The guidelines on low back pain are clear—drugs and surgery should be the last resort

Most people with low back pain aren’t getting the most effective treatment. Credit: shutterstock.com

Low back pain is the leading cause of disability worldwide and is becoming more common as our population ages. Most people who have an episode of low back pain recover within six weeks, but two-thirds still have pain after three months. By 12 months, pain may linger but is usually less intense.

17 may 2018--Still, recurrence is common and in a small number of people it may become persistent and disabling. Chronic back pain affects well-being, daily functioning and social life.
A series on low back pain by the global medical journal The Lancet outlined that most sufferers aren't getting the most effective treatment. The articles state that recommended first-line treatments – such as advice to stay active and to exercise – are often overlooked. Instead, many health professionals seem to favour less effective treatments such as rest, opioids, spinal injections and surgery.
So, here's what evidence shows you need to do to improve your low back pain.
Risk factors for low back pain
The cause of most people's low back pain remains unknown. But we do know of a number of risk factors that could increase the chance of developing low back pain. These include a physically demanding job that involves lifting, bending and being in awkward postures. Lifestyle factors such as smoking, obesity and low levels of physical activity are also associated with developing low back pain.
People with low back pain should see a health professional to rule out the more serious causes of pain such as fracture, malignancy (cancer) or infection.
Once patients are cleared of these, the current guidelines from Denmark, the UK and the US advise self-management and psychological therapies as the initial response for persistent low back pain. These include staying active, doing appropriate exercises and undertaking a psychological program to help manage the pain.
Exercises such as Tai Chi, yoga, motor control (to restore strength, co-ordination and control of the deep core stabilising muscles supporting the spine) and aerobic exercises (such as walking, swimming, cycling and general muscle reconditioning exercises) are recommended.
If any of these therapies fail or stop working, the guidelines point to manual and physical therapies such as spinal manipulation (Denmark, UK, US), massage (UK and US) and yoga and acupuncture (US) – particularly for low back pain lasting more than 12 weeks.
Exercise and psychological therapy
The guidelines are based on many studies that have shown the benefits of exercise and psychological therapies. For instance, a 2006 study compared pain levels across two groups of physically active people with chronic low back pain.
Participants who followed a four-week program using Pilates exercise equipment reported a more significant reduction in pain and disability than those in a control group who received usual care (consultations with a health care professional as needed). The benefit for the exercise group was maintained over a 12-month period.

Credit: The Conversation

Another, 2011 trial explored the benefits of Tai Chi for those with persistent low back pain. Participants who completed a ten-week course of Tai Chi sessions had less bothersome back symptoms, pain intensity and self‐reported disability, compared with a control group who continued with their normal medical care, fitness or health regimen.
Chronic pain is linked with chemical and structural changes at all levels of the nervous system. These include the level of neurotransmitter changes that alter pain modulation, and sensitisation of the nerves involved in transmitting pain signals. Incoming pain signals can be modified by our response to persistent pain.
Psychological treatments – such as mindfulness-based stress reduction – focus on increasing awareness and acceptance of physical discomfort, as well as challenging emotions often associated with chronic pain.
In a trial including 342 participants, around 45% of those who had completed eight sessions of cognitive behaviour therapy or mindfulness-based stress reduction had clinically meaningful improvements in bothersome pain at 26 weeks of follow-up. This was compared to only 26.6% of people who had received usual care.
Manual therapy
In Australia, physiotherapists, chiropractors and osteopaths use manual and physical therapy to treat lower back pain. The treatments often include some form of spinal manipulation and massage, as well as advice to stay active and do exercises. This is consistent with The Lancet's recommendations, also based on evidence from studies.
A 2013 trial of people with acute low back pain compared the effects of spinal manipulation with those of the non-steroidal anti-inflammatory drug diclofenac (Voltaren) and placebo on their pain. Spinal manipulation was found to be significantly better than diclofenac and clinically superior to placebo in reducing disability, pain and the need for rescue medication. It was also found to improve quality of life.
Similar results came from another study of 192 people with low back pain that lasted around two to six weeks. Participants were randomly allocated to one of three groups: chiropractic manipulation with a placebo medication; muscle relaxants with sham manipulation; or placebo medicine with sham manipulation. All subjects improved over time, but the chiropractic group responded significantly better, with a bigger decrease in pain scores, than the control group.
Physiotherapists, chiropractors and osteopaths are required by law to be registered with the Australian Health Practitioner Regulation Agency (AHPRA) to practise in Australia. To be registered, a person must complete a minimum of four years' study at a university in a degree that includes a focus on non-pharmacological (drug-based), non-surgical management of musculoskeletal conditions, including low back pain.
Under the government's Chronic Disease Management Plan patients with persistent low back pain may be referred to physiotherapists, chiropractors or osteopaths for evidence-based therapies such as spinal manipulation and massage. If patients are unfamiliar with these therapies, they can discuss referral with their GP.
Physiotherapists, chiropractors and osteopaths can also be consulted without referral. Their services are usually covered by private health insurance. The AHPRA website lists registered practitioners in your area.
One thing to look out for when you see a practitioner is the number of treatments they recommend. Patients usually start with a short course of two to six treatments to see if the treatment helps. It shouldn't take many treatments for a change in symptom pattern to become obvious.
The message to the public and to health professionals is clear. People with non-specific low back pain need to learn how to independently manage their pain while remaining active, staying at work and maintaining their social life as far as possible.

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

Provided by The Conversation

Review shows lack of evidence supporting use of antidepressants for insomnia

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A rigorous review of research, led by the University of Southampton, has found there is not enough evidence to support the current clinical practice of prescribing antidepressants for insomnia.
Part-funded by the NIHR School for Primary Care Research, the review, published in the Cochrane Systematic Reviews Library, re-examined 23 previous studies involving a total of 2,806 patients with insomnia.

17 may 2018--The researchers found that, overall, evidence supporting the use of antidepressants for people with sleep problems is of low quality – partly due to the small number of people in individual studies and partly due to how the studies were undertaken and reported.
Some low quality evidence was identified supporting short term (weeks, rather than months) use of some antidepressants, but no evidence was found for amitriptyline, which is commonly used in clinical practice. There was also no evidence to support long-term antidepressant use for insomnia.
Lead researcher, Associate Professor Hazel Everitt, says: "High quality trials of antidepressants for insomnia are needed to provide better evidence in this area to inform clinical practice. Additionally, health professionals and patients should be made aware of the current lack of evidence for antidepressant medications commonly used for insomnia management."
Insomnia causes unsatisfactory sleep – both difficulty getting to sleep and staying asleep. It is a common problem, with one in five people reporting sleep problems each year. It can significantly impair quality of life, leading to physical or mental health problemsand is associated with anxiety, depression and drug and alcohol abuse.
Management of the condition depends on its duration and nature. It may involve treating coexisting medical problems, providing advice on sleep habits and lifestyle, or using medicines and psychological therapies. Medicines called hypnotics are most commonly used to treat insomnia and are known to help, but can have problems, such as tolerance (needing to take more of the medicine to get the same effect) and dependence (physical or mental problems if the medicine is stopped). The use of antidepressant drugs to help with insomnia is widespread, but none are licensed for the condition and, as this study has shown, their effectiveness is unclear.

More information: Antidepressants for insomnia in adults. Cochrane Database of Systematic Reviews, DOI: 10.1002/14651858.CD010753.pub2


Provided by University of Southampton

EULAR recommendations for pain management in inflammatory arthritis and osteoarthritis

The European League Against Rheumatism, EULAR, has published a set of recommendations, designed to help health professionals implement approaches to pain management in inflammatory arthritis and osteoarthritis patients. The aim is to reduce pain and the burden on the individual and society.

