Experts release guidelines for evaluating, managing syncope

The American College of Cardiology, with the American Heart Association and the Heart Rhythm Society, today released a guideline on the evaluation and management of patients with syncope. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Syncope will publish online today in the Journal of the American College of Cardiology, Circulation and HeartRhythm.

20 mar 2017--Syncope, or fainting, is caused by low blood pressure resulting in an insufficient supply of blood, and therefore oxygen, to the brain. This can happen due to several causes, some of them even due to a serious underlying medical condition. Until now, there have been no written standards outlining the best course of action to take when treating patients who faint.
"This is very important because fainting impacts thousands of people every day," said Win-Kuang Shen, MD, chair of the writing group that developed the guidelines. "Now that we have these guidelines, physicians and clinicians will be able to make better-informed decisions and this will contribute to improved patient outcomes."
The new recommendations include:

1. If a patient faints, a doctor should perform a detailed history and physical examination during the initial evaluation.
2. The most common cause of fainting usually occurs while standing when blood pressure drops, reducing circulation to the brain and causing loss of consciousness. This condition is not life threatening although it can cause worries and interfere with one's quality of life. Physicians should inform patients that common faints are not life threatening.
3. Using an electrocardiogram (ECG) when initially evaluating patients who faint is useful. It is important to find out the cause of fainting and treat the heart condition in the patient if he or she has an abnormal ECG after fainting.
4. If a person has a serious medical condition that could be related to their fainting, they should be evaluated and/or treated at a hospital after the initial assessment.
5. There are a number of tests that are not useful in evaluating patients who faint. These include: routine laboratory testing, routine cardiac imaging, like an MRI or CT scan, unless the patient has a suspected cardiac issue, and carotid artery or head imaging, unless there is a specific reason why the patient needs to be evaluated further.
6. Implantable cardioverter-defibrillators (ICD) can be helpful for certain patients who faint because they have irregular heartbeats that are life threatening.
7. Beta-blockers can be a good choice in patients who faint and who have certain heart conditions as defined in the guidelines.
8. Patients who faint and who also have certain types of heart issues as defined in the guidelines should restrict their exercise.
9. A pacemaker may be helpful for some patients who experience reoccurring common faints that are associated with a very slow heart rate. Drugs are usually not very effective in treating patients with common faints.
10. Heart rhythm monitoring can be a good choice for patients with unexplained fainting who may have intermittent heart rhythm issues that cause fainting.
11. An athlete who has problems with fainting should have a heart assessment done by an experienced health care provider or specialist before returning to competitive sports.

"Studies show that in the U.S., about one-third to half the population faints at some point in their lifetime. That means there is a very good chance these guidelines will either affect you directly or someone you know. Therefore, having these guidelines is not only good for the clinicians using them—but for everyone," Shen said.
The guideline was written in collaboration with the American College of Emergency Physicians and the Society for Academic Emergency Medicine.

More information: Journal of the American College of Cardiology, DOI: 10.1016/j.jacc.2017.03.003


Provided by American College of Cardiology

Delirium is associated with five-fold increased mortality in acute cardiac patients

Delirium is associated with a five-fold increase in mortality in acute cardiac patients, according to research published today in European Heart Journal: Acute Cardiovascular Care. Delirium was common and affected over half of acute cardiac patients aged 85 years and older.

16 mar 2017--Delirium is a clinical syndrome caused by a disturbance in the normal functioning of the brain. Delirious patients are less aware of, and responsive to, their environment. They can be disorientated, incoherent, and in a dream-like state, with hallucinations, disordered speech and memory disturbances.
Delirium affects at least one in ten hospitalised patients and is more common in the elderly. These patients have worse long-term prognosis and more complications during their hospital stay.
"Among hospitalised patients, those admitted to an intensive care unit are more likely to develop delirium and there are strategies to limit its consequences," said lead author Dr Giovanni Falsini, interventional cardiologist, San Donato Hospital, Arezzo, Italy. "Less is known about delirium and its significance in patients admitted to cardiac intensive care units. This study investigated the incidence and clinical impact of delirium in patients with acute cardiac diseases."
The study included all patients aged 65 years and older admitted to two cardiac intensive care units during a period of 15 months. Only non-intubated patients were enrolled. Validated score systems and questionnaires were used to detect and diagnose the presence of delirium at admission or during the hospital stay.
Delirious patients were closely followed by nursing and medical staff who used a flowchart for delirium treatment. This included treating pain and anxiety, and discontinuing medications known to cause delirium. Patient survival at six months was determined by telephone call.
The investigators found that delirium was a frequent condition among elderly patients with acute cardiac diseases. The study population consisted of 726 patients with an average age of 79 years, of whom 15% had delirium (at admission or during the hospital stay). More than half (52%) of patients aged 85 years and older were delirious.
Patients with delirium had a worse prognosis, with a five-fold increase in both in-hospital and 30-day mortality and a two-fold increase in six-month mortality. Delirium was not only a strong and independent factor in predicting mortality, but was also associated with longer hospital stay and more frequent rehospitalisations during follow-up.
"Delirium is a common and serious condition in acute cardiac patients," said Dr Falsini. "They stay in hospital longer, return to hospital more often, and are more likely to die in the short- and long-term."
Dr Falsini said elderly patients may be at higher risk because they usually have pre-existing issues that can predispose to delirium such as dementia, visual and hearing impairments, depression, use of psychoactive drugs, infections, or electrolyte disturbances.
He said: "The more complex and frail the patient is, the higher the rate of delirium and subsequent worse outcomes. It is unknown whether delirium can be treated to improve prognosis in critically ill patients, or whether it is a marker of organ dysfunction or systemic disease and an early sign that complications are likely. Monitoring delirium has been linked with reduced in-hospital mortality in mechanically ventilated patients and it is possible that similar benefit might occur in acute non-intubated patients."
Dr Falsini concluded: "Delirium is common, serious, costly and under-recognised. A protocol is needed to identify and treat delirium in high-risk settings, like cardiac intensive care units."

More information: Falsini G, et al. Long-term prognostic value of delirium in elderly patients with acute cardiac diseases admitted to two cardiac intensive care units: a prospective study (DELIRIUM CORDIS). European Heart Journal: Acute Cardiovascular Care. 2017. DOI: 10.1177/2048872617695235


Provided by European Society of Cardiology

Most atrial fibrillation patients don't get preventive drug before stroke

A 12 lead ECG showing atrial fibrillation at approximately 150 beats per minute.

More than 80 percent of stroke patients with a history of atrial fibrillation either received not enough or no anticoagulation therapy prior to having a stroke, despite the drugs' proven record of reducing stroke risk, according to a Duke Clinical Research Institute study.

14 mar 2017--Reporting in the March 14 issue of the Journal of the American Medical Association, the researchers also found that when patients did receive recommended anticoagulation drugs, they had less severe stroke outcomes and less risk of dying.
"Atrial fibrillation is very common, and people with the condition are at a much higher risk of having stroke," said lead author Ying Xian, M.D., Ph.D., assistant professor of neurology at Duke and member of the Duke Clinical Research Institute. "Treatment guidelines call for these patients to receive an anticoagulant such as warfarin at a therapeutic dose or a non-vitamin K antagonist oral anticoagulant (NOAC), so it's surprising that this is not occurring in the vast majority of cases that occur in community settings."
The study included more than 94,000 patients with atrial fibrillation from the American Heart Association's "Get With The Guidelines-Stroke" registry who had had an acute ischemic stroke. The analysis was sponsored by the Patient-Centered Outcomes Research Institute to inform patients, physicians and others about optimal stroke care.
The researchers found that only 16 percent of patients with atrial fibrillation had received the recommended anticoagulation medication prior to having a stroke. These medications include therapeutic levels of warfarin or NOAC.
A total of 84 percent of patients were not treated according to the guidelines prior to stroke:

• 30 percent were not taking any antithrombotic treatment at all;
• 40 percent were taking an antiplatelet drug such as baby aspirin or clopidogrel;
• and 13.5 percent were on warfarin, but at a level that was not considered therapeutic at the time of their stroke.

