Ketamine for depression encouraging, but questions remain around long-term use

3-D model of Ketamine. 

A world-first systematic review into the safety of ketamine as a treatment for depression, published in the prestigious Lancet Psychiatry, shows the risks of long-term ketamine treatment remain unclear.
Led by researchers from UNSW Sydney and Black Dog Institute, the review examined all prior published studies of ketamine treatment for depression, and finds few existing studies effectively report the safety of repeated doses or sustained use.


29 july 2017--Ketamine research leader UNSW Professor Colleen Loo, who is based at the Black Dog Institute, said these major gaps in the literature must be addressed before ketamine is widely adopted as a clinical treatment for depression.
"Despite growing interest in ketamine as an antidepressant, and some preliminary findings suggesting its rapid-acting efficacy, to date this has not been effectively explored over the long term and after repeated dosing," said Professor Loo, a co-author of the study.
"As ketamine treatment will likely involve multiple and repeated doses over an extended time period, it is crucial to determine whether the potential side effects outweigh the benefits to ensure it is safe for this purpose."
The review follows research revealed earlier this week, which provided preliminary evidence of promising results for ketamine delivered to elderly patients in repeated intravenous doses.
Globally, ketamine is increasingly being used off-label to treat severe and treatment-resistant depression. Also known by its party drug name 'Special K', ketamine is not approved for use in Australia, but has Therapeutic Goods Administration (TGA) approval as an anaesthetic.
Researchers in the current study trawled the literature on ketamine for depression to identify its main side effects and whether these differed between single or repeated dosing. They analysed 288 articles, of which 60 studies met the inclusion criteria, which encompassed a total of 899 patients who had received at least one dose of ketamine.
The results show that despite acute side effects commonly occurring after a single treatment of ketamine, not all studies actively monitored for or reported on them. Side effects were more likely to occur when ketamine was given intravenously, and were usually reported on immediately following a single dose.
The most common side effects reported in the literature were headache, dizziness, dissociation, elevated blood pressure and blurred vision. This is consistent with side effects reported in existing user groups - recreational drug users or those prescribed ketamine for chronic pain. However, most studies only reported on side effects in an ad-hoc way, with a lack of conclusive data available into ketamine's longer-term or cumulative effects.
"Despite low ketamine doses currently being used in depression studies, urological toxicity, liver function abnormalities, negative cognitive affects and risk of dependency may limit the safe use of ketamine as a long-term antidepressant treatment," the authors state.
Previous studies have linked longer-term ketamine use to bladder inflammation, liver damage, cognitive changes like memory loss, and craving or addiction. Very few studies have examined human ketamine dependence, with less than 15 cases described in the scientific literature over the past 20 years.
"Our study also raises questions over the risk of administering ketamine in patients with pre-existing or co-morbid medical conditions, such as those with a history of high blood pressure or heart disease," said Professor Loo.
"For instance, we know that when used to treat chronic pain, ketamine is associated with acute blood pressure changes, and experts recommend lower doses administered through slower-acting, non-intravenous means accordingly."
Future ketamine-related depression studies should focus on assessing the safety of repeated dosing regimes, consider co-morbid physical health factors, and actively assess and report on potential side effects in a systematic way, the authors recommend.
The research team are now developing a new tool to standardise future reporting on these side effects, called the Ketamine Side Effect Tool (K-SET) and Ketamine Safety Screening Tool (KSST), to address inconsistencies in the literature.
Professor Colleen Loo is also currently leading the world's largest independent trial of ketamine to treat depression, testing its effects after twice-weekly treatments over a period of four weeks amongst 200 participants.

More information: Lancet Psychiatry (2017). www.thelancet.com/journals/lan … ulltext?elsca1=tlxpr


Provided by University of New South Wale

World-first ketamine trial shows promise for geriatric depression

Australian researchers have completed the world's first randomised control trial (RCT) assessing the efficacy and safety of ketamine as a treatment for depression in elderly patients.
The results, published in the latest American Journal of Geriatric Psychiatry, provide preliminary evidence suggesting ketamine's effectiveness as an antidepressant when delivered in repeated intravenous doses.