17 may 2018--Pain is the predominant symptom for people with inflammatory arthritis (IA) and osteoarthritis (OA), mandating the development of new, evidence-based EULAR Recommendations for the health professional's approach to pain management. The target users of these recommendations are health professionals in the field of rheumatology, including rheumatologists. Prompt and knowledgeable pain management support can reduce pain, increase functioning and well-being, and reduce individual and societal costs. Practitioners in all healthcare settings should therefore have the knowledge and skills required to help people with IA and OA to better manage their pain; rheumatology health professionals are ideally placed to provide comprehensive, evidence-based, and patient-centred care.
Pain management typically includes education. Based on the needs of the patient, education is complemented by physical activity and exercise, aids and assistive devices, psychological and social interventions, sleep hygiene education, weight management, pharmacological and joint-specific treatment options, and interdisciplinary pain management. Underpinned by available systematic reviews and meta-analyses, these recommendations enable health professionals to provide knowledgeable pain managementsupport for people with IA and OA.
A multidisciplinary task force including patient representatives conducted a systematic literature review to evaluate evidence regarding effects on pain of multiple treatment modalities. The task force that included 18 members from 12 countries, consisted of patient representatives, nurses, physiotherapists, psychologists, rheumatologists, a general practitioner, an occupational therapist, a clinical epidemiologist, and a research fellow.
From 2,914 studies initially identified, 186 met inclusion criteria. Based on the reviewed studies and expert opinion, the task force emphasised the importance for the health professional to adopt a patient-centred framework within a biopsychosocial perspective, to have sufficient knowledge of IA and OA pathogenesis, and to be able to differentiate localised and generalised pain. The assessment of patient needs, preferences and priorities; pain characteristics; previous and ongoing pain treatments; inflammation and joint damage; and psychological and other pain-related factors were deemed important.

More information: EULAR Recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis: www.eular.org/sysModules/obxCo … management_ia_oa.pdf


Provided by European League Against Rheumatism (EULAR)

The Yogi masters were right—meditation and breathing exercises can sharpen your mind

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It has long been claimed by Yogis and Buddhists that meditation and ancient breath-focused practices, such as pranayama, strengthen our ability to focus on tasks. A new study by researchers at Trinity College Dublin explains for the first time the neurophysiological link between breathing and attention.

17 may 2018--Breath-focused meditation and yogic breathing practices have numerous known cognitive benefits, including increased ability to focus, decreased mind wandering, improved arousal levels, more positive emotions, decreased emotional reactivity, along with many others. To date, however, no direct neurophysiological link between respiration and cognition has been suggested.
The research shows for the first time that breathing—a key element of meditation and mindfulness practices—directly affects the levels of a natural chemical messenger in the brain called noradrenaline. This chemical messenger is released when we are challenged, curious, exercised, focused or emotionally aroused, and, if produced at the right levels, helps the brain grow new connections, like a brain fertiliser. The way we breathe, in other words, directly affects the chemistry of our brains in a way that can enhance our attention and improve our brain health.
The study, carried out by researchers at Trinity College Institute of Neuroscience and the Global Brain Health Institute at Trinity, found that participants who focused well while undertaking a task that demanded a lot of attention had greater synchronisation between their breathing patterns and their attention, than those who had poor focus. The authors believe that it may be possible to use breath-control practices to stabilise attention and boost brain health.
Michael Melnychuk, Ph.D. candidate at the Trinity College Institute of Neuroscience, Trinity, and lead author of the study, explained: "Practitioners of yoga have claimed for some 2,500 years, that respiration influences the mind. In our study we looked for a neurophysiological link that could help explain these claims by measuring breathing, reaction time, and brain activity in a small area in the brainstem called the locus coeruleus, where noradrenaline is made. Noradrenaline is an all-purpose action system in the brain. When we are stressed we produce too much noradrenaline and we can't focus. When we feel sluggish, we produce too little and again, we can't focus. There is a sweet spot of noradrenaline in which our emotions, thinking and memory are much clearer."
"This study has shown that as you breathe in locus coeruleus activity is increasing slightly, and as you breathe out it decreases. Put simply this means that our attention is influenced by our breath and that it rises and falls with the cycle of respiration. It is possible that by focusing on and regulating your breathing you can optimise your attention level and likewise, by focusing on your attention level, your breathing becomes more synchronised."
The research provides deeper scientific understanding of the neurophysiological mechanisms which underlie ancient meditation practices. The findings were recently published in a paper entitled 'Coupling of respiration and attention via the locus coeruleus: Effects of meditation and pranayama' in the journal Psychophysiology. Further research could help with the development of non-pharmacological therapies for people with attention compromised conditions such as ADHD and traumatic brain injury and in supporting cognition in older people.
There are traditionally two types of breath-focused practices—those that emphasise focus on breathing (mindfulness), and those that require breathing to be controlled (deep breathing practices such as pranayama). In cases when a person's attention is compromised, practices which emphasise concentration and focus, such as mindfulness, where the individual focuses on feeling the sensations of respiration but make no effort to control them, could possibly be most beneficial. In cases where a person's level of arousal is the cause of poor attention, for example drowsiness while driving, a pounding heart during an exam, or during a panic attack, it should be possible to alter the level of arousal in the body by controlling breathing. Both of these techniques have been shown to be effective in both the short and the long term.
Ian Robertson, Co-Director of the Global Brain Health Institute at Trinity and Principal Investigator of the study added: "Yogis and Buddhist practitioners have long considered the breath an especially suitable object for meditation. It is believed that by observing the breath, and regulating it in precise ways—a practice known as pranayama—changes in arousal, attention, and emotional control that can be of great benefit to the meditator are realised. Our research finds that there is evidence to support the view that there is a strong connection between breath-centred practices and a steadiness of mind."
"Our findings could have particular implications for research into brain ageing. Brains typically lose mass as they age, but less so in the brains of long term meditators. More 'youthful' brains have a reduced risk of dementia and mindfulness meditation techniques actually strengthen brain networks. Our research offers one possible reason for this—using our breath to control one of the brain's natural chemical messengers, noradrenaline, which in the right 'dose' helps the brain grow new connections between cells. This study provides one more reason for everyone to boost the health of their brain using a whole range of activities ranging from aerobic exercise to mindfulness meditation."

More information: Michael Christopher Melnychuk et al. Coupling of respiration and attention via the locus coeruleus: Effects of meditation and pranayama, Psychophysiology (2018). DOI: 10.1111/psyp.13091


Provided by Trinity College Dublin

Why alcohol health warning labels are a good idea: findings from the latest Global Drug Survey

Credit: lOvE lOvE/Shutterstock.com

Drink-driving and drinking while pregnant are socially unacceptable in many countries, yet when it comes to other alcohol-related health risks, public awareness is low.

17 may 2018--Globally around 3.3m people die from causes directly related to alcohol consumption – the top ones being heart disease, cancer, liver disease and accidents. However, a 2016 survey of 2,100 adults in the UK found that just 13% of respondents identified cancer as a potential health risk of alcohol consumption.
It seems that the alcohol industry and governments aren't too bothered about changing this. In fact, mandatory health warnings for alcohol are rare. Across the EU, which boasts the highest per capita alcohol consumption in the world, there is no legislation requiring health warnings.
We know that the most effective strategies to change behaviour and reduce alcohol consumption are legislative. These include raising taxes, minimum unit pricing and lower drink-drive limits. But the alcohol industry lobbies hard against interventions that threaten profits, and most governments seem to defer to the industry's preferred alternative of self-regulation.
The industry and governments don't seem that keen on health warning labels either. One argument is that health messages don't change behaviour or that drinkers don't want to have their pleasure spoiled by uncomfortable truths. And it's true that information in isolation of other public health and health promotion strategies may be of limited value. But when it comes to motivating behaviour change, it can be helpful to raise awareness and challenge people's beliefs about their behaviour.
Health messages, if done well, could raise awareness and for some people might be the switch that gets them thinking about drinking less. Providing accurate information can also help to counter common myths and misunderstandings. For example, ambiguity about the potential health benefits of moderate drinking can be the "excuse" we need to resist changing our behaviour.
On the other hand, it is important to acknowledge evidence that health messages that try to induce fear often backfire – images of diseased lungs on cigarette packaging, being a case in point. Smokers don't want to be confronted by the negative consequences of their behaviour and they may smoke more to deal with the discomfort experienced. The same is likely to be true of alcohol health warnings.