"While some of these patients may have had reasons for not being anticoagulated, such as high bleeding or fall risk, more than two-thirds had no documented reason for receiving inadequate stroke prevention therapy," Xian said.
Xian added that in those rare cases where anticoagulation failed to prevent a stroke, patients who were taking the therapy showed a tendency to have less severe strokes, with less disability and death.
"These findings highlight the human costs of atrial fibrillation and the importance of appropriate anticoagulation, Xian said. "Broader adherence to these atrial fibrillation treatment guidelines could substantially reduce both the number and severity of strokes in the U.S. We estimate that between 58,000 to 88,000 strokes might be preventable per year if the treatment guidelines are followed appropriately."

More information: Journal of the American Medical Association, doi:10.1001/jama.2017.1371


Provided by Duke University Medical Center

Index predicts 10-, 14-year mortality in older adults

13 mar 2017—An 11-factor index predicts 10- and 14-year mortality with excellent calibration and discrimination among community-dwelling U.S. adults aged ≥65 years, according to a study published online Feb. 21 in the Journal of the American Geriatrics Society.

Mara A. Schonberg, M.D., M.P.H., from Beth Israel Deaconess Medical Center in Boston, and colleagues examined the performance of an index in predicting 10- and 14-year mortality for community-dwelling adults aged ≥65 years from the 1997 to 2000 National Health Interview Surveys. Data were included for 16,063 and 8,027 respondents from the original development and validation cohorts. Risk scores were calculated based on the presence or absence of 11 factors that make up the index. Model calibration was examined by computing the 10- and 14-year mortality estimates with the Kaplan Meier method.
The researchers found that 14-year mortality was 23 percent for participants with risk scores of 0 to 4, compared with 89 percent for those with risk score of 13+. In both cohorts, the C-index was 0.73 and 0.72 for predicting 10- and 14-year mortality, respectively. Overall, 18.4 and 60.2 percent of those aged 65 to 74 years and ≥75 years had more than 50 percent risk of mortality in 10 years.
"Information on long-term prognosis is needed to help clinicians and older adults make more informed person-centered medical decisions and to help older adults plan for the future," the authors write.

More information: Abstract

Virtual puppets developed by kinetic imaging professor help older adults feel more comfortable telling their stories

VoicingElder avatars mimic the motions of users. Credit: Virginia Commonwealth University

Semi Ryu had performed "Parting on Z"—her play about a farewell between lovers—a couple of times before that 2013 night in London. Ryu doesn't know what made this performance different, but something unexpected happened: She found herself sobbing in the middle of it.

09 mar 2017--"It was not acting," she said. "Something was touching me so deeply about it."
Ryu, an associate professor of kinetic imaging in the Virginia Commonwealth University School of the Arts, played both parts in the play about a man and woman ending their affair because of a difficult family disagreement. She physically played the female lover and spoke through an avatar, a virtual puppet, as the male lover.
"Sometimes I act as the female lover and then after that I activate a microphone on the avatar and then my voice becomes the male lover's voice," she said. "So we exchanged a dialogue of farewell and we drink together ... and then I took off my ring and placed it [in his hand to] keep it forever for your memory.
"It was extremely sad and I was really crying," she said. "I didn't expect to cry in front of this live audience and live performance setting and I [felt] so unprofessional. … I had to control myself but I couldn't control my emotions because there is something really overwhelming in this situation—[the] relationship between [the] virtual body and me."
She felt as if she was saying farewell to a part of herself, a symbolic farewell that made her think about how the self has different aspects.

VCUarts Associate Professor Semi Ryu, right, demonstrates how the on-screen avatar mimics the user’s motions. Credit: Virginia Commonwealth University

"There are multiple selves, but what is left out is maybe my social self," Ryu said. "Something defined by [society] as a role, as a woman … but I had to [say farewell to] my virtual body. … It was really about self-exploration and it made me cry."
She was embarrassed, but couldn't stop. The audience, equally moved, started crying as well. As the play ended, Ryu realized her primary emotion was no longer embarrassment, but rather relief. Speaking through the avatar had exposed suppressed feelings and given her emotional release.

'The puppet is speaking to me'

Having grown up in a Korean Confucian society, Ryu was discouraged from expressing emotion. Somehow this particular performance had revealed a lifetime of suppressed feelings. Ryu attributes those feelings of repression to han, the Korean cultural concept that encompasses feelings of oppression and grief with a strong hope and desire to overcome the impossible. Using the virtual puppet had allowed a different side of Ryu to emerge in the storytelling.
"I felt like something unresolved was resolved and then I felt this could also benefit … somebody else who has some kind of communication dilemma in society," Ryu said, realizing that han can be universal.
She immediately thought of the older adult population. As people get older, their image of themselves differs from how other people see them.
"They have ageless bodies happening in their mind but biologically it's degeneration and downgrading," she said. "There is an interesting tension happening, a kind of dilemma between what they want to be [and how they have been portrayed in the] media as powerless, hopeless and helpless individuals. Those images never fit [how] older adults perceive themselves. In this sense, they have han, and maybe we can … process a kind of ritual with older adults so they can start to release what they want to express."
Ryu was inspired by her brother, an occupational therapist who volunteered at area nursing homes and regularly talked about his amazing experiences working with older adults. She applied for the VCU Presidential Research Quest Fund in 2015 and started collaborating with Tracey Gendron, Ph.D., an associate professor in the VCU Department of Gerontology who also serves as the department's director of community engagement and research. Yet Ryu's motivation was always as an artist.
After years of using technology to explore the relationship between herself as the user and the virtual puppet, she became interested in what happens psychologically to users when they speak through the avatar.
"I was always curious about users' psyche…," Ryu said. "What kind of psychological relationship is possible between the user and avatar? That has been my primary research focus for a long time—more than 10 years. It seems to me it's such a different experience when I talk with or without 'puppet me.' [With the puppet], the puppet is speaking to me and so a different part of myself is emerging during the process of storytelling."

Developing VoicingElder

For years, Ryu has collaborated with Stefano Faralli of University of Manheim, Germany, to develop the interactive technology for her virtual puppetry. Together, they developed VoicingElder, an avatar system with four different development stages: childhood, teenage years, young adulthood and older adulthood, with four female and four male avatars. They implemented lip-sync technology so the avatars can speak in real time, giving the illusion that the puppet is the speaker. Users are then in the position of listening to their own stories even as they are telling them.

The VoicingElder program uses avatars from four different development stages: childhood, teenage, young adulthood and older adulthood. Credit: Virginia Commonwealth University

"It's an interesting psychology, looking at the puppet and the puppet is actually telling the story to them. They're going to get some distance from their story so they can easily talk about an emotional story … with more safe distance," Ryu said.
They also created a sentiment analysis algorithm, which detects emotional content from live speech and provides a virtual background to match. Happy stories have bright sunlight, while thunderstorms accompany angry stories. Other emotions detected are sadness, anxiety, fear and laugher.
"The VoicingElder project uses an artistic framework to combine technology and storytelling in an innovative way that actively engages older adult users in a virtual platform that provides the opportunity to share their life stories and experiences," said Gendron.
In March 2016, Ryu was ready to put the system to use. She worked with 10 residents of the Gayton Terrace Senior Living Center for three months, visiting every week or two. At the beginning, the seniors brought scripts with prepared stories, because they were self-conscious about speaking in front of each other. But around the fifth week, they began improvising and volunteering stories.
"It's wonderful because mainly your face is not there," said Connie Cole, 86. "It's a caricature there, so that takes the personal part away from it. … I think the fact that you're using the caricature and our voices and our stories blend beautifully for someone who's having dementia or some other elderly problem. … The fact the avatar's disconnected from me, it was easier for me to talk."
Vikki Fleming, resident program director at the center, said the project is a tool for residents to connect emotionally with important stories that are meaningful to them.