28 july 2017--Led by a team of researchers from UNSW Sydney and Black Dog Institute, the trial tested different doses of ketamine among 16 older age participants (aged over 60 years) who had treatment-resistant depression, administered at Wesley Hospital.
"These findings take us a big step forward as we begin to fully understand the potential and limitations of ketamine's antidepressant qualities," said lead author UNSW Professor Colleen Loo, who is based at Black Dog Institute.
"Not only was ketamine well-tolerated by participants, with none experiencing severe or problematic side effects, but giving the treatment by a simple subcutaneous injection (a small injection under the skin) was also shown to be an acceptable method for administering the drug in a safe and effective way."
Participants received increasing doses of ketamine over a period of five weeks, with doses optimised for each individual participant using a new dose-titration approach developed by Professor Loo's Sydney research team and collaborators.
As part of the double-blind, placebo-controlled trial, an active control treatment which causes sedation similar to ketamine, was used to substitute for one of the treatment sessions. Researchers monitored for mood and other side-effects after each treatment session.
Following the RCT, participants also received 12 ketamine treatments in an open-label phase to investigate the effectiveness of multiple doses of ketamine.
By the six-month follow-up, 43% of participants (7 of 14) who completed the RCT had entered remission, with five remitting at amounts below the commonly-used dose of 0.5 mg/kg. Repeated treatments also resulted in a higher likelihood of remission or a longer time to relapse, with an overall response and remission rate of 68.8% for the patients receiving ketamine treatment.
"Elderly patients with severe depression face additional barriers when seeking treatment for the condition. Many medications may cause more side effects or have lower efficacy as the brain ages," said co-author Dr Duncan George from UNSW.
"Older people are also more likely to have co-morbidities like neurodegenerative disorders and chronic pain, which can cause further complications due to ketamine's reported side effects.
"Our results indicate a dose-titration method may be particularly useful for older patients, as the best dose was selected for each individual person to maximise ketamine's benefits while minimising its adverse side effects."
Previous studies into ketamine treatments for older people with depression – which are limited to just five case reports – show mixed success, with findings limited by small sample sizes.
More broadly, little is known about ketamine's potential side effects at different doses, which include cognitive and dissociative effects, elevated blood pressure and heart rate, liver inflammation and urinary problems.
"These results are a promising early piece of the puzzle, but the risks of ketamine use are still not wholly understood. Future studies with greater sample sizes are needed to formally assess ketamine's side effects, such as its impact on liver function," Professor Loo added.

More information: Duncan George et al. Pilot Randomized Controlled Trial of Titrated Subcutaneous Ketamine in Older Patients with Treatment-Resistant Depression, The American Journal of Geriatric Psychiatry (2017). DOI: 10.1016/j.jagp.2017.06.007


Provided by University of New South Wales

New global aging index gauges health and wellbeing of aging populations

The five countries in the index coping best with their aging populations are: Norway, Sweden, the United States, the Netherlands and Japan. Credit: John A. Hartford Foundation Index of Societal Aging

27 july 2017--Researchers from Columbia University's Mailman School of Public Health and University of Southern California Schaeffer Center for Health Policy & Economics, with the support of The John A. Hartford Foundation, have developed a new barometer that estimates how countries are adapting to the dramatic increases in the number and proportion of older persons. The Index is composed of specific measures across five social and economic Indicators that reflect the status and wellbeing of older persons in a country and which can be followed over time and used to compare across nations.
"Now that previously unimagined numbers of older persons are living longer it is critical that we shift from our prior sole focus on the characteristics of individuals and their immediate environments to one that includes a strategy for the entire society to successfully adapt to an aging population" said John Rowe, MD, Julius B. Richmond Professor of Health Policy and Aging, Health Policy and Management at the Mailman School of Public Health, who led the interdisciplinary team of researchers.
Developed for 30 countries at the outset, the Index can track national sources of data for countries with aged populations including the United States and Western Europe. A sample analysis of the data shows that the five countries in the index coping best with their aging populations are: Norway, Sweden, the United States, the Netherlands and Japan. (See chart)
"Interestingly, the Index demonstrates that the United States - despite general problems with inequity and social cohesion - has done well in keeping older Americans financially secure, productive, and engaged," noted Dana Goldman, PhD, Distinguished Professor and Leonard D. Schaeffer Director's Chair at the USC Schaeffer Center for Health Policy & Economics.
The John A. Hartford Index of Societal Aging's five indicators provide new context for measuring the health of aging populations including an evidence-based metric to assess effectiveness over time and across many countries. Earlier indexes either made comparisons for a select group of industrialized nations only, sometimes excluding the U.S., were heavily weighted on economic metrics, such as late life labor force participation, did not fully capture inequalities within the advanced developed aging societies or did not measure many other characteristics of an aging society.
"The Index provides an accurate look at how well societies are adapting to this aging challenge," said Goldman. "Utilizing reliable and sensitive economic and social indicators that are widely available, the tool allows countries to take a broader view of both current conditions and likely future demographic realities."

Elements of the index. Credit: John A. Hartford Index of Societal Aging

Elements of The Hartford Index

• Productivity and Engagement - Measures connectedness within and outside the workforce.
• Well-being - Measures the state of being healthy.
• Equity—Measures gaps in well-being and economic security between the haves and have-nots.
• Cohesion - Measures across generations and social connectedness
• Security—Measures support for retirement and physical safety.

"Failure to adapt to aging is a risky strategy for a country," noted Rowe. "If we neglect to develop and implement effective policies we will be left with a society rife with intergenerational tensions, characterized by enormous gaps between the haves and the have-nots, and unable to provide needed goods and services for any of its members—especially a progressively older and more dependent population. The good news is this gloomy scenario is avoidable."
In addition to Drs. Rowe and Goldman, the Index was presented at the conference by Cynthia Chen, a postdoctoral fellow at the USC Schaeffer Center who worked on the project. Other members of the MacArthur Research Network on an Aging Society served as advisors to the project.*


Provided by Columbia University's Mailman School of Public Health

Using money to buy time linked to increased happiness

New research is challenging the age-old adage that money can't buy happiness.
The study, led by researchers at the University of British Columbia and Harvard Business School, suggests that using money to buy free time— such as paying to delegate household chores like cleaning and cooking— is linked to greater life satisfaction.