Possible label. Author provided

Some labels that might work
For the latest Global Drug Survey (GDS2018) – a survey of 130,000 people from more than 40 countries – we explored the potential of seven different health messages to change people's drinking habits. We chose a variety of health and social issues to focus on and used a mixture of positive messages, highlighting the benefits of reducing consumption, and negative messages, highlighting risks.
The results show that cancer remains the area that people least associate with alcohol use, and a message such as "drinking less can reduce your risk of seven different types of cancer" could get almost 40% of drinkers to think about drinking less.
The top two other messages that people reported would make them – or maybe make them – think about drinking less were: "Even people with heavy alcohol use can reduce their risk of liver disease by cutting down by even a small amount" (31%), and a label highlighting that a bottle of wine or six small beers has the same number of calories as a hamburger and fries (28%).
Our study also shows that different cultures may be more or less responsive to health warning labels, with Scandinavian countries, which certainly have high rates of alcohol-related harms, seemingly less concerned than those from South America and the Mediterranean.
Of particular interest was the relatively high rate of disbelief of the statement: "Most people get little or no health benefit from alcohol use, even at low levels of drinking". The subtle message that a little alcohol is good for your health is one the alcohol industry is fiercely protective of, and our results show that more work is required to diminish this falsehood.
Conversely, the label stating that alcohol increases the rate of violence and abuse was the one that was believed most by participants.

Globally, this was also rated as the most personally relevant label, closely followed by those about calories and the benefits of having two days off. This perhaps reflects that people are more concerned about the immediate effects of drinking.
Again, there were regional variations; our findings suggest that countries in South America and Eastern Europe may be more affected by the social impact of alcohol than other countries.
Self-regulation doesn't work
Consumers of alcohol, like any other drug, need to be given the facts about the risks they expose themselves to when they drink. They need to know that risk is dependent on how much they drink and that drinking less reduces that risk. They need specific positive messages that allow people to feel OK about making decisions that may improve their health and well-being.
In the same way that plain packaging and health warnings on tobacco products were used as part of a broader public health approach to reducing consumption, appropriate and proportionate health messages on alcohol should be explored as a cheap, easy-to-implement strategy that could raise awareness of alcohol-related harms.
The latest Global Drug Survey supports the call for mandatory health warning labels on alcohol. An industry that makes profits from selling a product will never embrace anything that might lead to people drinking less. A self-regulated industry will always regulate to optimise profits not public health.

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

Provided by The Conversation

Training for 21st century doctors: medicine, business, and leadership development

Given the complex and rapidly evolving health care system in the United States, medical schools must focus their efforts on training more physician leaders to master the diverse skills needed to navigate emerging challenges in the field, urge leaders from the Perelman School of Medicine at the University of Pennsylvania in a new Perspective piece published today in the New England Journal of Medicine.

17 may 2018--"Academic medicine has been somewhat complacent in the face of the disruptive forces in health care, and as a result, the gap between the physician-leader workforce and the needs of our system has only widened," said J. Larry Jameson, MD, Ph.D., executive vice president of the University of Pennsylvania for the Health System and dean of Penn's Perelman School of Medicine. "Health care systems need a new prescription to close this leadership gap. Given the societal impact of health care, we need to accelerate the development of skills that are not typically acquired during traditional medical training."
Historically, physician leaders have been chosen based on their national prominence and excellence as master clinicians, star researchers, and revered educators. While these credentials remain important, they aren't sufficient in the current health care climate, the authors write.
Today's physicians practice in an era of changing payment models, rising costs, IT advances, and emerging technologies and therapies that are reshaping the delivery of patient care. Dynamic changes have also come with ongoing health system mergers and market consolidation. To lead effectively in this environment, doctors need not only sharp clinical expertise, but also opportunities to hone their communication, team building, and decision making skills, and gain knowledge of finance and business.
Jameson and co-author Caryn Lerman, Ph.D., vice dean for Strategic Initiatives and the John H. Glick, MD Professor in Cancer Research in the department of Psychiatry in the Perelman School of Medicine, suggest health systems focus on three strategies to create this new wave of leaders: rigorous mining of diverse talent pools to identify the most promising emerging physician leaders; building pipelines of future leaders with targeted leadership development to enable progressively increasing responsibility; and deliberate onboarding processes to integrate new leaders and assure alignment across missions and with the institutional culture.
Training in finance and business planning and personnel management should be central to professional development, as many physician leaders may manage budgets similar to those of medium-sized businesses, for example, and work in organizations which are among the largest employers in their community.
"Given the high rate of turnover among physician leaders, such as department chairs and deans, we can no longer afford to neglect the skills that are essential for leaders to succeed," they wrote. "We believe there is a need for a new generation of leaders who can promote strategic and cultural alignment in the face of rapid change."
At Penn, the Perelman School of Medicine has joined with the Wharton School to create an executive education program which will launch in 2019 for health care and academic medical leaders from across the nation and world. The program will provide targeted leadership development experiences and practical skills to enable today's and tomorrow's leaders of health systems and academic medical centers to adapt to a rapidly changing environment.
The new endeavor joins the Penn-Wharton MD/Master of Business Administration (MD/MBA) program, which is designed for medical students interested in integrating their medical course work with training in managerial, financial, and technical expertise in the health care field.
Another example is Penn Medicine's Healthcare Leadership for Quality Residency Track. This two-year training pathway for future physician leaders is one of only a few in the country to offer a pathway for residents aspiring to be leaders in health care quality, patient safety, or informatics. So far, more than one hundred residents have participated in the program.
To help meet the challenges of an increasingly complex landscape, the authors say, health systems should make leadership development an organizational priority—an emphasis which will also pay off in improved patient satisfaction and clinical outcomes.
"The 21st century physician leader must be equipped with a new tool kit of skills for the leadership agility necessary for them to respond proactively to rapidly changing environments," Lerman said. "Leadership development should be an organizational priority, preparing today's medical students and physicians to thrive in a continuously evolving era of health care."


Provided by Perelman School of Medicine at the University of Pennsylvania

Brazilians with less education more likely to report being in poor health, study finds

The study found that people in Brazil with less education were more likely to identify themselves as being in poor health. The data pictured are from the Brazil National Health Survey 2013. Credit: Julie McMahon, University of Illinois

Brazilians with less education are more likely to self-report as being in poor health, according to a study using data from nationwide surveys distributed every five years from 1998 to 2013. The study also found that general subjective health did not improve over the study period, even though more people gained education throughout the study, indicating that other factors associated with poor education may need to be addressed to improve self-perceptions of health.

17 may 2018--University of Illinois researchers Flavia Cristina Drumond Andrade, a professor of kinesiology and community health, and Jeenal Deepak Mehta, an undergraduate student, published the study in the journal PLOS ONE.
"Self-reported perceived health is an effective health indicator that has been shown to be a good predictor of mortality," Andrade said. "In social contexts such as developing countries, in which some diseases may go unnoticed or undiagnosed for a while, survey data can give a good sense of individuals' assessment of their overall health."
Andrade and Mehta used data from the 1998, 2003 and 2008 Brazilian National Household Sample Survey and the Brazil National Health Survey 2013. The surveys included many factors, such as education levels, employment, race, location and health. Participants reported themselves as being in "good" or "poor" health.
Overall, the percentage of those who reported themselves as being in poor health was fairly small—the highest being 5.9 percent in 2013. However, when the researchers separated the respondents by education level, they found that the less education a group had, the higher the percentage of self-reported poor health.
The gradient was sharp, and consistent across all years of the survey: Those with no education were seven to nine times more likely to report poor health than those with at least some college.
"Often, those with lower education experience worse employment—with lower wages, worse working conditions and less access to health care—than those with more education," Andrade said. "They may also engage in unhealthy lifestyle behaviors, in part due to lower health knowledge and in part due to economic restrictions. All these conditions put them in relative disadvantage, which could be translated as worse perceived health."
Over the course of the surveyed years, Brazil experienced a period of educational development, Andrade said. The percentage of those who had completed high school rose from 13.9 percent in 1998 to 28.6 percent in 2013, and the percentage of those with some college or more rose from 9 percent to 19.1 percent. Yet the overall percentage of self-reported poor health has not varied largely, and even rose a bit in 2013, although education levels rose.
Again, the researchers noticed a difference in health reporting over time according to education levels.
"There was a worsening of self-reported perceived health among those with primary or secondary education. This is important because most Brazilians are in this group—74.8 percent in 1998 and 68 percent in 2013. On the other hand, we do not see this pattern among those with some college or more. For them, the levels of poor self-reported health did not change."
The researchers posit that these changes may be related to the slowing of economic growth that Brazil experienced over the last two survey cycles.
"Those with less education often suffer with lower incomes and more during these economic decelerations. When relative conditions worsen, perceptions of health and well-being also tend to get worse among those at the bottom of the social scale," Andrade said.
In addition, Andrade urges those seeking to improve general health in Brazil to address not only education but also the aging of the population—the average age of the survey respondents increased from 40 to 44 years over the study period—and the prevalence of chronic conditions, such as diabetes, that were reported on the surveys.
"With increases in age, there are also increases in poor self-perceived health," Andrade said. "Along with the demographic transition, there were also increases in the prevalence of some chronic conditions, which also impacts the perception of health. Therefore, efforts to prevent and control chronic conditions are necessary to improve self-perceptions of health in Brazil."