Connie Cole gestures as she tells a story through the VoicingElder system. Credit: Virginia Commonwealth University

"It's an interesting concept and it's fun to see residents experimenting with technology and getting to try new things because they want to continue to learn new things and this is one way of doing that," she said.
Ryu recorded the avatars at each session and at the end of the three months screened the film for residents, who all asked for a copy to share with their families.
"This can contribute to intergenerational relationships, so some story of the grandparents can be delivered to the grandsons … and it can work as a family legacy," she said.
Ryu is applying for a National Endowment for the Arts grant this spring and is pursuing National Institutes of Health grants as well. She has already presented the VoicingElder project at national and international conferences, including the National Center for Creative Aging in Washington, D.C., and Arts in Society as well as gerontology and drama therapy conferences and an upcoming Human-Computer Interaction International Conference. Many attendees have introduced the prototype system—which is very low-tech, requiring a simple setup: a computer with a decent processor, a connected camera and a wireless microphone—into their programs.
Ryu foresees extending the program to other populations and has begun collaboration with Tony Gentry, Ph.D., in the VCU Department of Occupational Therapy to apply the program to people with memory loss and PTSD.
"It's not just for older people but for [those who are] disabled, autistic [or have] communications difficulties," she said. "It can also be used to address diversity in society to increase awareness of racial, cultural and gender issues. It can help us be more empathetic to each other."


Provided by Virginia Commonwealth University

May smartphones help to maintain memory in patients with mild Alzheimer's disease?

The patient is a retired teacher who had reported memory difficulties 12 months prior to the study. These difficulties referred to trouble remembering names and groceries she wanted to purchase, as well as frequently losing her papers and keys. 

06 mar 2017--According to the patient and her husband, the main difficulties that she encountered were related to prospective memory (e.g., forgetting medical appointments or to take her medication).
To help her with her symptoms, Mohamad El Haj, a psychologist and assistant professor at the University of Lille, proposed Google Calendar, a time-management and scheduling calendar service developed by Google. The patient accepted as she was already comfortable using her smartphone. She also declared that she preferred the application as it offers more discrete assistance than a paper-based calendar.
With the patient and her husband, Dr. El Haj and his colleagues defined several prospective omissions in the patient, such as forgetting her weekly medical appointment, forgetting her weekly bridge game in the community club, and forgetting to go to weekly mass at the church. These omissions were targeted by sending automatic alerts, prompted by Google Calendar, at different times before each event (e.g., the medical appointment).
The researchers compared omissions before after the use of Google Calendar, they observed less omission after implementing the application.
The study is the first to suggest positive effects of smartphones applications on everyday life prospective memory in Alzheimer's disease. The findings, published in Journal of Alzheimer's disease, are encouraging, however, Dr. El Haj notes that this is a case study and therefore entails a few limitations, including generalizability of the results. The current, anecdotal findings require a larger study, not only to confirm or refute the findings reported here, but also to address challenges such as the long-term benefits of Google calendar.
Regardless of its potential limitations, Dr. El Haj notes that this study addresses memory loss, the main cognitive hallmark of Alzheimer's disease and the major concern of the patients and their families. By demonstrating positive effect of Google Calendar on prospective memory in this patient, Dr. El Haj hopes that his study paves the way for exploring the potential of smartphone-integrated memory aids in Alzheimer's disease. The future generation of patients may be particularly sensitive to the use of smartphones as a tool to alleviate their memory compromise.

More information: Mohamad El Haj et al. Google Calendar Enhances Prospective Memory in Alzheimer's Disease: A Case Report, Journal of Alzheimer's Disease (2017). DOI: 10.3233/JAD-161283


Provided by IOS Press

Geriatricians can help aging patients navigate multiple ailments

For months, Teresa Christensen's 87-year-old mother, Genevieve, complained of pain from a nasty sore on her right foot. She stopped going to church. She couldn't sleep at night. Eventually, she stopped walking except when absolutely necessary.
Her primary care doctor prescribed three antibiotics, one after another. None worked.
"Doctor, can't we do some further tests?" Teresa Christensen remembered asking. "I felt that he was looking through my mother instead of looking at her."

05 mar 2017--Referred to a wound clinic, Genevieve was diagnosed with a venous ulcer, resulting from poor circulation in her legs. A few weeks ago, she had a successful procedure to correct the problem and returned home to the house where she's lived for more than 50 years in Cottage Grove, Minn., a suburb of St. Paul.
Would her mother benefit from seeing a geriatrician going forward, wondered Christensen, her mother's primary caregiver, in an email to me? And, if so, how would she go about finding one?
I reached out to several medical experts, and they agreed that a specialist in geriatrics could help a patient like Genevieve, with a history of breast cancer and heart failure, who'd had open heart surgery at age 84 and whose mobility was now compromised.
Geriatricians are "experts in complexity," said Dr. Eric Widera, director of the geriatrics medicine fellowship at the University of California, San Francisco.
No one better understands how multiple medical problems interact in older people and affect their quality of life than these specialists on aging. But their role in the health care system remains poorly understood and their expertise underused.
Interviews with geriatricians offer insights useful to older adults and their families:
Basic knowledge. Geriatricians are typically internists or family physicians who have spent an extra year becoming trained in the unique health care needs of older adults.
They're among the rarest of medical specialties. In 2016, there were 7,293 geriatricians in the U.S. - fewer than two years before, according to the American Geriatrics Society.
Geriatricians can serve as primary care doctors, mostly to people in their 70s, 80s and older who have multiple medical conditions. They also provide consultations and work in interdisciplinary medical teams caring for older patients.
Recognizing that training programs can't meet expected demand as the population ages, the specialty has launched programs to educate other physicians in the principles of geriatric medicine.
"We've been trying to get all clinicians trained in what we call the '101 level' of geriatrics," said Dr. Rosanne Leipzig, a professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York City.
Essential competencies. Researchers have spent considerable time over the past several years examining what, exactly, geriatricians do.
A 2014 article by Leipzig and multiple co-authors defined 12 essential competencies, including optimizing older adults' functioning and well-being; helping seniors and their families clarify their goals for care and shaping care plans accordingly; comprehensive medication management; extensive care coordination; and providing palliative and end-of-life care, among others skills.
Underlying these skills is an expert understanding how older adults' bodies, minds and lives differ from middle-age adults.
"We take a much broader history that looks at what our patients can and can't do, how they're getting along in their environment, how they see their future, their support systems, and their integration in the community," said Dr. Kathryn Eubank, medical director of the Acute Care for Elders unit at the San Francisco Veterans Affairs Medical Center. "And when a problem arises with a patient, we tend to ask 'How do we put this in the context of other concerns that might be contributing?'"
Geriatric syndromes. Another essential competency is a focus on issues that other primary care doctors often neglect - notably falls, incontinence, muscle weakness, frailty, fatigue, cognitive impairment and delirium. In medicine, these are known as "geriatric syndromes."
"If you're losing weight, you're falling, you can't climb a flight of stairs, you're tired all the time, you're unhappy and you're on 10 or more medications, go see a geriatrician," said Dr. John Morley, professor of geriatrics at Saint Louis University.
"Much of what we do is get rid of treatments prescribed by other physicians that aren't working," Morley continued.
Recently, he wrote of an 88-year-old patient with metastasized prostate cancer who was on 26 medications. The older man was troubled by profound fatigue, which dissipated after Morley took him off all but one medication. (Most of the drugs had minimal expected benefit for someone at the end of life.) The patient died peacefully eight months later.
Eubank tells of an 80-year-old combative and confused patient whom her team saw in the hospital after one of his legs had been amputated. Although physicians recognized the patient was delirious, they had prescribed medications that worsened that condition, given him insufficient pain relief and overlooked his constipation.
"Medications contributing to the patient's delirium were stopped. We made his room quieter so he was disturbed less and stopped staff from interrupting his sleep between 10 p.m. and 6 a.m.," Eubank said. "We worked to get him up out of bed, normalized his life as much as possible and made sure he got a pocket talker [hearing device] so he could hear what was going on."
Over the next four days, the patient improved every day and was successfully discharged to rehabilitation.
Finding help. A geriatric consultation typically involves two appointments: one to conduct a comprehensive assessment of your physical, psychological, cognitive and social functioning, and another to go over a proposed plan of care.
The American Geriatrics Society has a geriatrician-finder on its website - a useful resource. Also, you can check whether a nearby medical school or academic medical center has a department of geriatrics.
Many doctors claim competency in caring for older adults. Be concerned if they fail to go over your medications carefully, if they don't ask about geriatric syndromes or if they don't inquire about the goals you have for your care, advised Dr. Mindy Fain, chief of geriatrics and co-director of the Arizona Center on Aging at the University of Arizona.
Also, don't hesitate to ask pointed questions: Has this doctor had any additional training in geriatric care? Does she approach the care of older adults differently - if so, how? Are there certain medications she doesn't use?
"You'll be able to see in the physician's mannerisms and response if she takes you seriously," Leipzig said.
If not, keep looking for one who does.

