is There a Gun in the Home?" Assessing the Risks of Gun Ownership in Older Adults' Journal of the American Geriatrics Society', DOI: 10.1111/jgs.12836

Provided by Wiley

The ethics of knowing where to stop treatment in a sick and elderly patient

An Emeritus Professor of medical ethics at Imperial College London will deliver a presentation at this year's Euroanaesthesia meeting titled 'Escalating care for the comorbid elderly-where do we stop?". Raanan Gillon, who is President of the UK's Institute of Medical Ethics, will argue that a patient's age should not in itself be considered an ethically relevant criterion for deciding 'where to stop'.

04 jun 2014--Acknowledging that there is a morally plausible counter-argument – known in the UK as 'the fair innings argument'- according to which scarce life prolonging resources should be preferentially deployed to younger patients, Professor Gillon will argue against it. He says: "If societies do wish to pursue such 'ageist' policies then they should do so only do so after widespread consultation and the enactment of democratically established laws according to which patients condemned to be denied life-prolonging therapies on grounds of age alone should have a legal right of appeal!"

The moral criteria that are relevant can be summarised, he argues, as the likelihood of achieving a beneficial outcome for the patient, at the cost of a minimised and acceptable risk of harm, in the light of the patient's own views and values where these are ascertainable, and also in the context of fair consideration of competing claims on available resources.

"However, co-morbidity and age may in some circumstances justifiably have a bearing on these criteria," concludes Professor Gillon. "For example co-morbidity may adversely and substantially influence the probability of a beneficial outcome; and some old people may be less inclined than when they were younger to accept the risks and discomforts of major surgery even if it might prolong their lives."

Provided by European Society of Anaesthesiology

Study finds that suicides are far more likely to occur after midnight

03 jun 2014--A new study provides novel evidence suggesting that suicides are far more likely to occur between midnight and 4 a.m. than during the daytime or evening.

Results show that the weighted, scaled mean suicide rate per hour was 10.27 percent after midnight, peaking at 16.27 percent between 2 a.m. and 2:59 a.m. In contrast, the mean suicide rate per hour was 2.13 percent between 6 a.m. and 11:59 p.m. When six-hour time blocks were examined, the observed frequency of suicide between midnight and 5:59 a.m. was 3.6 times higher than expected.

"This appears to be the first data to suggest that circadian factors may contribute to suicidality and help explain why insomnia is also a risk factor for suicidal ideation and behavior," said principal investigator Michael Perlis, PhD, associate professor in the Department of Psychiatry and Director of the Penn Behavioral Sleep Medicine Program at the University of Pennsylvania in Philadelphia. "These results suggest that not only are nightmares and insomnia significant risk factors for suicidal ideation and behavior, but just being awake at night may in and of itself be a risk factor for suicide," he said.
The research abstract was published recently in an online supplement of the journal Sleep and will be presented Tuesday, June 3, in Minneapolis, Minnesota, at SLEEP 2014, the 28th annual meeting of the Associated Professional Sleep Societies LLC.
According to the authors, previous research suggesting that more suicides occur during the day failed to account for the proportion of the population that is awake at each given hour. The current study involved archival analyses of both the National Violent Death Reporting System, which provided data for the estimated time of fatal injury, and the American Time Use Survey, which provided an hourly proportion of the American population that is awake. Time of fatal injury was categorized into one-hour bins, and the hourly distribution of these data were weighted by the proportion of people awake at each hour and scaled to 100 percent. A total of 35,332 suicides were included in the analysis.
According to Perlis, an important implication of the study is that the treatment of insomnia may be one way to reduce suicide risk. The American Academy of Sleep Medicine reports that about 10 percent of adults have a chronic insomnia disorder lasting at least three months.
Accounting for more than 38,000 deaths each year, suicide is the 10th leading cause of death in the U.S. according to the Centers for Disease Control and Prevention. In comparison, about 16,000 deaths occur each year due to homicide.
More information: "When Accounting for Wakefulness, Completed Suicides Exhibit an Increased Likelihood during Circadian Night," Sleep, 2014.
Provided by American Academy of Sleep Medicine

Study of 55 million people adds further evidence that patients admitted to hospital at weekends have higher mortality

A systematic review and meta-analysis of hospital data worldwide, presented as this year's Euroanaesthesia meeting in Stockholm, adds further evidence that patients admitted to hospital at weekends have higher mortality than those admitted on weekdays. The study is by Dr Hiroshi Hoshijima, Tohoku University, Sendai, Japan, and colleagues.