More information: Flavia Cristina Drumond Andrade et al, Increasing educational inequalities in self-rated health in Brazil, 1998-2013, PLOS ONE (2018). DOI: 10.1371/journal.pone.0196494


Provided by University of Illinois at Urbana-Champaign

Experts have new advice on prostate cancer screening. Here's why they put it back on the table

Micrograph showing prostatic acinar adenocarcinoma (the most common form of prostate cancer) Credit: Wikipedia

In a shift that puts early detection of prostate cancer back on the agenda of middle-aged men and their doctors, a federal panel of experts is recommending that men ages 55 to 69 weigh the potential harms and benefits of prostate cancer screening and judge whether getting tested feels right to them.

15 may 2018--A recommendation issued Tuesday by the U.S. Preventive Services Task Force judged the "net benefits" of screening these men for prostate cancer to be small. But the panel said the prostate-specific antigen, or PSA, test should be offered to them "based on professional judgment and patient preferences."
For men 70 and older, the task force stuck with an earlier recommendation against routine prostate cancer screening.
The new guidance for men in late middle age is an unusual reversal of advice the panel offered in 2012. At that time, the task force suggested that for most men at any age, getting screened for prostate cancer just wasn't worth the risks—including anxiety, infection, erectile dysfunction and incontinence—of the unnecessary treatment that too often came with it.
Since then, the ledger of risks and benefits has changed on both sides.
As large studies have followed men for longer periods of time, researchers have seen that the PSA test can save lives—at least a few more lives than earlier believed—when used to screen men in their late 50s and 60s.
In a European clinical trial, periodic testing was initially found to prevent seven deaths for every 10,000 men screened. But with four years of additional follow-up, researchers have discovered the number of lives saved per 10,000 men screened is closer to 13. And mathematical models suggest that number will likely rise further as the men in the trial get older.
The increase "is not a big number," said Dr. Alex H. Krist, vice chairman of the task force, an independent group that operates under the auspices of the federal Agency for Healthcare Research and Quality. But the new data gave his panel "a little bit more confidence that fewer men would die" when more were screened before age 70.
At the same time, the responses of both doctors and patients to a prostate cancer diagnosis have undergone a significant shift.
In 2012, 90 percent of men who had their diagnosis confirmed with a biopsy were quickly ushered into surgery or treated with radiation, despite growing evidence that many of these cancers would never become dangerous.
Now, no more than 60 percent of such men proceed directly to treatment. The rest begin a process of "active surveillance" in which surgery or radiation is used only if the cancer progresses.
Meanwhile, urologists are using genetic testing, more precisely targeted biopsy procedures and improved imaging techniques to identify the more aggressive prostate tumors that warrant quick action.
Despite efforts to improve prostate cancer treatment, surgery and radiation therapy still exacts a high toll on patients: two out of three men will experience long-term erectile dysfunction, and about 20 percent of those who undergo radical prostatectomy will experience urinary incontinence.
But as more men "watch and wait," fewer men are exposed to the negative effects of treatment that might never have been necessary in the first place.
"That has changed the math of risks and benefits for screening," said Dr. David Penson, who chairs the Department of Urologic Surgery at Vanderbilt University in Nashville and was not involved in the new task force recommendation. "Take that small benefit and then reduce the harms of screening, and suddenly, the equation looks quite different."
In the United States, a man's risk of being diagnosed with prostate cancer at some point in his life is 13 percent, but his risk of dying of the disease is just 2.5 percent. Without screening, many men would never even know they had the disease, which can grow slowly for years. One-third of men who died in their 70s of other causes were found to have had prostate cancer.
For men between 55 and 69, the evolution of both knowledge and medical practice have made the question of whether to get the PSA test a potentially complex judgment call.
"This is what's called a preference-sensitive decision," said Ruth Etzioni, a biostatistician at Seattle's Fred Hutchinson Cancer Research Center who crunched the numbers from two of the largest clinical trials on prostate cancer screening but was not directly involved in setting the new guidelines. "It means the benefits and harms of the decision are going to be different for different people. Screening might be a good decision for you, but your friend may come up with a different decision."
Race would likely be a factor in those deliberations: African American men are nearly twice as likely to die of prostate cancer as white men.
A family history of prostate cancer, and of cancers called adenocarcinomas (which include breast, ovarian, pancreatic and colorectal cancer), also might nudge a man toward regular screening. Smoking, too, is linked to a higher risk of death from prostate cancer.
The task force cautioned, however, that there is insufficient evidence on the role of race and family medical history to draft separate recommendations for subgroups.
"My typical prostate cancer consultation used to be 30 minutes," said Dr. Inderbir S. Gill, chairman of USC's Department of Urology. "Now it's become a one-hour, 15-minute consult, and we're not finished. That's the price of our evolving knowledge."
A man's decision should also take into account such intangibles as his tolerance for uncertainty and his willingness to act in response to an ambiguous threat to his health.
"Don't ask the question if you're not sure what you'll want to do with the result," said Dr. Christopher Saigal, the vice chair of urology at UCLA's Geffen School of Medicine who studies how doctors and patients make decisions about prostate cancer treatment.
Saigal, who was not involved in the task force's deliberations, said he remains convinced that for most men in the designated age group, PSA screening is a sensible choice.
"This is still the most common solid cancer in men, and it's treatable," he said.
But some men are skeptical of screening's value, and others are anxious that any possible threat to their health should be reckoned with head-on. Some have family histories of cancer, and others have so many health issues that a long-term threat like prostate cancer takes a back seat to more immediate concerns.
"The key thing is talking to the man before you draw his blood," Saigal said. Such nuanced discussions take time and time, and in modern medicine, time is in short supply. "We're moving into an era in which personalized medicine and shared decision making is going to come to the forefront. The data is too complex, and people are too complex, for one model to fit everyone."
The new task force recommendations are in line with those of the American Urological Association, which specify that men ages 55 to 69 with a life expectancy of more than 10 to 15 years be informed of screening's benefits and harms. The AUA notes that successive screening tests should be performed at least two years apart.
USC's Gill praised the new recommendations. But he added that the task force was not wrong in issuing its earlier, more skeptical views on prostate screening.
"This group very rightly said in 2008 and 2012, 'You urologists are hurting far more patients than you're helping, and the whole rigamarole starts when you take the PSA,'" Gil said.
"They have certainly stirred soul-searching in the urological community. They have certainly prodded urologists into acknowledging that yes, not every prostate cancer needs to be treated. They have done a great service."

Easy-to-measure grip strength test could help predict major disease risk

Credit: University of Glasgow

Measuring grip strength – a clinical test that is both cheap and easy to perform – could be an important way to identify people who are at high risk for a wide range of diseases.