©2017 Kaiser Health News
Distributed by Tribune Content Agency, LLC.

Elderly people who choose the wrong shoes have a lower quality of life

As people get older, they experience changes in their foot morphology. If they do not change their shoe size along with these transformations, older people—most of whom choose the wrong shoes—suffer, among other things, anxiety, apathy, loss of balance and falls, according to a study by the University of A Coruña.

02 mar 2017--In 2015, a research team led by the University of A Coruña conducted a study of people with a mean age of 80 years. They analysed whether the changes to foot morphology that occur in elderly individuals, and their tolerance for pain, led to subjects wearing the wrong shoes. They concluded that the majority (83 percent) did not choose the correct size, and that they often should have been wearing a different size for each foot.
As Daniel López López, a scientist at the University of A Coruña who led this study, tells SINC: "In this stage of life, there are changes in foot morphology involving increased width and length, as well as changes in pain tolerance linked to age, and the loss of muscle mass and fatty tissue in the feet."
The study has for the first time analysed the consequences of this poor shoe choice on the health of elderly individuals. "Because of people's lifestyles at this age, they often use shoes that are harmful to their feet. This, combined with the appearance of chronic diseases such as obesity, vascular diseases, diabetes or rheumatoid arthritis, causes a worrying increase in foot problems in elderly people of between 71 percent and 87 percent. This means having to seek medical and podiatric attention more frequently, as it affects their functional capacity and quality of life," the scientist explains. The study is published in the Revista da Associação Médica Brasileira, the Brazilian Medical Association's journal.

Decreased independence and well-being

The participants in this research project were volunteers from the Podiatry University Clinic at the University of A Coruña with a mean age of 75 years.
Their results demonstrate that elderly people who use the wrong shoes have a lower quality of life in all areas related to pain, foot function, footwear, food health, general health, physical activity, social capacity and vitality.
The most common disorders are foot bone deformities, bunions, toenail malformations, plantar keratosis and flat feet. "This often leads to chronic pain, infections, limited mobility when walking, anxiety, apathy, social disturbances, changes to pressure distribution in feet related to loss of balance and falls, which as a result negatively impact upon health, independence and well-being," López informs us.
These individuals should use proper footwear, including wide-fit shoes with velcro or straps, rubber soles to prevent slipping and falling and those that reduce the impact on joints when walking.
"Additionally, regular visits and monitoring on the part of a podiatrist helps to prevent, control and reduce the appearance of foot diseases and deformities, increase autonomy and, in summary, improve people's quality of life," López concludes.

More information: Daniel López-López et al. Impact of shoe size in a sample of elderly individuals, Revista da Associação Médica Brasileira (2016). DOI: 10.1590/1806-9282.62.08.789


Provided by Plataforma SINC

Increased levels of active vitamin D can help to optimize muscle strength

Researchers at the University of Birmingham have shown that increasing the levels of active vitamin D can help to optimise muscle strength in humans.
The team hope that the findings will inform the design of future supplementation studies, and begin to answer questions as to the optimal levels of vitamin D required for healthy muscles.

28 feb 2017--The study, published in PLOS ONE, builds on previous knowledge showing levels of inactive vitamin D to be associated with a lack of muscle mass.
The research is the result of a cutting edge technique that allowed both active and inactive forms of vitamin D to be assessed alongside their impact on various muscle functions.
Dr Zaki Hassan-Smith, from the University of Birmingham, explained, "We have a good understanding of how vitamin D helps bone strength, but we still need to learn more about how it works for muscles. When you look at significant challenges facing healthcare providers across the world, such as obesity and an ageing population, you can see how optimising muscle function is of great interest."
"Previous studies have tested for the inactive forms of vitamin D in the bloodstream, to measure vitamin D deficiency. Here, we were able to develop a new method of assessing multiple forms of vitamin D, alongside extensive testing of body composition, muscle function and muscle gene expression."
116 healthy volunteers, aged between 20-74, were recruited to the trial. Participants had both active and inactive levels of vitamin D measured alongside physical characteristics including body fat and 'lean mass', a measure of muscle bulk.
Women with a healthy body composition, and lower body fat, were less likely to have high levels of inactive vitamin D, a marker of vitamin D deficiency. This was echoed by the finding that levels of inactive vitamin D were lower in women with increased body fat. This would suggest a relationship between vitamin D and body composition.
However, the active form of vitamin D was not associated with body fat, but was associated with lean mass.
Individuals with an increased lean mass, and muscle bulk, had a higher level of active vitamin D in the bloodstream.
Dr Hassan Smith added, "By looking at multiple forms in the same study, we can say that it is a more complex relationship that previously thought. It may be that body fat is linked to increased levels of inactive vitamin D, but lean mass is the key for elevated levels of active vitamin D. It is vital to understand the complete picture, and the causal mechanisms at work, so we can learn how to supplement vitamin D intake to enhance muscle strength."
In this study some of the positive associations between active vitamin D and muscle bulk were not seen in men.
Future studies with larger cohorts will help to identify if this is due to biological differences. The team will now work alongside international collaborators to further investigate the mechanisms at work through lab-based studies and clinical trials.

More information: PLOS ONE, DOI: 10.1371/journal.pone.0170665


Provided by University of Birmingham

What is high lipoprotein(a), and should I be concerned?

A team of researchers from the Research Institute of the McGill University Health Center (RI-MUHC) found that elevations in a unusual form of cholesterol, called Lipoprotein(a) or Lp(a), as responsible for 1 in 14 heart attacks and 1 in 7 cases of aortic valve disease.

27 beb 2017--This form of cholesterol is not commonly screened for in Canada, so most people do not even know they are at risk. Although no specific treatments exist to lower Lp(a), new therapies are being developed, and in addition to this study, the researchers hope to demonstrate how lowering this form of cholesterol could have an important impact on the population.
"Approximately 20 per cent of individuals have high Lp (a), a form of cholesterol that is highly heritable and runs in families," says Dr. George Thanassoulis, who is a researcher at the RI-MUHC and principal author of the study.
"We hope that our work will raise awareness that individuals with high Lp(a) are at high risk of heart disease and hopefully stimulate the development and testing of new therapies."
The study Estimating the Population Impact of Lp(a) Lowering on the Incidence of Myocardial Infarction and Aortic Stenosis was co-written by Mehdi Afshar, Pia R. Kamstrup, Ken Williams, Allan D. Sniderman, Børge G. Nordestgaard and George Thanassoulis, and is published in the journal Arteriosclerosis, Thrombosis, and Vascular Biology.


Provided by McGill University Health Centre

Dietary prebiotics improve sleep, buffer impacts of stress, says study

Credit: CC0 Public Domain

In recent years, reams of research papers have shed light on the health benefits of probiotics, the "good bacteria" found in fermented foods and dietary supplements. Now a first-of-its kind study by University of Colorado Boulder scientists suggests that lesser-known gut-health promoters called prebiotics - which serve as food for good bacteria inside the gut—can also have an impact, improving sleep and buffering the physiological impacts of stress.

26 feb 2017--"We found that dietary prebiotics can improve non-REM sleep, as well as REM sleep after a stressful event," said Robert Thompson, a post-doctoral researcher in the Department of Integrative Physiology and first author of the new study published in the journal Frontiers in Behavioral Neuroscience.
Prebiotics are dietary fibers found naturally in foods like chicory, artichokes, raw garlic, leeks and onions. When beneficial bacteria digest prebiotic fiber, they not only multiply, improving overall gut health, but they also release metabolic byproducts. Some research suggests these byproducts can influence brain function, explains lead author Monika Fleshner, a professor in the Department of Integrative Physiology.
For the study, the researchers fed 3-week-old male rats a diet of either standard chow or chow that included prebiotics. They then monitored the rats' body temperature, gut bacteria and sleep-wake cycles - using EEG, or brain activity testing—over time.
They found that the rats on the prebiotic diet spent more time in non-rapid-eye-movement (NREM) sleep, which is restful and restorative, than those on the non-prebiotic diet.
"Given that sufficient NREM sleep and proper nutrition can impact brain development and function and that sleep problems are common in early life, it is possible that a diet rich in prebiotics started in early life could help improve sleep, support the gut microbiota and promote optimal brain/psychological health," the authors wrote.
After being exposed to a stressor, the rats on the prebiotic diet also spent more time in rapid-eye-movement (REM) sleep. REM sleep is believed to be critical for promoting recovery from stress, with research showing that those who get more REM sleep post-trauma are less likely to suffer from post-traumatic stress disorder.
Stress has previously been shown to reduce healthy diversity of gut bacteria and to lead to a temporary flattening of natural fluctuations in body temperature.
But rats on the prebiotic diet were buffered from these impacts, maintaining a healthy and diverse gut microbiota and normal temperature fluctuations even after stress exposure.
Fleshner said it's far too early to recommend prebiotic supplements as a sleep aid. More studies are in the works to examine what role prebiotics can play in promoting sleep, or buffering stress in people.
But she does recommend loading up on healthy prebiotic fiber from food. "It can't hurt and it might help," she said.