02 jun 2014--The analysis included 72 studies from various world regions, covering 55,053,719 participants. The authors found that weekend admission was associated with increased morality of between 15% and 17% depending on the statistical technique used.

Subgroup analysis revealed that patients admitted during the weekend were at a higher risk of death than weekday admission in patients in almost all categories. "There are at least two potential explanations for our results. First, these differences reflect poorer quality of care in hospital at the weekend, and second, patients admitted on at weekend could be more severely ill than those admitted on at weekday. We believe that poorer care at the weekends is the much more likely explanation."

The only exception to this trend was for the patients who underwent surgery, with the authors saying the lack of association between postoperative mortality and weekdays being potentially due to the few numbers of studies (just 4 studies) specifically examining postoperative mortality.

Furthermore, the authors say that, in some patients who underwent selected high risk procedures, these patients could received a substantial proportion of their postoperative care in critical care units that are more likely to provide the same type of service at all times during both weekdays and weekends. This would therefore dilute any effect of increased weekend mortality in these post-surgery patients.

The authors conclude: "Our systematic review shows that weekend admission is associated with higher mortality compared with weekday admission."

Provided by European Society of Anaesthesiology

Standard approaches to menopause symptoms discount non-Western experiences

Understanding menopausal symptoms through a simple checklist has serious limitations, particularly within different ethnic groups or populations, according to a new study of British Pakistani women's beliefs about and experiences of menopause.

01 jun 2014--Dr Mwenza T. Blell of the University of Bristol interviewed 257 British Pakistani women aged 39-61 living in West Yorkshire and found that the standard checklist approach to studying menopause symptoms, which ignores women's understanding of their own experience, leaves researchers and clinicians with gaps in their knowledge of the 'true' symptoms of menopause.

Many previous studies into the menopause have relied on standardised checklists, such as the Blatt-Kupperman index and the Menopause Symptom Checklist, that were derived from the clinical experiences of women living in New York and Chicago in the mid-twentieth century and so focus on a distinctly Western bio-medical model of menopause.

Dr Blell's study explored the potential of using an alternative approach to better identify women's beliefs about the experiences attributable to menopause. Information was gathered through interviews and in informal settings in order to gain a more rounded understanding of the variety of beliefs within the British Pakistani community. The findings suggest a considerable discrepancy between women's understanding of menopausal symptoms and the assumptions made by previous research.

Dr Blell said: "The standardised checklists claim to tell the whole story of what menopause is when really we haven't let everyone be part of the conversation. By adopting a more open-ended approach, instead of the standard checklist mode, useful data can be captured that specifically reflects varied beliefs and understandings of the experience of the menopause."

For example, the use of a more open-ended approach highlighted that many of the study participants mentioned an increase in the size of the abdomen – which many standard checklists consider to be unrelated to menopause – as one of their symptoms.

This is an important finding as it suggests other populations may have a different understanding about the relationship between changes in body fat patterning and menopause that has not been fully explored in Western medicine due to the established assumptions surrounding the experience of menopause.

Dr Blell said: "The amazing thing is that this finding has come up before in other studies of women of South Asian origin and has just been swept under the carpet, assumed to be a mistaken belief women need to be educated out of, when that really isn't the case."

The research concludes that the symptom experience of non-Western groups has not had the opportunity to inform theoretical developments around menopause symptoms in the same way that the experience of Western groups has.

The understanding of other groups may indicate new directions for research such as the identification of change in body fat distribution, which seems to apply cross-culturally, and its relationship with the local understanding of menopause and its population-specific chronic disease risk.