13 may 2018--New research, led by the University of Glasgow's Institute of Cardiovascular and Medical Sciences and published today in the BMJ, found that lower grip strength was strongly associated with a wide range of poorer health outcomes, including cardiovascular disease and cancer. The study also demonstrated that higher grip strength was associated with a lower risk of all causes of mortality.
The grip strength test only takes a few seconds to do and, the researchers suggest that the addition of this test within clinical practice could improve the prediction ability of an office-based risk score (which currently comprises assessment of age, sex, diabetes status, body mass index, systolic blood pressure, and smoking), by identifying people with low grip strength that might benefit from further health assessments. Researchers believe that this may be of particular use in areas where access to blood biochemical measures, such as cholesterol, is not possible.
Lower muscle strength is already known to be associated with greater mortality and morbidity. However in this study researchers were able to specifically link lower grip strength to a higher incidence of and mortality from, cardiovascular disease, respiratory disease, chronic obstructive pulmonary disease and cancer.
The study looked at 500,293 participants from the UK Biobank and the associations between lower grip strength and adverse health outcomes were consistent between men and women.
Researchers also investigated if the grip strength risk differed by age, and found that the risks associated with low grip strength were slightly stronger in younger age groups. These findings suggest that measuring grip strength could be useful over a broad range of ages.
Lead author Dr. Stuart Gray, Lecturer in Exercise and Metabolic Health, said: "Many studies have already shown that lower muscle strength is associated with greater mortality and morbidity. We wanted to investigate the association of grip strength with the incidence of specific diseases and mortality, and whether grip strength could be used in the clinic to enhance the prediction of an established office-based risk score.
"We found that not only was lower grip strength strongly associated with a broad range of adverse health outcomes, but that it predicted risk of death and cardiovascular disease even more strongly than systolic blood pressure or physical activity."
Dr. Gray said: "Our findings are important because they indicate that the addition of the measurement of grip strength may be useful in screening for risk of cardiovascular disease in community or rural settings, and in developing countries where access to measurements, such as total cholesterol, is not possible.
"Going forward, we need to perform trials which measure grip strength in clinical settings and investigate its effectiveness in risk prediction."
The UK Biobank is made up of 502, 628 participants recruited between April 2007 and December 2010, aged 40-69 years, from the general population across England, Wales, and Scotland.
The paper, "Associations of grip strength with cardiovascular, respiratory, and cancer outcomes and all cause mortality: prospective cohort study of half a million UK Biobank participants," is published in the BMJ.

More information: Yili Wu et al. Association of Grip Strength With Risk of All-Cause Mortality, Cardiovascular Diseases, and Cancer in Community-Dwelling Populations: A Meta-analysis of Prospective Cohort Studies, Journal of the American Medical Directors Association (2017). DOI: 10.1016/j.jamda.2017.03.011


Provided by University of Glasgow

How older patients want to discuss health concerns

Credit: CC0 Public Domain

Nancy Schoenborn, M.D., assistant professor in the Department of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine, and colleagues went straight to the source and conducted three qualitative studies that put older adults at the forefront in order to gain a better understanding of if, and how, they prefer to discuss various health topics.

Let's Talk About Life Expectancy … or Not?

11 may 2018--In a small group study published in November 2017 in the Journal of the American Board of Family Medicine, researchers interviewed 40 older adults on how and when they preferred to discuss life expectancy with their primary care doctor. Schoenborn and team found that 32.5 percent of participants never wanted to discuss their life expectancy, 35 percent were open for discussion if expectancy were longer than one year, and 32.5 percent only wanted to have this discussion toward the end of life. Researchers also found that the majority of the participants, even the ones who never wanted to discuss, were open to be offered the opportunity to discuss life expectancy with their primary care doctor. This research also assessed how the discussion should be phrased when initiating the conversation about life expectancy with older adults.

Frailty Misconceptions

Due to the negative perception of the word "frail," older adults oftentimes overlook frailty as a medical syndrome. Researchers at Johns Hopkins Medicine conducted the first study in the United States that explored older adults' perception of frailty. It was published on Feb. 13, 2018, in BMC Geriatrics.
In a study of 29 participants, Schoenborn and team conducted focus groups with participants in various frailty statuses (frail, prefrail, nonfrail) and at different ages to evaluate existing ideas about frailty. Three major themes were established through this research. First, older adults' ideas about frailty were different from the medical definition of frailty. Many of the participants associated old age with frailty, but not everyone who ages develops the medical syndrome of frailty. Second, participants who were in the nonfrail or prefrail stages were strongly against discussing frailty with their physicians. However, frail participants were more open to having the discussion, but without being labeled "frail." Third, participants in all frailty statuses wanted information regarding prevention of frailty or ways to improve their current condition. This study provides insight on how older adults perceive frailty, but further research needs to be conducted to understand the proper way in which physicians should communicate about frailty.

To Stop or Not to Stop Cancer Screening in Older Adults

Screening for cancer in older adults with limited life expectancy can oftentimes be more harmful than beneficial. However, studies have shown that clinicians may feel uncomfortable stopping cancer screenings on patients with limited life expectancy. In a study published on Aug. 1, 2017, in JAMA Internal Medicine, Schoenborn and other Johns Hopkins researchers conducted interviews with 40 older adults who were 65 years or older to understand what this population thought about stopping cancer screening when life expectancy is limited. Researchers found that the participants were open to considering cessation of cancer screenings. In addition, their willingness to consider stopping screenings was dependent on trusting their physicians. The participantsexpressed that they would commend their physicians for even providing this option. This study showed that older adults do not use life expectancy as a factor when deciding to stop screening; they are more likely to use age and health status to make this decision. Even though life expectancy was not used as a factor when deciding, the group was divided on whether or not physicians should discuss life expectancy in the cancer screening conversation. Researchers also found that the way a physician words the message about life expectancy is very important during the discussion about cancer screening cessation.

More information: Nancy L. Schoenborn et al. Older adults' perceptions and informational needs regarding frailty, BMC Geriatrics (2018). DOI: 10.1186/s12877-018-0741-3

Nancy L. Schoenborn et al. Older Adults' Preferences for When and How to Discuss Life Expectancy in Primary Care, The Journal of the American Board of Family Medicine (2017). DOI: 10.3122/jabfm.2017.06.170067


Provided by Johns Hopkins University

104-year-old Australian breaks into joyful song as he awaits death

Australian scientist David Goodall, 104, does not have a terminal illness but says his quality of life has deteriorated and that he wants to die

A 104-year-old Australian scientist burst into song Wednesday as he told a roomful of journalists that he was looking forward to finally being allowed to end his life.

10 may 2018--David Goodall does not have a terminal illness but says his quality of life has deteriorated significantly in recent years and that he wants to die.
"I no longer want to continue life," Goodall told the dozens of journalists and television crews who had crammed into a small room at a hotel in the northern Swiss city of Basel to hear him speak.
"I am happy to have the chance tomorrow to end it, and I appreciate the help of the medical profession here in making that possible," he said.
When asked whether he had chosen any music to listen to in his finally moments, he said he hadn't thought about it.

Ode to Joy

"But if I had to choose something, I think it would be the final movement of Beethoven's ninth symphony," he said, before belting out a verse from the Ode to Joy, in German, to loud applause.
Goodall was barred from seeking help to end his life in Australia, so he was forced to travel to Switzerland, something he has said he resents.
"I would have preferred to have (ended) it in Australia, and I greatly regret that Australia is behind Switzerland" when it comes to right-to-die laws, he said.
The 104-year-old said he hoped the widespread interest in his case would spur Australia and other countries to rethink their legislation.

An instrument for change?

"I would quite like to be remembered as an instrument of freeing the elderly from the need to pursue their life irrespective," he said.
The honorary research associate at Perth's Edith Cowan University set off from Australia a week ago, and stopped in Bordeaux, France to see family before arriving in Basel on Monday.
He was speaking alongside Philip Nitschke, the founder of Exit International which helped him make his final journey, and Moritz Gall of Eternal Spirit, the Swiss foundation that has agreed to help him die.
Goodall secured a fast-track appointment with the foundation after he attempted but failed to commit suicide on his own earlier this year.
"It would have been much more convenient for everyone if I had been able to, but unfortunately it failed," he said of the suicide attempt.
But he said he was happy that he had been offered the "Swiss option", since he has been able to see most of his large family, which is spread over several countries, in the run up to his final day.
Assisted suicide is illegal in most countries and was banned in Australia until the state of Victoria became the first to legalise the practice last year.
But that legislation, which takes effect in June 2019, only applies to terminally ill patients of sound mind and a life expectancy of less than six months.
According to Swiss law meanwhile, anyone who is of sound mind and who has over a period of time voiced a consistent wish to end their life can request so-called assisted voluntary death, or AVD.
Eternal Spirit, one of several foundations in Switzerland that assist people who want to end their lives, said Wednesday that Goodall had undergone two medical visits by different doctors since arriving in the city.

No hesitation

"Tonight the board of the foundation will study the documents and also judge the wish to die of David Goodall," Eternal Spirit head Erika Preisig said in an email, adding that the answer would "likely" be yes.
But Gall stressed to reporters that Goodall had the option until the very last minute to back down if he changed his mind.
Asked if he had any hesitations or doubts, the 104-year-old said: "No. None whatsoever."
In assisted dying, the person must be physically capable of carrying out the final deed on their own.
Most Swiss foundations ask patients to drink sodium pentobarbital, an effective sedative that in strong enough doses causes the heart muscle to stop beating.
Since the substance is alkaline and burns a bit when swallowed, Eternal Spirit has instead opted for intravenous infusions.
A professional prepares the needle, but it is up to the patient to open the valve that allows the short-acting barbiturate to mix with a saline solution and begin flowing into their vein.
Goodall said he expected his death to take place around noon on Thursday.
Exit International and Eternal Spirit are advocating for all countries to introduce systems similar to the Swiss one, allowing people to choose to die "in dignity".
"This is a human right, to be able to make an elected decision by a rational adult to take this step," Nitschke said.