More information: Robert S. Thompson et al, Dietary Prebiotics and Bioactive Milk Fractions Improve NREM Sleep, Enhance REM Sleep Rebound and Attenuate the Stress-Induced Decrease in Diurnal Temperature and Gut Microbial Alpha Diversity, Frontiers in Behavioral Neuroscience (2017). DOI: 10.3389/fnbeh.2016.00240


Provided by University of Colorado at Boulder

The effects of drinking on the aging brain

Credit: Human Brain Project

Wisdom and grace come with age, but so do mental slowing and increased risk for dementia. As the elderly population continues to grow, preserving brain health to maintain independence and quality of life into older age is a pressing concern. Researchers have identified some unsurprising factors that reduce one's risk for cognitive decline, including education, exercise or a healthy diet. But a more controversial question that continues to perplex scientists is whether alcohol consumption might also stave off cognitive impairment with age.

The aging brain on alcohol

25 feb 2017--Anyone who's experienced the fatigue and brain fog that follow a night of heavy drinking doesn't need science to explain the dangers of excessive alcohol intake. These health risks may be especially impactful to the older brain, which is already particularly vulnerable to environmental stressors. However, in moderation, a glass of wine or beer may not only be harmless, but may in fact also confer resilience to the aging brain against cognitive decline. Numerous studies have reported that moderate drinking is associated with lower rates of dementia, better cognitive performance, and slower decline in memory and executive functions. Yet, not all studies support the notion that a nightcap can help keep the brain sharp into late life. These discrepant findings raise two obvious questions. First, why are some patterns of drinking neurobiologically healthy, while others are toxic? And second, how can we better identify drinking behaviors that promote the healthiest trajectories of cognitive aging?

Neuroprotective in moderation, neurotoxic in excess

In excess, alcohol works as a neurotoxin on may levels. Studies in animals have shown that binging on ethanol kills neurons and impairs neurogenesis–the birth of new neurons–in the hippocampus, a region critical to creating new memories. Furthermore, alcohol-induced dementia results from brain damage that occurs with prolonged alcohol abuse. The reasons for the observed benefits of alcohol are less clear. In contrast to binge drinking, moderate alcohol intake increases neurogenesis and may help combat oxidative stress to neurons. It's well documented that what's good for the heart is good for the brain, and indeed, vascular dysfunction often co-exists with or precipitates many forms of dementia. A prevailing theory is that the neuroprotective properties of drinking stem largely from their positive effects on cerebrovascular health. Alcohol can reduce risk for stroke and heart disease, lower blood pressure and increase HDL ("good") cholesterol. However, some evidence that wine is more strongly neuroprotective than other forms of alcohol suggests that resveratrol, a potent antioxidant found in red wine, may also play a role. Although resveratrol minimizes dementia pathology in animals, the extremely high doses required make it unlikely to be the primary source of neuroprotection from alcohol.

Unraveling healthy drinking patterns for the aging brain

For our aging population to reap the greatest benefit from alcohol, it will be essential to determine patterns of healthy drinking that are optimized for the individual. This will require, foremost, a comprehensive understanding of how alcohol distinctly affects you versus me based on our genetics, sex or lifestyle. For example, alcohol has been found to differentially influence brain structure and risk for dementia or cognitive impairment for those with and without the apolipoprotein E4 gene, a strong risk factor for Alzheimer's disease. Furthermore, studies have inconsistently reported sex differences in how drinking influences cognitive decline, which may be explained by differences in how men and women metabolize alcohol.
Despite overwhelming evidence that moderate alcohol intake can be healthy for the aging brain, there are striking incongruences across findings–which may be due to differences in study design or confounding factors­–that muddle our understanding of alcohol's benefits. 'Survival bias,' in which healthier individuals participate in studies for longer, is an unavoidable complication in longitudinal studies of aging. This could significantly skew results if unhealthy drinkers drop out early, leaving only "healthy" drinkers to be studied in very old age. Furthermore, most human studies on alcohol and brain aging rely on observed associations, which can be replete with confounding factors. For instance, it's known that drinkers tend to live more healthy lifestyles (e.g., they may exercise more or follow a Mediterranean diet), or may drink more often simply because they're more socially active, which alone is known to be brain-healthy. What's more, effects of alcohol on cognitive aging may depend on the type of alcohol consumed, how alcohol intake is measured, or the definition of "non-drinkers." Many studies group life-long abstainers together with quitters, who may avoid alcohol due to poor health or may have developed health problems from alcohol abuse. However, my postdoctoral adviser Linda McEvoy, who studies effects of alcohol on brain aging at UC San Diego, explains that "Randomized controlled trials offer a better alternative to more definitely answer the question of how moderate alcohol intake affects cognitive function. Such trials have demonstrated beneficial cardiometabolic effects in those randomized to drink moderate amounts of alcohol."

A prescription for alcohol?

Despite some uncertainties in the research so far, it appears that regular moderate drinking is unlikely to be hazardous to cognitive function and may even support healthy brain aging. Until we have further clarification, McEvoy offers some advice to those hoping to preserve brain health into late life: "If a person consumes alcohol, I would advise drinking moderate amounts of alcohol (one or two drinks) with dinner. If the person does not drink, I would not advise starting. Some individuals have a hard time controlling the amount they drink, and heavy drinking has detrimental effects on brain health and cognitive function."

More information: Elin Åberg et al. Moderate ethanol consumption increases hippocampal cell proliferation and neurogenesis in the adult mouse, The International Journal of Neuropsychopharmacology (2005). DOI: 10.1017/S1461145705005286

Kaarin J. Anstey et al. Alcohol Consumption as a Risk Factor for Dementia and Cognitive Decline: Meta-Analysis of Prospective Studies, The American Journal of Geriatric Psychiatry (2009). DOI: 10.1097/JGP.0b013e3181a2fd07

T. Anttila. Alcohol drinking in middle age and subsequent risk of mild cognitive impairment and dementia in old age: a prospective population based study, BMJ (2004). DOI: 10.1136/bmj.38181.418958.

BE May A Beydoun et al. Epidemiologic studies of modifiable factors associated with cognition and dementia: systematic review and meta-analysis, BMC Public Health (2014). DOI: 10.1186/1471-2458-14-643

B. J. K. Davis et al. The Alcohol Paradox: Light-to-Moderate Alcohol Consumption, Cognitive Function, and Brain Volume, The Journals of Gerontology Series A: Biological Sciences and Medical Sciences (2014). DOI: 10.1093/gerona/glu092

M. Ganguli et al. Alcohol consumption and cognitive function in late life: A longitudinal community study, Neurology (2005). DOI: 10.1212/01.wnl.0000180520.35181.24

L M Hines. Moderate alcohol consumption and coronary heart disease: a review, Postgraduate Medical Journal (2001). DOI: 10.1136/pmj.77.914.747

Kristin R. Krueger et al. Social Engagement and Cognitive Function in Old Age, Experimental Aging Research (2009). DOI: 10.1080/03610730802545028

Francesco Panza et al. Alcohol consumption in mild cognitive impairment and dementia: harmful or neuroprotective?, International Journal of Geriatric Psychiatry (2012). DOI: 10.1002/gps.3772

Nicole J Ridley et al. Alcohol-related dementia: an update of the evidence, Alzheimer's Research & Therapy (2013). DOI: 10.1186/alzrt157

Meir J. Stampfer et al. Effects of Moderate Alcohol Consumption on Cognitive Function in Women, New England Journal of Medicine (2005). DOI: 10.1056/NEJMoa041152

This story is republished courtesy of PLOS Blogs: blogs.plos.org.