More information: 'Menopausal symptoms among British Pakistani women: a critique of the standard checklist approach' by Mwenza T. Blell in Menopause, The Journal of the North American Menopause Society.

Provided by University of Bristol

Eating prunes can help weight loss

The study found those in the group eating prunes as part of a healthy life-style diet lost 2kg in weight and shed 2.5cm off their waists

31 may 2014--Research by the University of Liverpool has found that eating prunes as part of a weight control diet can improve weight loss.

Consumption of dried fruit is not readily recommended during weight loss despite evidence it enhances feelings of fullness.

Low fibre consumers

However, a study by the University's Institute of Psychology, Health and Society of 100 overweight and obese low fibre consumers tested whether eating prunes as part of a weight loss diet helped or hindered weight control over a 12-week period.

It also examined if low fibre consumers could tolerate eating substantial numbers of prunes in their diet, and if eating prunes had a beneficial effect on appetite.

To assess the effects of prunes on weight and appetite, participants in the study were divided into two groups – those who ate prunes every day (140g a day for women and 171g a day for men) and those who were given advice on healthy snacks over the period of active weight loss.

The researchers found that members of the group which ate prunes as part of a healthy life-style diet lost 2kg in weight and shed 2.5cm off their waists. However, the people in the group which was given advice on healthy snacks lost only 1.5kg in weight and 1.7cm from their waists.

The study also found that the prune eaters experienced greater weight loss during the last four weeks of the study. After week eight, participants showed increased feelings of fullness in the prune group. Moreover, despite the high daily doses, prunes were well tolerated.

Useful and convenient addition

Liverpool psychologist, Dr Jo Harrold who led the research, said: "These are the first data to demonstrate both weight loss and no negative side effects when consuming prunes as part of a weight management diet. Indeed in the long term they may be beneficial to dieters by tackling hunger and satisfying appetite; a major challenge when you are trying to maintain weight loss."

Professor Jason Halford, Professor of Experimental Psychology and Director of the University's Human Ingestive Behaviour Laboratory, added: "Maintaining a healthy diet is challenging. Along with fresh fruit and vegetables, dried fruit can provide a useful and convenient addition to the diet, especially as controlling appetite during dieting can be tough."

Provided by University of Liverpool

Stopping statins may benefit terminally ill patients

This image depicts Jean Kutner, MD, MSPH, CU Cancer Center investigator and professor of medicine at the University of Colorado School of Medicine. Credit: CU Cancer Center

31 may 2014--Results presented today at the 50th Annual Meeting of the American Society for Clinical Oncology (ASCO) and June 6 at the European Association of Palliative Care Research Conference show that stopping statins for cholesterol management in the late stages of cancer or other terminal illnesses may offer quality-of-life and even life-extending benefits. The results highlight the larger question of when, if ever, it is appropriate in patients with life-limiting illnesses to discontinue medications prescribed for other conditions that will likely not lead to their death.

Researchers from the University of Colorado Cancer Center and the Palliative Care Research Cooperative Group report that discontinuing statins in patients with advanced illnesses resulted in improved overall quality of life, lower costs and no increased deaths. In fact, the patients who stopped taking statins appeared to live slightly longer.

"Based on the study, for patients that are on medications for primary or secondary prevention – for example, those who have not just had a stroke or heart attack – and have a limited life expectancy of less than one year, I would recommend discussing with their physicians the potential to stop taking statins," says Jean Kutner, MD, MSPH, CU Cancer Center investigator and professor of medicine at the University of Colorado School of Medicine.

"We tend to be so focused on which medications are effective to start but there's no research on if and when to stop them. It's a new line of investigation. Especially in the context of end-of-life care, we believe there are many situations in which preventative drugs may be doing more harm than good," Kutner says.

Kutner points to medicines taken to prevent osteoporosis, blood clots, high blood pressure, and diabetes as candidates for future study. These are things people take to prevent something or treat a chronic illness. But particularly in the advanced cancer population, they may not be achieving the intended benefits," Kutner says.

The study enrolled 381 patients who faced the likelihood of dying within a year. All patients had been taking statins for at least three months; roughly half were randomized to continue taking the drug, the other half to discontinuing it.