Australia's oldest scientist heads to Switzerland to end life

Australia's oldest scientist, wearing a top labelled "ageing disgracefully", has left the country for Switzerland to end his life at the age of 104, saying he is resentful that he must go overseas to die.

10 may 2018--David Goodall does not have a terminal illness but his quality of life has deteriorated and he has secured a fast-track appointment with assisted dying agency Life Circle in Basel.
He got on a plane in Perth late Wednesday surrounded by friends and family saying their final goodbyes, euthanasia advocates told AFP.
He will spend several days with other family in Bordeaux, France, before heading to Switzerland where he is due to end his life on May 10.
"I don't want to go to Switzerland, though it's a nice country," he told broadcaster ABC before leaving.
"But I have to do that in order to get the opportunity of suicide which the Australian system does not permit. I feel very resentful."
Assisted suicide is illegal in most countries around the world and was banned in Australia until the state of Victoria became the first to legalise it last year.
But that legislation, which takes effect from June 2019, only applies to terminally ill patients of sound mind and a life expectancy of less than six months.
Other states in Australia have debated euthanasia in the past, but the proposals have always been defeated, most recently in New South Wales state last year.
Exit International, which helped Goodall make the trip, said it was unjust that one of Australia's "oldest and most prominent citizens should be forced to travel to the other side of the world to die with dignity".
It launched a GoFundMe campaign to get plane tickets for Goodall and his helper upgraded to business class from economy and quickly raised more than Aus$20,000 (US$15,000).
Goodall, an honorary research associate at Perth's Edith Cowan University, made international headlines in 2016 when he was declared unfit to be on campus.
After an uproar and support from scientists globally, the decision was reversed.
He has produced dozens of research papers and until recently continued to review and edit for different ecology journals.
Goodall told ABC he appreciated the public's interest in his plight and hoped it would spark more discussion about voluntary euthanasia.
"I would like them to understand it," he said.
"I am 104 years old so I haven't got much time left anyway. I might as well not have (my health) getting worse and worse, making me unhappy as it goes."

Study reveals that people who travel by car are four times more likely to be injured than people who travel by city bus

Credit: CC0 Public Domain

Taking the bus is a whole lot safer than taking the car - and it's also safer for cyclists and pedestrians who take the same routes, according to a new study led by the Université de Montréal Public Health Research Institute (IRSPUM).

09 may 2018--Published in the Journal of Urban Health, the study looked at the risk of injury along the 10 busiest bus routes on the island of Montreal and showed that the risk is four times greater for car occupants than for bus occupants.
Besides looking at specific routes, the study is the first to compare the effect of car and bus use on the safety of pedestrians and cyclists. Per kilometre travelled, car trips were associated with a greater number of pedestrian injuries (four times more), cyclist injuries (five times more), and fatal and severe injuries (five times more) compared to bus trips.
There were 28 times more seriously injured people in cars (278 over 10 years, including 19 deaths) than bus occupants (10 seriously injured, no deaths). Forty-two pedestrians and three cyclists were killed by cars, versus four pedestrians and zero cyclists by bus.
Why is bus travel safer? For one, drivers are professionally trained. Second, they drive more slowly than cars. Third, buses travel along designated routes and usual stick to the right lane, which make them more predictable in traffic. Fourth, far fewer buses than cars are needed to transport the same number of people.
In Montreal, a shift towards public transit will help reduce the number of injuries, the study argues. For the period studied, 2001 to 2010, it estimates that bus travel along these 10 routes saved 1,805 vehicle occupants, 156 cyclists and 476 pedestrians from injury.
"The fundamental point is that pedestrians, cyclists and motor-vehicle occupants are mostly injured where the speeds are highest and where there are the most vehicles, on the major arteries," said lead author Patrick Morency.
"The solution? Permanent structure to reduce speeds, and public transit,' said Morency, an assistant clinical professor at IRSPUM who works at the Montreal Public Health Department.
Helped by colleagues there and along with others at the Réseau de transport métropolitain (RTM) and the Sociéte de transport de Montréal (STM), Morency looked at weekday collision and injury data compiled in police reports to Quebec's automobile insurance board, the SAAQ, between 2001 and 2010. During that period, car travel on the 10 routes accounted for four times as many passenger kilometres annually than bus travel: 1.3 billion versus 257 million.
(Car travel was actually much higher, since the data include all vehicles and don't differentiate cars from heavy trucks and buses.)
The busiest car and bus routes were along Henri-Bourassa Blvd., Sherbrooke St. and Côte Vertu Blvd. and Sauvé St. But those weren't the most dangerous routes; the highest injury rates in cars were seen along Jarry St., Jean-Talon Blvd. and Beaubien St. The highest cyclist injury rates associated with car travel were Beaubien, Jarry and Sherbrooke; for pedestrians, Beaubien, Jarry and Jean-Talon. Lacordaire Blvd. and (involving pedestrians) Pie-IX Blvd. were also in the top 3 for bus accidents.
Although newer injury data, up to 2016, is available, precise traffic data for the routes studied were not, and so the current research had to be limited to 2001-2010, Morency said. He is now working with Jillian Strauss and Catherine Morency (Polytechnique Montréal) on compiling figures not only for the 10 busiest routes but also for the Montreal metropolitan area. In the meantime, he has presented his latest study to Montreal transit officials, and hopes they'll use the analysis in public-information campaigns touting not just the savings but also the safety of traveling by bus.

More information: Patrick Morency et al, Traveling by Bus Instead of Car on Urban Major Roads: Safety Benefits for Vehicle Occupants, Pedestrians, and Cyclists, Journal of Urban Health (2018). DOI: 10.1007/s11524-017-0222-6


Provided by University of Montreal

Neuroimaging research demonstrates how the brain translates altruism into feelings of thankfulness

Experiment procedure and behavioral results.(A) At the beginning of each trial, the participants were (ostensibly) paired with one of three co-players. Then the participants saw a pain-money pair and waited for the co-player's decision. If the coplayer chose Help, then the co-player lost the corresponding amount of bonus while the participants would be exempted from the pain stimulation on this trial. If the coplayer chose NoHelp, then the co-player could keep the bonus while the participants had to receive the corresponding pain stimulation. The presentation of the co-player'sdecision was defined as the critical events in the fMRI data analysis. At the end of the trial, the participant could allocate 20 Yuan (? 3 USD) between him/herself and the co-player, with the knowledge that the co-player was not aware of this procedure.(BC) Post-scan gratitude rating and allocation during scanning (i.e., reciprocity) as a function of self-benefit and benefactor-cost.(D) Relative weight of benefactor-cost over self-benefit in gratitude rating. Credit: Yu et al., JNeurosci (2018)

A brain network that gives rise to feelings of gratitude has been uncovered in new research published in JNeurosci. The study could spur future investigations into how these "building blocks" transform social information into complex emotions.

08 may 2018--Previous neuroimaging research in which participants imagined themselves as survivors of the Holocaust who received food, shelter and clothing from strangers identified the medial prefrontal cortex and perigenual anterior cingulate cortex (pgACC) as brain regions associated with gratefulness. However, it remains unclear how these parts of the brain translate such altruism into gratitude.
Xiaolin Zhou and colleagues addressed this question by having participants play a social interactive game in which their partner would decide whether to pay different sums of money to in order to prevent the participant from receiving a pain stimulation.
By manipulating the pain intensity and cost to the partner to help the participant, the researchers found that partner cost activated brain regions involved in mentalizing while levels of pain reduction were encoded in regions involved in reward representation.
Connectivity analyses revealed that these regions feed information to pgACC, which tracked feelings of gratitude over time.
Their findings indicate that gratitude may arise from the integration of relevant social information in pgACC.