Provided by Public Library of Science

Alzheimer's drug prescribed 'off-label' for mild cognitive impairment could pose risk for some

Credit: CC0 Public Domain

Donepezil, a medication that is approved to treat people with Alzheimer's disease, should not be prescribed for people with mild cognitive impairment without a genetic test. UCLA School of Nursing researchers discovered that for people who carry a specific genetic variation—the K-variant of butyrylcholinesterase, or BChE-K—donezpezil could accelerate cognitive decline.

24 feb 2017--Mild cognitive impairment is a transitional state between normal age-related changes in cognition and dementia. Because many people with the condition display symptoms similar to those caused by Alzheimer's disease, some physicians prescribe donepezil, which is marketed under the brand name Aricept and is the most-prescribed medication for Alzheimer's.
Donepezil was tested as a possible treatment for mild cognitive impairment in a large, federally funded study published in 2005, but it was not approved by the FDA. Still, doctors have often prescribed the drug "off-label"—meaning that it is not approved for that specific disorder—for their patients with mild cognitive impairment.
From data collected during the 2005 trial, the researchers looked at the association between BChE-K and changes in cognitive function. Using two tests that measure cognitive impairment, the Mini-Mental State Examination and the Clinical Dementia Rating Sum of Boxes, they found that people with the genetic variation who were treated with donepezil had greater changes in their scores than those who took placebos. They also found that those who took donepezil had a faster cognitive decline than those who took the placebo.
Physicians are increasingly using personalized medicine, including pharmacogenetics—the study of how genetics affect a person's response to a drug—to tailor their patients' care. The findings reinforce the importance of physicians discussing the possible benefits and risks of this treatment with their patients.

More information: Deleterious Effect of Butyrylcholinesterase K-Variant in Donepezil Treatment of Mild Cognitive Impairment. Journal of Alzheimer's Disease. www.j-alz.com/Vol56-1


Provided by University of California, Los Angeles

How gut microbiome and diet can affect depression

Credit: CC0 Public Domain

An international group of researchers headed by André Carvalho has published in Psychotherapy and Psychosomatics a paper that provides new data and prospects for the links between the intestinal flora and several disorders, notably depression.

22 feb 2017--Persistent low-grade immune-inflammatory processes, oxidative and nitrosative stress, and hypothalamic-pituitary-adrenal axis activation are integral to the pathophysiology of major depressive disorder. The microbiome, intestinal compositional changes, and resultant bacterial translocation add a new element to the bidirectional interactions of the gut-brain axis. New evidence implicates these pathways in the onset of major depressive disorder. In addition, abnormalities in the gut-brain axis are associated with several chronic non-communicable disorders, which frequently co-occur in individuals with depression, including but not limited to irritable bowel syndrome, chronic fatigue syndrome, obesity, and type 2 diabetes mellitus.
The composition of the gut microbiota is influenced by several genetic and environmental factors (e.g. diet). Several lines of evidence indicate that gut-microbiota-diet interactions play a significant pathophysiological role in depression and related medical comorbidities. Gut dysbiosis and the leaky gut may influence several pathways implicated in the biology of major depressive disorder, including but not limited to immune activation, oxidative and nitrosative stress, and neuroplasticity cascades. However, methodological inconsistencies and limitations limit comparisons across studies.
Authors conclude that intestinal dysbiosis and the leaky gut may constitute a key pathophysiological link between depression and its medical comorbidities. This emerging literature opens relevant preventative and therapeutic perspectives.

More information: Anastasiya Slyepchenko et al. Gut Microbiota, Bacterial Translocation, and Interactions with Diet: Pathophysiological Links between Major Depressive Disorder and Non-Communicable Medical Comorbidities, Psychotherapy and Psychosomatics (2017). DOI: 10.1159/000448957


Provided by Journal of Psychotherapy and Psychosomatics

Bringing evidence to health screening debates

Gatsonis will speak at the AAAS Annual meeting about how large screening trails are structured to provide the best evidence, not only of accuracy but also for many other pertinent questions regarding patient care. 

Whether to screen? How often? At what age? At what cost?—seem to readily breed conflicting opinions and public confusion. What's needed is rigorously produced evidence. 

20 feb 2017--That's where Constantine Gatsonis, chair of the Department of Biostatistics at Brown University, comes in.
In a talk and panel discussion at the 2017 annual meeting of the American Association for the Advancement of Science on Sunday, Feb. 19, Gatsonis, a veteran researcher on many large cancer screening studies, will discuss how such trials are designed and conducted to ensure that researchers can evaluate not only the accuracy of a test, but also its cost-effectiveness, its effect on doctor and patient decision-making and its effect on health outcomes.
After all, screening is not just about detection, Gatsonis said, but about health. Patients definitely want their cancers found, but not all accurate, positive diagnoses should lead to treatment.
"There is a growing concern of this notion of over-diagnosis," he said. "Screening is finding small lesions that would not hurt you. Generally speaking with screening, especially as the modalities become more and more accurate and can see smaller and smaller things, the question is, is that good for you? It's not a foregone conclusion."
In his talk, "Evaluating the Impact of Diagnostic Modalities Used in Screening for Disease," and the panel, "Medical Decision-Making: To Screen or Not to Screen?" in Room 309 of Hynes Convention Center at 8 a.m., Gatsonis will outline how large studies and statistical analysis bring data to bear on the many questions that swirl around screenings.

Big questions, big studies

Definitive screening trials feature huge sample sizes to ensure the highest degree of certainty when comparing one method against another. But even when the sample is large and the question is straightforward, the answers won't always be obvious. Gatsonis was the lead statistician of the Digital Mammographic Imaging Screening Trial, which sought to compare the accuracy of digital vs. film mammograms for detecting breast cancer in a sample of more than 49,000 women. The primary paper from that study was published in the New England Journal of Medicine in 2005.
The two technologies turned out to have similar accuracy overall, but with a huge sample and carefully gathered data, the study was able to also show that digital mammography had significantly greater accuracy in women younger than 50 years, women with radiographically dense breasts, and premenopausal or perimenopausal women.
The evidence of some clear advantages gave digital mammography a strong foothold, Gatsonis said: "That study is the study that essentially put digital mammography in every hospital."
Well-structured, thoughtfully designed trials can answer multiple questions. Gatsonis was co-lead statistician for the National Lung Screening Trial, which produced the 2010 finding that among 53,454 current or former heavy smokers aged 55 to 74, those who received low-dose helical CT scans had a 20 percent lower risk of dying from lung cancer than participants who received chest X-rays. The study therefore answered the question of which screening method was better based on health outcomes.
The trial also kept track of costs and so was able to assess that CT screening was cost-effective, at least given certain specific assumptions. The study also gathered the data needed to analyze another pertinent question that isn't always asked: Did false positives—CT scans that inaccurately detected cancer—trouble patients? An analysis led by Gatsonis's Brown colleague Ilana Gareen found that such results did not cause serious concern, at least in part because the study's informed consent procedures were clear about the possibility of the unduly dire-seeming result.
Gatsonis is now leading the statistical side of a new breast cancer screening study, the Tomosynthesis Mammography Imaging Screening Trial, which will compare the 3D technology of tomosynthesis with standard, 2D digital mammography.
Rather than just assessing accuracy, the trial, which is set to begin recruiting a whopping total of 165,000 U.S. and Canadian women between the ages of 45 and 74, will also focus on a specific clinical outcome that will be readily apparent within four and a half years from their entry into the study. At that point the research team will assess in which group—tomosynthesis or digital mammography—it was more frequent for a woman to be diagnosed with an advanced, aggressive cancer. The data will help to discern the health impact of each kind of screening, without the team having to wait until there was a sufficient number of breast cancer deaths to allow for a comparison based on mortality.
"We're actually trying to bridge the span between accuracy and ultimate outcome," Gatsonis said, and "do so within a reasonably short study."
In addition to using this innovative endpoint for the primary comparison, the trial is promoting a new approach to screening, which incorporates knowledge of breast cancer risk factors and tailors screening to these factors. For example, Gatsonis said, postmenopausal women will be screened annually or biennially depending on their risk profile.
Big screening trials are expensive and logistically complicated. They generate massive amounts of data that must be expertly interpreted to accomplish their goals. But Gatsonis said that's all still better than the alternative of speculative opining.
"Nobody said screening is a simple process," he said.