The researchers followed the patients for up to a year to monitor survival, cardiovascular events and changes in quality of life.

Among the 192 study patients who continued statins, the median survival was 190 days; the 192 participants who stopped taking the drugs had a median survival of 229 days.

Those who discontinued the drugs reported a better overall quality of life, particularly in their psychological wellbeing, and saved money: $716 per person over the course of the trial for name-brand drugs, and $629 for generics.

Using U.S. population estimates, the researchers reported that as much as $603 million a year could be saved if patients in the late stages of fatal illnesses were to cut out statins.

"One thing we found during the study was clinicians saying, 'hey I never thought about stopping people's statins.' The study raised awareness. Here's a setting in which these drugs may not be doing most patients any good any more and bringing up the subject of stopping unneeded medications offers the opportunity for shared decision-making. There's power in individual choice," Kutner says.

Provided by University of Colorado Denver

Study examines variation in cardiology practice guidelines over time

An analysis of more than 600 class I (procedure/treatment should be performed/administered) American College of Cardiology/American Heart Association guideline recommendations published or revised since 1998 finds that about 80 percent were retained at the time of the next guideline revision, and that recommendations not supported by multiple randomized studies were more likely to be downgraded, reversed, or omitted, according to a study in the May 28 issue of JAMA.

30 may 2014--As adherence to recommended clinical practice guidelines increasingly is used to measure performance, guidelines play a major role in policy efforts to improve the quality and cost-effectiveness of care. Past research has established the importance of revising guidelines over time to address advances in research and population-level changes in health risks. Nonetheless, unwarranted variability across guidelines can reduce trust in guideline processes and complicate efforts to promote consistent use of evidence-based practices. Moreover, policies based on recommendations that prematurely endorse practices subsequently found to be ineffective can lead to waste and potential harm. Little is known regarding the degree to which individual guideline recommendations endure or change over time, according to background information in the article.

Mark D. Neuman, M.D., M.Sc., of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues analyzed variations in class I American College of Cardiology/American Heart Association (ACC/AHA) guidelines (n = 11) published between 1998 and 2007 and revised between 2006 and 2013. The researchers reviewed and recorded all class I recommendations from the first of the 2 most recent versions of each guideline and identified corresponding recommendations in the subsequent version. Recommendations replaced by less determinate or contrary recommendations were classified as having been downgraded or reversed; recommendations for which no corresponding item could be identified were classified as having been omitted.

Out of 619 index recommendations, 495 (80.0 percent) were retained in the subsequent version; 8.9 percent were downgraded, 0.3 percent were reversed, and 10.8 percent were omitted. The percentage of recommendations retained varied across guidelines from 15.4 percent to 94.1 percent.

Among recommendations with available information on level of evidence, 90.5 percent of recommendations supported by multiple randomized studies were retained, vs 81.0 percent of recommendations supported by 1 randomized trial or observational data and 73.7 percent of recommendations supported by opinion. After accounting for guideline-level factors, the odds of a downgrade, reversal, or omission were more than 3 times greater for recommendations based on a single trial, observational data, consensus opinion, or standard of care than for recommendations based on multiple randomized trials.

"… our results may have important implications for health policy and medical practice. The categorization of medical evidence, through guidelines, into stronger and weaker recommendations, influences definitions of good medical practice and informs efforts to measure the quality of care on a large scale. Our findings stress the need for frequent re-evaluation of practices and policies based on guideline recommendations, particularly in cases where such recommendations rely primarily on expert opinion or limited clinical evidence," the authors write.

"Moreover, our results suggest that the effectiveness of clinical practice guidelines as a mechanism for quality improvement may be aided by systematically identifying and reducing unwarranted variability in recommendations. Finally, our work emphasizes the importance of greater efforts on the part of guideline-producing organizations to communicate the reasons that specific recommendations are downgraded, reversed, or omitted over time."

In an accompanying editorial, Paul G. Shekelle, M.D., Ph.D., of the VA West Los Angeles Medical Center, Los Angeles, and RAND Corporation, Santa Monica, discusses the importance of keeping clinical practice guideline recommendations up-to-date.