More information: Decomposing gratitude: representation and integration of cognitive antecedents of gratitude in the brain, JNeurosci (2018). DOI: 10.1523/JNEUROSCI.2944-17.2018


Provided by Society for Neuroscience

High prevalence of atherosclerosis found in lower risk patients

Image shows examples of whole-body angiograms. A, Normal study with no disease evident in a 45-year-old woman. B, Evidence of extensive disease including left carotid bulb stenosis (black arrow), bilateral renal artery stenosis (white arrows), and occluded right superficial femoral artery (arrowhead) in a 53-year-old woman. Credit: Radiological Society of North America

Researchers using whole-body magnetic resonance angiography (MRA) have found a surprisingly high prevalence of atherosclerosis in people considered to be at low to intermediate risk for cardiovascular disease, according to a study appearing online in the journal Radiology. Almost half of all study participants had at least one narrowed artery.

06 may 2018--Atherosclerotic disease is characterized by a narrowing of the arteries caused by plaque buildup. The condition often progresses to cardiovascular disease, the leading cause of death in the United States. Early intervention can slow or reverse disease progression, but standard imaging techniques for early detection focus on specific artery segments, potentially missing evidence of disease elsewhere in the body.
Whole-body MRA allows clinicians to take a broader view of the vascular system.
"The key advantages of this MRA technique include the 'whole-body' approach, which detects systemic disease that would be missed by modalities assessing single vascular sites," said study co-author Graeme Houston, M.D., from the University of Dundee in Dundee, Scotland. "The results offer a validated quantitative score of atherosclerotic burden, and the technique does not use ionizing radiation, which is an advantage over CT angiography."
Professor Houston and colleagues used whole-body MRA to quantify the burden and distribution of asymptomatic atherosclerosis in 1,513 people, average age 53.5 years old. The participants were considered in the low-intermediate risk group, with a 10-year cardiovascular disease risk of less than 20 percent. The researchers assessed 31 arterial segments in each participant.
The plaque burden, or overall amount of atherosclerotic plaque, and number of narrowed vessels correlated with age, blood pressure and cholesterol—all known risk factors for cardiovascular events like heart attacks. But the prevalence of atherosclerosis in the study group was surprisingly high. Almost half of the participants had at least one narrowed vessel, and more than a quarter had multiple narrowed vessels.
"This is surprising, given that the study group was made up of asymptomatic individuals without diabetes who had low to intermediate risk of future cardiovascular events by standard risk factor assessment," Prof. Houston said.
With whole-body MRA, the researchers were able to detect early atherosclerotic disease throughout the body, disease that would have been missed by methods that evaluate only a single vascular territory. The technique's high technical success rate—researchers were able to interpret 99.4 percent of the potentially analyzable arterial segments—underscores its potential for more widespread use.
"The results confirm the feasibility for MRA as an imaging method for detecting early atherosclerotic disease in individuals at low to intermediate risk of cardiovascular events," Prof. Houston said. "This approach could stratify individuals for the presence of disease burden, which could inform further preventative therapy in the future."
The researchers plan to conduct follow-up studies to look for links between whole-body MRA findings and long-term health outcomes.

More information: "Prevalence and Distribution of Atherosclerosis in a Low- to Intermediate-Risk Population: Assessment with Whole-Body MR Angiography" Radiology, 2018.


Provided by Radiological Society of North America

Caregivers can help assess whether older adults are dealing with delirium

Delirium is a sudden change in mental status that often occurs when older adults are in the hospital or after they have surgery. More than 20 percent of older adults may experience delirium. The condition can lead to longer hospital stays, the need to be placed on a respirator (a machine that helps you breathe), long-term changes in your cognitive (mental) health, physical disability, and even death.

05 may 2018--Acute illness (illnesses that happen suddenly, as opposed to chronic conditions that you live with over a longer period of time), surgery, and medications can contribute to delirium. In addition, disrupting regular routines may trigger sudden confusion or changes in behavior for certain people.
When healthcare professionals don't recognize or diagnose delirium, it can delay an older person's recovery. Prolonged delirium can have a lasting impact on health and well-being. What's more, delirium is distressing for caregivers—the family or friends involved in caring for an older adult. In hospitals, healthcare professionals screen ("test") for delirium. However, despite routine screening, more than 60 percent of older adults with delirium are not diagnosed in hospitals.
In a new study, published in the Journal of the American Geriatrics Society, researchers set out to learn whether caregivers could use existing questionnaires and other tools to detect delirium on their own. The researchers reviewed 6,056 scientific papers about delirium screening. They specifically were looking for proven methods that caregivers could use in home settings.
The researchers identified six tools that caregivers could use. Each one took just several minutes or less to use and had 11 items or fewer to complete. Three tools could be completed by the caregiver alone.
According to the researchers, using these caregiver-centered delirium detection tools, caregivers are generally able to identify delirium symptoms more easily than healthcare professionals who may be less familiar with the person being evaluated. Having caregivers test a person for delirium also makes it easier for the caregiver to be alert for delirium throughout a person's hospital stay. As a result, caregivers may be able to notify healthcare professionals of changes in mental status sooner, potentially leading to earlier and more frequent diagnoses for older people under their care. Engaging caregivers in delirium detection may also decrease caregiver distress. Many studies have shown that caregiver involvement in health care helps improve patient and caregiver outcomes.
Overall, caregiver-centered delirium detection tools enable caregivers to improve delirium detection. The tools can help to reduce the challenges that can accompany undiagnosed delirium. No risks associated with these tools have been reported. The researchers suggest that future studies should monitor caregiver use of delirium detection tools.

More information: Brianna Rosgen et al, Validation of Caregiver-Centered Delirium Detection Tools: A Systematic Review, Journal of the American Geriatrics Society (2018). DOI: 10.1111/jgs.15362


Provided by American Geriatrics Society

Sex after 65: Poll finds links to health, gender differences, lack of communication

Key findings from the May 2018 National Poll on Healthy Aging report, on sexual health after age 65. Credit: University of Michigan

A new poll busts stereotypes about the sex lives of older Americans—and reveals gender and health-related divides on key aspects of sexual health, while highlighting the need for more people to talk with their health providers about sexual issues.

04 may 2018--Forty percent of people between the ages of 65 and 80 are sexually active, according to the new findings from the National Poll on Healthy Aging. Nearly three-quarters of people in this age range have a romantic partner and 54 percent of those with a partner are sexually active.
Whether or not they have an active sex life, nearly two-thirds of older adults say they're interested in sex, and more than half say sex is important to their quality of life.
And when asked if they are satisfied with their current sex life, 73 percent of the nationally representative sample of 1,002 people polled said they were. The poll was conducted by the University of Michigan Institute for Healthcare Policy and Innovation, and sponsored by AARP and Michigan Medicine, U-M's academic medical center.
The poll explored how older adults might seek help or advice for sexual problems, and if they've talked with their doctors about their sexual health.
In all, 18 percent of older men and 3 percent of older women say they've taken medications or supplements to improve sexual function in the past two years. But only 17 percent of older adults said they have talked with their doctor or other health care provider about sexual health in the past two years. Most who had engaged in such discussions said they brought the topic up, suggesting the need for more proactive conversations by clinicians with their older patients.
"Sexual health among older adults doesn't get much attention but is linked closely to quality of life, health and well-being," says U-M's Erica Solway, Ph.D., co-associate director of the poll. "It's important for older adults and the clinicians who care for them to talk about these issues and about how age-related changes in physical health, relationships, lifestyles and responsibilities such as caregiving, affect them."