Provided by Brown University

New guideline provides clinical recommendations for specific insomnia drugs

A new clinical practice guideline is the first from the American Academy of Sleep Medicine to provide comprehensive, evidence-based analyses of individual agents commonly used in the treatment of chronic insomnia disorder.

19 feb 2017--The guideline, which is published in the Feb. 15 issue of the Journal of Clinical Sleep Medicine, provides recommendations to help clinicians choose a specific pharmacological agent for the treatment of chronic insomnia in adults, when such treatment is indicated. Developed by an expert task force and approved by the AASM board of directors, the guideline was based on a systematic literature review, meta-analyses, and assessment of the evidence using the GRADE methodology. A draft of the guideline was previously made available for public comment.
"The publication of this clinical practice guideline is an important step forward for the field of sleep medicine," said AASM President Ronald D. Chervin, MD, MS. "It further equips clinicians to provide high quality, patient-centered care for millions of people who suffer from chronic insomnia."
Although transient insomnia symptoms occur in 30 to 35 percent of the population, the full clinical syndrome of chronic insomnia disorder occurs in about 10 percent of people. The CDC has estimated that 4.1 percent of U.S. adults report having taken a prescription sleep aid in the past month, based on survey data collected from 2005 - 2010.
The clinical practice guideline includes 14 specific recommendations for individual agents, including prescription medications such as zolpidem and eszopiclone; over-the-counter medications such as diphenhydramine; and dietary supplements such as melatonin and valerian. Each recommendation suggests whether clinicians should or should not use the individual drug for sleep onset insomnia or sleep maintenance insomnia, versus no treatment. However, the guideline does not recommend one drug over another since few comparative efficacy studies have been conducted among these agents.
The authors noted that the data available to support these recommendations is often less than certain. As a result, the strength of each recommendation is classified as "weak," reflecting a lower degree of certainty in the appropriateness of the patient-care strategy. Therefore, clinicians must continue to exercise sound clinical judgment in their care for patients with chronic insomnia. Decisions should be based not only on these recommendations but also on a clinician's experience and the individual circumstances presented by the patient.
The guideline emphasizes that medications for chronic insomnia disorder should be considered mainly in patients who are unable to participate in cognitive behavioral therapy for insomnia (CBT-I), patients who still have symptoms after this therapy, or those who require a temporary adjunct to CBT-I. A clinical guideline previously published by the American Academy of Sleep Medicine indicates that CBT-I is an effective treatment that should be utilized as an initial intervention for chronic insomnia, and this position was reiterated by the AASM in a 2014 Choosing Wisely statement.
Anyone who is having trouble falling asleep or staying asleep should discuss the concern with a doctor. Help for an ongoing sleep problem is available from more than 2,500 sleep centers that are accredited by the American Academy of Sleep Medicine.

More information: Michael J. Sateia et al, Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline, Journal of Clinical Sleep Medicine (2017). DOI: 10.5664/jcsm.6470


Provided by American Academy of Sleep Medicine

Protein and carb intake post-exercise can benefit bone health, study finds

The findings have the potential to influence athletes' dietary and training practices. Credit: Nottingham Trent University

Protein and carbohydrate intake after exercise can have a beneficial impact on bone health and could help to stave off serious injury among athletes, new research suggests.

18 feb 2017--A study led by sport scientists at Nottingham Trent University showed that drinking a protein and carbohydrate-rich solution after strenuous exercise helped decrease bone resorption – the breakdown of tissue in the bone.
It also had a small positive impact on bone formation, creating a better balance of bone turnover – which at high levels is also associated with bone loss and damage.
It is known that prolonged and intense exercise causes increased resorption of the bone – which is linked to the occurrence of debilitating stress fracture injuries in athletes. Such injuries can see athletes out of action for months, resulting in major losses in training time or missed competitions.
The researchers, writing in the journal Medicine & Science in Sports & Exercise, say the findings have the potential to influence athletes' dietary and training practices.
As part of the study male endurance runners ran on a treadmill until exhaustion – and had their blood collected before and after exercise, to measure the impact upon bone health biomarkers. Participants drank either a placebo or a protein and carbohydrate solution developed by the researchers.
The scientists found that the solution reduced concentrations of the b-CTX biomarker – which is released into the blood stream during bone resorption – whether it was ingested immediately or two hours after exercise.
Those who had the solution immediately after exercise also showed increases in P1NP, a blood biomarker for bone formation, four hours after exercise.
Previous work has looked at effects of nutrition before and during exercise, but this is not always practical and can lead to gastrointestinal discomfort.
A key benefit of drinking a solution in this context is that it is quick and easy for the athlete to ingest. It would probably take longer to see any similar benefit from eating protein and carbohydrate-rich food, due to the additional time taken for transit through the gut.
"Given that endurance athletes train multiple times a day, preventing bone loss and stress fracture injury is hugely important," said Craig Sale, Professor of Human Physiology in Nottingham Trent University's School of Science and Technology.
He said: "These athletes have minimal recovery time and rest days and are likely to suffer in terms of bone health, with increased risk of injury. These findings are important for those individuals because post-exercise intake, or training sessions, can be timed so that training occurs when bone resorption is at its lowest and bone formation at its highest."
Researcher Becky Townsend added: "Although the study was performed with elite athletes in mind, the data could also be used by sub-elite or recreational endurance athletes training just once a day.
"The data may also be useful for athletes that perform a variety of different training sessions; from long slow runs, to high-intensity interval type sessions, as all of these types of sessions include repetitive mechanical loading and cause increased physiological/hormonal responses.
"Although the carbohydrate and protein drink used in the study was individualised based on participant body weight, there are a number of similar carbohydrate and protein recovery drinks that are commercially available."
The study also involved the English Institute of Sport and Norwich Medical School at the University of East Anglia.
Dr Kevin Currell, Director of Science and Technical Development at the English Institute of Sport, said: "Working with Nottingham Trent University to find a simple intervention which could support elite athletes bone health has been an impactful partnership. This research has already been put into practice, and helped keep a number of athletes fit and healthy leading into Rio 2016."

More information: Rebecca Townsend et al. The Effect of Postexercise Carbohydrate and Protein Ingestion on Bone Metabolism, Medicine & Science in Sports & Exercise (2017). DOI: 10.1249/MSS.0000000000001211


Provided by Nottingham Trent University

Vitamin D protects against colds and flu, finds major global study

Credit: CC0 Public Domain

Vitamin D supplements protect against acute respiratory infections including colds and flu, according to a study led by Queen Mary University of London (QMUL).

17 feb 2017--The study provides the most robust evidence yet that vitamin D has benefits beyond bone and muscle health, and could have major implications for public health policy, including the fortification of foods with vitamin D to tackle high levels of deficiency in the UK.
The results, published in the BMJ, are based on a new analysis of raw data from around 11,000 participants in 25 clinical trials conducted in 14 countries including the UK, USA, Japan, India, Afghanistan, Belgium, Italy, Australia and Canada. Individually, these trials yielded conflicting results, with some reporting that vitamin D protected against respiratory infections, and others showing no effect.
Lead researcher Professor Adrian Martineau from QMUL said: "This major collaborative research effort has yielded the first definitive evidence that vitamin D really does protect against respiratory infections. Our analysis of pooled raw data from each of the 10,933 trial participants allowed us to address the thorny question of why vitamin D 'worked' in some trials, but not in others.
"The bottom line is that the protective effects of vitamin D supplementation are strongest in those who have the lowest vitamin D levels, and when supplementation is given daily or weekly rather than in more widely spaced doses.
"Vitamin D fortification of foods provides a steady, low-level intake of vitamin D that has virtually eliminated profound vitamin D deficiency in several countries. By demonstrating this new benefit of vitamin D, our study strengthens the case for introducing food fortification to improve vitamin D levels in countries such as the UK where profound vitamin D deficiency is common."
Vitamin D - the 'sunshine vitamin' - is thought to protect against respiratory infections by boosting levels of antimicrobial peptides - natural antibiotic-like substances - in the lungs. Results of the study fit with the observation that colds and 'flu are commonest in winter and spring, when levels of vitamin D are at their lowest. They may also explain why vitamin D protects against asthma attacks, which are commonly triggered by respiratory viruses.
Daily or weekly supplementation halved the risk of acute respiratory infection in people with the lowest baseline vitamin D levels, below 25 nanomoles per litre (nmol/L). However, people with higher baseline vitamin D levels also benefited, although the effect was more modest (10 per cent risk reduction). Overall, the reduction in risk of acute respiratory infection induced by vitamin D was on a par with the protective effect of injectable 'flu vaccine against 'flu-like illnesses.
Acute respiratory infections are a major cause of global morbidity and mortality. Upper respiratory infections such as colds and 'flu are the commonest reason for GP consultations and days off work. Acute lower respiratory infections such as pneumonia are less common, but caused an estimated 2.65 million deaths worldwide in 2013. Vitamin D supplementation is safe and inexpensive, so reductions in acute respiratory infections brought about by vitamin D supplementation could be highly cost-effective.