"The need for surveillance and updating of practice guidelines is increasingly gaining attention. To meet the need, guideline development organizations need to change their focus. This change is not easy. It is not just a matter of resources, although guideline organizations are going to have to devote more resources to active surveillance and maintenance of their guidelines than most probably do at present. It also has to be a change to the mindset, recognizing that keeping existing guidelines up-to-date in a timely way is an important goal for good patient care."

More information: DOI: 10.1001/jama.2014.4949
DOI: 10.1001/jama.2014.4950

Provided by The JAMA Network Journals

Disturbance in blood flow leads to epigenetic changes and atherosclerosis

This image shows the effects of 5aza on atherosclerosis model. Credit: Dunn et al JCI (2014)

Disturbed patterns of blood flow induce lasting epigenetic changes to genes in the cells that line blood vessels, and those changes contribute to atherosclerosis, researchers have found. The findings suggest why the protective effects of good blood flow patterns, which aerobic exercise promotes, can persist over time. An epigenetic change to DNA is a chemical modification that alters whether nearby genes are likely to be turned on or off, but not the letter-by-letter sequence itself.

30 may 2014--The results are scheduled for publication in the Journal of Clinical Investigation.

Atherosclerosis is the buildup of fats and inflammatory cells in arteries, a process that can lead to heart attacks and strokes. The curvature of arteries and resulting disturbed flow influence where atherosclerotic plaques develop. Biomedical engineer Hanjoong Jo and his colleagues have developed a model that allows them to see the inflammatory effects of disturbed blood flow quickly. Jo is professor of biomedical engineering in the Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University.

"This new study shows that disturbed blood flow induces epigenetic changes that lead to atherosclerosis," Jo says. "It had been known for a long time that plaques preferentially develop in curved and branched arteries, but our lab has been able to prove that disturbed blood flow can actually trigger atherosclerosis, in the presence of risk factors such as high blood cholesterol."

Despite the demonstrated importance of blood flow patterns in atherosclerosis, it can be blocked in mouse models with a drug that interrupts the process of DNA methylation, an epigenetic change that often turns genes off. Jo's team has identified several genes that become turned off under disturbed flow conditions, in a way that requires DNA methylation. Some of these genes may represent new therapeutic targets in atherosclerosis.

The co-first authors of the JCI paper are biomedical engineering graduate students Jessilyn Dunn and Haiwei Qiu, and postdoc Soyeon Kim, PhD.

In the Jo lab's mouse model, researchers restrict blood flow in three carotid arteries on one side, in the presence of a high-fat diet. In a 2010 paper in Blood, they had found that one of the genes induced by disturbed blood flow is DNMT1, encoding a DNA methyltransferase enzyme.

DNMT1 carries out DNA methylation, an epigenetic modification of DNA. Changes in DNA methylation are important for cells differentiating into different tissues such as blood, muscle or bone, and for the development of cancer.

Dunn and her colleagues found that treatment with 5-aza-2'-deoxycytidine, a drug that is now used to treat acute myeloid leukemia, can prevent atherosclerotic plaques fr om forming in the mouse model.

"While we do not envision using 5-aza for atherosclerosis treatment clinically, our results do revealpotential therapeutic targets," Jo says.

A broader implication is that improving blood flow patterns, through aerobic exercise for example, can induce a lasting imprint on gene expression in the blood vessels, he says.

Provided by Emory University

Gene expression signature identifies patients at higher risk for cardiovascular death

Georgia Tech Professor Gregory Gibson poses with a chart showing death rate differentials between groups of coronary artery disease patients identified with a new gene expression profile. Credit: Rob Felt

30 may 2014--A study of 338 patients with coronary artery disease has identified a gene expression profile associated with an elevated risk of cardiovascular death. Used with other indicators such as biochemical markers and family history, the profile – based on a simple blood test – may help identify patients who could benefit from personalized treatment and counseling designed to address risk factors.