Key findings from the May 2018 National Poll on Healthy Aging report, on sexual health after age 65. Credit: University of Michigan

Gender, age and health status divides
Solway notes that the poll finds some sharp differences along health, age and gender lines.
For instance, compared with the 45 percent of respondents with excellent, very good, or good health who reported they were sexually active, only 22 percent of those who said they are in fair or poor health were sexually active. Only 28 percent of those with fair or poor health said they were extremely or very satisfied with their sex lives.
There are also differences within age groups. Those between the ages of 65 and 70 were nearly twice as likely as those in their late 70s to be sexually active. One-third of those in their late 60s said they were extremely or very interested in sex, compared with 19 percent of those in their late 70s.
The gender gaps that emerged reveal some differences that may create challenges for relationships. For instance, women were less likely than men to be sexually active—31 percent overall, compared with 51 percent of men—but were more likely to be extremely or very satisfied with their sex lives. And while 84 percent of older men said sex was an important part of a romantic relationship, 69 percent of older women agreed with that statement.
But the biggest gender difference was the percentage of those who said they were extremely or very interested in sex. Half of men aged 65 to 80 said they had this level of interest, compared with just 12 percent of women in the same age range.
"This survey just confirms that the need for and interest in sexual intimacy doesn't stop at a certain age," says Alison Bryant, Ph.D., senior vice president of research for AARP. "Although most older adults say that they would talk with their doctor about sexual concerns, health care providers should routinely be asking all of their older patients about their sexual health and not assume that bringing up the issue will offend or embarrass them."
A key takeaway from the poll, Solway notes, is that there appears to be opportunity for more proactive conversations between providers and their older patients about sexual health.
In all, 62 percent of the older adults polled said that if they were having a problem with their sexual health, they would talk with their health provider about it, yet only 17 percent had actually done so in the past two years. The majority (88 percent) of those who had talked with their provider about their sexual health said they were comfortable doing so.
The poll results are based on answers from a nationally representative sample of 1,002 people ages 65 to 80. The poll respondents answered a wide range of questions online. Questions were written, and data interpreted and compiled, by the IHPI team. Laptops and Internet access were provided to poll respondents who did not already have it.

More information: A full report of the findings and methodology is available at www.healthyagingpoll.org , along with past National Poll on Healthy Aging reports.


Provided by University of Michigan

Blood pressure readings often higher outside doctor's office

Blood pressure readings taken outside of the doctor's office often read higher than those in the office, a new study says. Spanish researchers found that 39 percent of people who had normal blood pressure readings at the doctor registered high blood pressure readings out of the office over a 24-hour period when using American Heart Association/American College of Cardiology treatment guidelines.

03 may 2018--The researchers found that 20 percent had high blood pressure when doing out-of-office readings under European blood pressure criteria.
The phenomena of people registering normal at the doc but higher at home or the office is called "masked hypertension." The AHA/ACC and European guidelines both warn of the dangers of the condition and the need for improved treatment.
Masked hypertension comes with stark implications because it isn't diagnosed by a routine medical examination and brings an adverse prognosis of organ damage or heart disease, stroke or other cardiovascular diseases if it continues to go unrecognized.
Cardiovascular disease has been the leading cause of death in the United States for more than half a century. From 2005 to 2015, the death rate attributable to high blood pressure increased by about 10 percent.
Males, younger people who are active or those with additional cardiovascular risk factors are most at risk for high blood pressure that isn't apparent at the doctor's office, according to the study published April 30 in the American Heart Association journal Circulation.
High blood pressure is defined as a systolic pressure of 130 or above, or a diastolic pressure of 80 or above, according to AHA/ACC treatment guidelines. The target guideline from the European Society of Hypertension and the European Society of Cardiology is generally 140/90.
Among people treated for high blood pressure, masked hypertension "is often seen in those who seem apparently controlled, but signs of silent organ damage are still present," said study author Dr. Alejandro de la Sierra. He heads the Internal Medicine Department at Hospital Mutua Terrassa at the University of Barcelona in Spain.
The high prevalence of masked hypertension was observed in the study of 115,708 people who were monitored for 24 hours using devices. Their blood pressure was measured every 20 minutes during the day and every 30 minutes at night. Those in the study are part of the Spanish Ambulatory Blood Pressure Measurements registry.
The study supports a wider use of blood pressure monitoring at regular intervals in routine clinical practice. Both guidelines recommend such screening for masked hypertension for people who are at risk.
The possible barriers to doing that include out-of-pocket costs, test accuracy and instruction time.
But the payoff is there, said Dr. Willie Lawrence, an interventional cardiologist for Midwest Heart and Vascular Specialists at Research Medical Center in Kansas City, Mo. Lawrence recommends 24-hour monitoring, which is more widely applicable than other types of blood pressure monitoring.
"Twenty-four-hour monitoring is a great research tool and it's very valuable in select clinical situations. It allows us to better understand how to use more basic tools to detect and treat large populations under various circumstances," he said.
Dr. Robert Eckel, an endocrinologist and physician-scientist at the University of Colorado Anschutz Medical Campus, agreed that more measurements provide more insight.
"Ambulatory measurements are valuable but should be performed carefully using the right equipment and if possible under optimal conditions," he said. "Moreover, 24-hour assessments are always better than one to three measurements per day."

Primary care can effectively manage obstructive sleep apnea

Primary care management of obstructive sleep apnea (OSA) is as effective and more cost-effective than in-laboratory diagnosis, according to a study published online April 17 in the American Journal of Respiratory and Critical Care Medicine.

02 may 2018--M. Ángeles Sánchez-Quiroga, M.D., from Virgen del Puerto Hospital in Madrid, and colleagues randomized 303 sequentially screened patients with an intermediate-to-high probability of OSA to primary care management (a portable monitor with automatic scoring and semi-automatic therapeutic decision-making) or in-laboratory management (polysomnography and specialized therapeutic decision-making). All patients received continuous positive airway pressure treatment or sleep hygiene and dietary treatment alone.
The researchers found that the primary care protocol was noninferior to the in-laboratory protocol based on use of the Epworth sleepiness scale. Furthermore, primary health care management was more cost-effective, with a lower cost of €537.8 per patient.
"Primary health care area management may be an alternative to in-laboratory management for patients with an intermediate to high OSA probability," the authors write. "Given the clear economic advantage of outpatient management, this finding could change established clinical practice."

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

Following five healthy lifestyle habits may increase life expectancy by decade or more

Credit: CC0 Public Domain

Maintaining five healthy habits—eating a healthy diet, exercising regularly, keeping a healthy body weight, not drinking too much alcohol, and not smoking—during adulthood may add more than a decade to life expectancy, according to a new study led by Harvard T.H. Chan School of Public Health.

01 may 2018--Researchers also found that U.S. women and men who maintained the healthiest lifestyles were 82% less likely to die from cardiovascular disease and 65% less likely to die from cancer when compared with those with the least healthy lifestyles over the course of the roughly 30-year study period.
The study is the first comprehensive analysis of the impact of adopting low-risk lifestyle factors on life expectancy in the U.S. It will be published online April 30, 2018 in Circulation.
Americans have a shorter average life expectancy—79.3 years—than almost all other high-income countries. The U.S. ranked 31st in the world for life expectancy in 2015. The new study aimed to quantify how much healthy lifestyle factors might be able to boost longevity in the U.S.
Harvard Chan researchers and colleagues looked at 34 years of data from 78,865 women and 27 years of data from 44,354 men participating in, respectively, the Nurses' Health Study and the Health Professionals Follow-up Study. The researchers looked at how five low-risk lifestyle factors—not smoking, low body mass index (18.5-24.9 kg/m²), at least 30 minutes or more per day of moderate to vigorous physical activity, moderate alcohol intake (for example, up to about one 5-ounce glass of wine per day for women, or up to two glasses for men), and a healthy diet—might impact mortality.
For study participants who didn't adopt any of the low-risk lifestyle factors, the researchers estimated that life expectancy at age 50 was 29 years for women and 25.5 years for men. But for those who adopted all five low-risk factors, life expectancy at age 50 was projected to be 43.1 years for women and 37.6 years for men. In other words, women who maintained all five healthy habits gained, on average, 14 years of life, and men who did so gained 12 years, compared with those who didn't maintain healthy habits.
Compared with those who didn't follow any of the healthy lifestyle habits, those who followed all five were 74% less likely to die during the study period. The researchers also found that there was a dose-response relationship between each individual healthy lifestyle behavior and a reduced risk of early death, and that the combination of all five healthy behaviors was linked with the most additional years of life.
"This study underscores the importance of following healthy lifestyle habits for improving longevity in the U.S. population," said Frank Hu, chair of the Department of Nutrition at Harvard Chan School and senior author of the study. "However, adherence to healthy lifestyle habits is very low. Therefore, public policies should put more emphasis on creating healthy food, built, and social environments to support and promote healthy diet and lifestyles."

More information: "The Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population," Yanping Li, An Pan, Dong D. Wang, Xiaoran Liu, Klodian Dhana, Oscar H. Franco, Stephen Kaptoge, Emanuele Di Angelantonio, Meir Stampfer, Walter C. Willett, Frank B. Hu, Circulation, April 30, 2018, DOI: 10.1161/CIRCULATIONAHA.117.032047


Provided by Harvard T.H. Chan School of Public Health