More information: Adrian R Martineau et al, Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data, BMJ (2017).DOI: 10.1136/bmj.i6583


Provided by Queen Mary, University of London

Review links albuminuria to cognitive impairment, dementia

14 feb 2017—Albuminuria is associated with cognitive impairment, dementia, and cognitive decline, according to a review published online Feb. 2 in the Journal of the American Geriatrics Society.

Marios K. Georgakis, M.D., from the University of Athens in Greece, and colleagues conducted a systematic review to examine the correlation between albuminuria and cognitive impairment, dementia, and cognitive function. Data were included for 32 eligible studies.
The researchers found that albuminuria correlated with cognitive impairment, dementia, clinical Alzheimer's disease, and vascular dementia (odds ratios, 1.35, 1.35, 1.37, and 1.96, respectively). The significant effect persisted in longitudinal, population-based, and high-quality studies. In time-to-event analysis of prospective studies involving individuals without dementia at baseline, there was a significant association with incident dementia (risk ratio, 1.52). Subjects with albuminuria had worse global cognitive performance and accelerated cognitive decline (Hedge's g, −0.13 and −0.20, respectively); they also scored lower in executive function, processing speed, verbal fluency, and verbal memory.
"The stronger effects for vascular dementia and cognitive performance in domains primarily affected by microvascular disease support that the association could be mediated by shared microvascular pathology in the kidney and the brain," the authors write.

More information: Full Text (subscription or payment may be required)

Hand-grip test can indicate decline in physical function of Parkinson's patients

UBC researchers Jenn Jakobi, sitting, and Gareth Jones, right, review results from recent electromyography tests on patients with Parkinson's disease with their student researchers. Credit: UBC Okanagan

12 feb 2017--UBC researchers Jenn Jakobi and Gareth Jones, both Health and Exercise Sciences professors at UBC's Okanagan campus, recently completed a study that examined the methods used to monitor the progressive advancement of Parkinson's disease (PD)—a degenerative disease that affects the central nervous system.
The study compared results from electromyography assessments of leg and arm muscles to basic physical performance tests such as gait speed, balance and hand-grip strength. The results were surprising.
"It became very clear that the hand-grip test was one of the functional tests that proved to be a reliable and valuable test measure," says Jakobi. "The hand-grip test is an easy and conclusive way to test muscle strength decline in this group of people."
The study involved 23 men and women with PD and 14 people without the disease, all 50 years or older living independently in Kelowna. The participants wore a portable monitoring device to measure muscle activity with the device recording electrical activity of muscles in the arms and legs for approximately eight hours. Participants also underwent three physical function tests—hand-grip, gait and balance—each morning and afternoon.
Jones says the data gleaned from the three physical tests was as conclusive and as informative as the lengthy recordings of muscle activity. And the tests were easier for participants and those administering the experiments.
"The hand-grip dynamometer is a tool that is easily accessible, easy to use, and is reliable," says Jones. "In addition they are readily available to health professionals such as family doctors, community therapists and physiotherapists."
"It seems these devices have come full circle and are back being used by clinicians," adds Jakobi. "It's a tool that is ideal for Parkinson's patients as you can easily record a decline in an individual's physical strength and function as the disease progresses."
Patients with PD suffer symptoms like uncontrollable shaking, slowness of movement, and eventually difficulty with balance, coordination and walking. It's important for health care professionals to track early functional decline of Parkinson's patients, says Jakobi. In this way, individual health can be monitored and future falls related to the disease prevented.
According to Statistics Canada more than 67,000 Canadians are living with Parkinson's today, and it is mostly diagnosed in men over the age of 45.
The study was recently published in the journal Archives of Physical Medicine and Rehabilitation.


Provided by University of British Columbia

New data reveal aging experiences of LGBT Americans

A new supplemental issue of the journal The Gerontologist presents the findings of the largest national survey to date focused on the health and well-being of lesbian, gay, bisexual, and transgender (LGBT) older adults.

10feb 2017--The issue, titled "Aging with Pride: National Health, Aging, and Sexuality/Gender Study (NHAS)," provides cutting edge research, drawing upon the 2014 wave of data from the first national, longitudinal study of more than 2,400 diverse LGBT adults aged 50 to 100. This research was supported by a grant from the National Institute on Aging.
Karen I. Fredriksen-Goldsen, PhD, a professor in the University of Washington School of Social Work, served as editor for this journal issue, which contains 10 articles.
"These articles provide the opportunity to consider how social, historical, and environmental contexts influence the health and well-being of LGBT older adults as we move forward in aging-related research, services, and policies—especially if we are to understand the realities of older adulthood across diverse and vulnerable communities." said Fredriksen-Goldsen. "The insights gleaned from this study of aging among LGBT older adults can deepen our understanding of the richness, diversity, and resilience of lives across the life course."
Findings in the journal reveal that 2.4 percent of older adults in the U.S. currently self-identify as LGBT, accounting for 2.7 million adults aged 50 and older, including 1.1 million aged 65 and older.
Collectively, the articles cut across three major themes: risk and protective factors and life course events associated with health and quality of life among LGBT older adults; heterogeneity and subgroup differences in LGBT health and aging; and processes and mechanisms underlying health and quality of life of LGBT older adults. The authors address the intersection of health and well-being with such topics as race and ethnicity, HIV status, military service, marriage, social networks, and depression.
"LGBT older adults face disparities in health and well-being compared to heterosexual peers, including higher rates of disability, cardiovascular disease, depression and social isolation," Fredriksen-Golden said. "Discrimination, stigma, and lack of healthcare access is associated with these elevated disparities. It is important to understand that these communities are diverse, and unique groups face distinct challenges to their health."


Provided by The Gerontological Society of America

Benefits for intensive BP lowering in older HTN patients

For older patients with hypertension, intensive blood pressure (BP) lowering strategies are associated with reduced risk of certain cardiovascular events, according to research published in the Feb. 7 issue of the Journal of the American College of Cardiology.

09 feb 2017--Chirag Bavishi, M.D., M.P.H., from Mount Sinai St. Luke's & Mount Sinai West Hospitals in New York City, and colleagues examined data from four high-quality trials involving 10,857 older hypertension patients (aged ≥65 years) with a mean follow-up of 3.1 years.
The researchers found that, compared with standard BP lowering, intensive BP lowering correlated with significant reductions in major adverse cardiovascular events (MACE), cardiovascular mortality, and heart failure (pooled relative risks [RR], 0.71 [95 percent confidence interval (CI), 0.60 to 0.84], 0.67 [95 percent CI, 0.45 to 0.98], and 0.63 [95 percent CI, 0.43 to 0.99], respectively). There were no between-group differences in the rates of myocardial infarction or stroke. No significant between-group difference was seen in the incidence of serious adverse events or renal failure (RRs, 1.02 [95 percent CI, 0.94 to 1.09] and 1.81 [95 percent CI, 0.86 to 3.80], respectively). In a fixed effects model, results were largely similar except the risk of renal failure was increased with intensive BP-lowering therapy (RR, 2.03 [95 percent CI, 1.30 to 3.18]).
"When considering intensive BP control, clinicians should carefully weigh benefits against potential risks," the authors write.
Several authors disclosed financial ties to the pharmaceutical and medical technology industries.

More information: Full Text
Editorial