Researchers found the risk signature by comparing gene expression profiles in 31 study subjects who died of cardiovascular causes against the profiles of living members of the study group. Twenty-five of the 31 deaths occurred in the group with the high-risk profile, though coronary deaths were also recorded among the lower risk members of the study group. All of the patients studied had coronary artery disease (CAD), and about one in five had suffered a heart attack prior to the study.

Researchers from the Georgia Institute of Technology, Emory University and Princeton University participated in the study, which obtained gene expression profiles from blood samples taken from patients undergoing cardiac catheterization at Emory University clinics in Atlanta. The results are scheduled to be published in the open-access journal Genome Medicine on May 29, 2014.

"We envision that with our gene expression-based marker, plus some biochemical markers, genotype information and family history, we could produce a tiered evaluation of people's risks of adverse coronary events," said Gregory Gibson, director of the Center for Integrative Genomics at Georgia Tech and one of the study's senior authors. "This could lead to a personalized medicine approach for people recovering from heart attack or coronary artery bypass grafting."

Coronary artery disease is the leading cause of death for both men and women in the United States. Manifested in the narrowing of blood vessels through the buildup of plaque, CAD sets the stage for heart attacks and long-term heart failure.

As many as half of Americans over the age of 50 suffer from CAD to some extent, so the researchers wondered if they could single out those with the highest risk of death. From a cohort of more than 3,000 persons known as the Emory Cardiovascular Biobank (EmCD), they selected two groups of patients for extensive gene expression analysis based on blood samples.

After following the patients for as long as five years, the researchers examined gene expression patterns in a total of 31 persons from the study group who had suffered coronary deaths. Comparing these patterns against those of other study subjects revealed a pattern in which genes affecting inflammation were up-regulated, while genes affecting T-lymphocytes were down-regulated.

The patients studied ranged in age from 51 to 73, were mostly Caucasian, and 65 percent male. Seventy percent of the subjects had significant CAD, and 18 percent were experiencing an acute myocardial infarction when blood samples were taken. Gene expression was analyzed using microarrays and two different normalization procedures to control for technical and biological covariates. Whole genome genotyping was used to support comparative genome-wide association studies of gene expression. Two phases of the study were conducted independently with the two different groups, and produced similar results.

"What's new in this research is the recognition that this risk pathway exists and that it relates to particular aspects of immune system functions that include T-cell signaling," said Gibson, who is also a professor in Georgia Tech's School of Biology. "We went beyond the signature of coronary artery disease to really provide a signature for adverse outcomes in that high-risk population."

The pattern, said Gibson, doesn't indicate the causes of the disease. The researchers would now like to expand the study to include a larger group of patients and learn more about what causes the disease. They'd also like to know whether the risks can be reversed through diet, exercise or drug therapy.

Cardiologist Arshed Quyyumi, the paper's other senior author, directs Emory University's Clinical Cardiovascular Research Center and created the Biobank five years ago to facilitate cardiovascular research. He says that identifying patients at highest risk could help encourage their compliance with treatment programs, and prioritize introduction of newer therapeutics, such as cholesterol lowering medications like PCSK9 inhibitors.

"A number of patients with CAD are currently not maximally treated," said Quyyumi, who is a professor in Emory's School of Medicine. "In those that appear to have been prescribed adequate medication, a significant proportion of subjects are non-compliant with their medications. Thus, knowledge of a high risk genetic profile in a patient can prompt both the patient and physician to maximize currently available medications and improve patient compliance."

Approximately 15,000 genes are expressed in human blood, but analyzing them is not as daunting as it sounds. Most of the gene expression is correlated, so there may be only a few dozen independent measurements that can be related to disease states, Gibson said. In the study, researchers identified nine "axes" that represented specific biological pathways to disease. Two of them were relevant to the high-risk profile.

Gibson believes identifying the high-risk signatures in CAD patients may lead to opportunities for improving their health.

"Our dream would be a hand-held device that would allow patients to take a droplet of blood, much like diabetics do today, and obtain an evaluation of these transcripts that they could track at home," he said. "If we can use this information to help people adopt healthier behaviors, it will be very positive."

Provided by Georgia Institute of Technology

Study links unexpected death of a loved one with onset of psychiatric disorders

The sudden loss of a loved one can trigger a variety of psychiatric disorders in people with no history of mental illness, according to researchers at Columbia University's Mailman School of Public Health and colleagues at Columbia's School of Social Work and Harvard Medical School. While previous studies have suggested there is a link between sudden bereavement and an onset of common psychiatric disorders, this is the first study to show the association of acute bereavement and mania in a large population sample. Findings are published online in the American Journal of Psychiatry.

30 may 2014--In people aged 30 years or older, the unexpected death of a loved one roughly doubled the risk for new-onset mania after controlling for prior psychiatric diagnoses, other traumatic experiences, and certain demographic variables like sex, race, income, education, and marital status.

The researchers analyzed data from 27,534 participants in the National Epidemiologic Survey on Alcohol and Related Conditions. Between about 20% and 30% of these participants identified the unexpected death of a loved one as the most traumatic event in their lives. This was still the case among those reporting 11 or more lifetime traumatic events, where losing a loved one unexpectedly was most traumatic for 22%.

"Our findings should alert clinicians to the possible onset of a wide range of psychiatric disorders, including disorders such as mania, after an unexpected death in otherwise healthy individuals," says Katherine Keyes, PhD, assistant professor of Epidemiology at the Mailman School of Public Health, and principal investigator. "However, it is also notable that the majority of individuals in the present study did not develop mental health issues in the wake of an unexpected death of a loved one."

Losing a loved one suddenly also raised the risk of major depression, excessive use of alcohol, and anxiety disorders, including panic disorder, post-traumatic stress disorder, and phobias. The largest risk increases were for post-traumatic stress disorder, which was seen across age groups with an increased risk as high as 30-fold. Most other disorders were concentrated in the older age groups.

While developing a psychiatric disorder for the first time in old age is relatively rare, these data indicate that psychiatric disorder onset in older age is commonly associated with the death of a loved one, according to the authors.

"Clinically, our results highlight the importance of considering a possible role for loss of close personal relationships through death in assessment of psychiatric disorders. When someone loses a close personal relationship, even late in life, there is a profound effect on sense of self and self reflection. These data indicate that, even in adults with no history of psychiatric disorders, it is also a vulnerable risk period for the onset of a potentially disabling psychiatric disorder," says Dr. Keyes.

Provided by Columbia University's Mailman School of Public Health

Most Baby Boomers have no intention of retiring

Research from the University of Adelaide shows that almost three-quarters of South Australian Baby Boomers do not intend to completely give up work.

30 may 2014--In a survey of almost 900 people aged 50-65, only 26% said they would completely retire, while 74% said they would either: move from full-time to part-time employment (42%); reduce their part-time hours (25%); or not retire at all (7%).

The study was conducted by a team of researchers in the University's Population Research and Outcome Studies unit (School of Medicine) and the Australian Population and Migration Research Centre (School of Social Sciences) to better understand the health, social and economic factors involved in people's intentions to retire.

"What surprised us about the results of this survey is the large number of Baby Boomers who indicated that they would either just reduce their hours and keep working beyond the age of 65 years, or not retire at all," says study co-author Dr Helen Feist, Deputy Director of the Australian Population and Migration Research Centre at the University of Adelaide.

"This group represents almost three-quarters of Baby Boomers surveyed, which is a significant number with major implications for the future of the Australian workforce."

"Australia's culture of early retirement, which has been so pervasive over so many years, is being replaced by a culture of gradual retirement, with continued part-time employment."

"At a time when there is national debate about the retirement age being lifted to 70 by 2035, studies such as this will help us to better understand what our population is intending to do, and why. Importantly, this survey was conducted before the current Federal Government was elected," Dr Feist says.

The survey shows that Baby Boomer women, those with lower education levels, and those who save their money regularly are the most likely to retire completely from the workforce. The authors also believe that the Global Financial Crisis of 2008 has impacted on people's intentions to retire.

"There are many implications here for policymakers across the workplace, employment and health sectors," says Dr Feist. "We need to ensure that policies are in place so that workplaces remain safe, welcoming, flexible and productive for ageing workers."

The results of this survey were published online in the international journal BMC Public Health.

More information: "A survey of retirement intentions of baby boomers: an overview of health, social and economic determinants." Anne W Taylor, et al. BMC Public Health 2014, 14:355.  DOI: 10.1186/1471-2458-14-355

Provided by University of Adelaide

Most physicians would forgo aggressive treatment for themselves at the end of life

Most physicians would choose a do-not-resuscitate or "no code" status for themselves when they are terminally ill, yet they tend to pursue aggressive, life-prolonging treatment for patients facing the same prognosis, according to a study from the Stanford University School of Medicine to be published May 28 in PLOS ONE.

29 may 2014--It's a disconnect that needs to be better understood, said VJ Periyakoil, MD, clinical associate professor of medicine and lead author of the study.

"Why do we physicians choose to pursue such aggressive treatment for our patients when we wouldn't choose it for ourselves?" said Periyakoil, director of the Stanford Palliative Care Education and Training Program. "The reasons likely are multifaceted and complex."

In the study, Periyakoil and her colleagues set out to determine how physicians' attitudes have changed toward advance directives since passage of the Self-Determination Act in 1990, a law designed to give patients more control over determining end-of-life-care decisions. Advance directives are documents that patients can use to indicate end-of-life care preferences.

The study involved two sets of subjects: One comprised 1,081 physicians who in 2013 completed a web-based advanced directive form and a 14-item advance directive attitude survey at Stanford Hospital & Clinics and the Veterans Affairs Palo Alto Health Care System; the other comprised 790 physicians from Arkansas who were asked the same 14 survey questions—but did not complete an advance directive form—in a 1989 study published in the Journal of the American Medical Association.

Surprisingly, results showed that doctors' attitudes toward advance directives have changed little in 25 years.

"The needle has not moved very much," Periyakoil said, who is also associate director of palliative care services at the Palo Alto VA center.

The lack of change in physicians' attitudes toward advance directives mirrors what the study describes as the medical system's continued focus on aggressive treatment at the end of life, despite the fact that most Americans now say they would prefer to die at home without life-prolonging interventions.

"A big disparity exists between what Americans say they want at the end of life and the care they actually receive," the study said. "More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden."

In fact, the type of treatments they receive depends not on the patients' care preferences or on their advance directives, but rather on the local health-care system variables, such as institutional capacity and individual doctors' practice style, according to the study.

"Patients' voices are often too feeble and drowned out by the speed and intensity of a fragmented health-care system," Periyakoil said.

Other results from the study showed that because of the Self-Determination Act, doctors now feel they are less likely to be sued for not providing the most aggressive care if a patient has an advance directive. The law requires hospitals to inform patients about advance directives, but it doesn't ensure that the directives be followed.

Physicians' attitudes toward end-of-life care also differed depending on their ethnicity and gender. Emergency physicians, pediatricians, obstetrician-gynecologists and those in physical medicine and rehabilitation had more favorable attitudes toward advance directives. Radiologists, surgeons, orthopaedists and radiation oncologists were less favorable. Caucasian and African American doctors were the most favorable; Latino physicians were the least favorable.

An overwhelming percentage of the 2013 doctors surveyed—88.3 percent—said they would choose "no-code" or do-not-resuscitate orders for themselves.

As a geriatrics and palliative care physician who sits at the bedside of sick patients herself, Periyakoil said she understands the disconnect between the type of care doctors want for themselves at the end of life and what they actually do for their patients. It's not because doctors are trying to make more money or because they are intentionally insensitive to their patients' desires. At the core of the problem is a biomedical system that rewards doctors for taking action, not for talking with their patients.

"Our current default is 'doing,' but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself," said Periyakoil, who trains physicians in palliative medicine. "It's tricky, but physicians don't have to figure it out by themselves. They can talk to the patients and their families and to the other interdisciplinary team members, and it becomes much easier.

"But we don't train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed."

Provided by Stanford University Medical Center