26 july 2017--"People who hire a housecleaner or pay the kid next door to mow the lawn might feel like they're being lazy," said study lead author Ashley Whillans, assistant professor at Harvard Business School who carried out the research as a PhD candidate in the UBC department of psychology. "But our results suggest that buying time has similar benefits for happiness as having more money."
The researchers surveyed more than 6,000 adults in the United States, Denmark, Canada and the Netherlands. Respondents were asked if and how much they spent each month to buy themselves free time. They also rated their life satisfaction, and answered questions about feelings of time stress.
Respondents who spent money on time saving purchases reported greater life satisfaction. The effect held up even after controlling for income.
"The benefits of buying time aren't just for wealthy people," said UBC psychology professor and the study's senior author Elizabeth Dunn. "We thought the effects might only hold up for people with quite a bit of disposable income, but to our surprise, we found the same effects across the income spectrum."
To test whether buying time actually causes greater happiness, the researchers also conducted a field experiment. Sixty adults were randomly assigned to spend $40 on a time saving purchase on one weekend, and $40 on a material purchase on another weekend. The results revealed that people felt happier when they spent money on a time saving purchase than on a material purchase.
Despite the benefits, the researchers were surprised to discover how few people choose to spend their money on time saving purchases in daily life. Even in a sample of 850 millionaires who were surveyed, almost half reported spending no money outsourcing disliked tasks. A survey of 98 working adults asking how they would spend a windfall of $40 also revealed that only two per cent would use it in a way that saved them time.
"Although buying time can serve as a buffer against the time pressures of daily life, few people are doing it even when they can afford it," said Dunn. "Lots of research has shown that people benefit from buying their way into pleasant experiences, but our research suggests people should also consider buying their way out of unpleasant experiences."
The study was published today in Proceedings of the National Academy of Sciences.

More information: Ashley V. Whillans el al., "Buying time promotes happiness," PNAS (2017). www.pnas.org/cgi/doi/10.1073/pnas.1706541114


Provided by University of British Columbia

Study finds day-to-day experiences affect awareness of aging, mood

A study of older adults finds an individual's awareness of aging is not as static as previously thought, and that day-to-day experiences and one's attitude toward aging can affect an individual's awareness of age-related change (AARC) - and how that awareness affects one's mood.

25 july 2017--"People tend to have an overall attitude toward aging, good or bad, but we wanted to know whether their awareness of their own aging - or AARC - fluctuated over time in response to their everyday experiences," says Shevaun Neupert, an associate professor of psychology at North Carolina State University and lead author of a paper on the study.
For the study, researchers enrolled 116 participants between the ages of 60 and 90. Each participant took a survey to establish baseline attitudes toward aging. For the following eight days, participants kept a log of daily stressors (such as having an argument), completed a daily evaluation of age-related experiences (such as "I am becoming wiser" or "I am more slow in my thinking"), and reported on their affect, or mood.
"We found that people's AARC, as reflected in their daily evaluations, varied significantly from day to day," says Jennifer Bellingtier, a recent Ph.D. graduate from NC State and co-author of the paper. "We also found that people whose baseline attitudes toward aging were positive also tended to report more positive affect, or better moods."
"People with positive attitudes toward aging were also less likely to report 'losses,' or negative experiences, in their daily aging evaluations," Neupert says.
"However, when people with positive attitudes did report losses, it had a much more significant impact on their affect that day," Neupert says. "In other words, negative aging experiences had a bigger adverse impact on mood for people who normally had a positive attitude about aging."
The study expands on previous work that found having a positive attitude about aging makes older adults more resilient when faced with stressful situations.
The paper, "Aging Attitudes and Daily Awareness of Age-Related Change Interact to Predict Negative Affect," is published in the journal The Gerontologist.

More information: Shevaun D. Neupert et al, Aging Attitudes and Daily Awareness of Age-Related Change Interact to Predict Negative Affect, The Gerontologist (2017). DOI: 10.1093/geront/gnx055


Provided by North Carolina State University

Aging Americans enjoy longer life, better health when avoiding three risky behaviors

We've heard it before from our doctors and other health experts: Keep your weight down, don't smoke and cut back on the alcohol if you want to live longer.

24 july 2017--Now, research from the University of Michigan School of Public Health shows that people of fairly normal weight who never smoked and drank only in moderation have a life expectancy at age 50 that is seven years longer than the average American. They also are able to delay disability up to six years.

Current life expectancy in the United States is about 78 years for men and 82 years for women but for the low-risk group the ages are 85 and 89, respectively.
"It's important to convince people to improve these behaviors in order, not only to live a longer life, but live a long life free of disability," said Neil Mehta, assistant professor of health management and policy at the U-M School of Public Health. "However, from a societal perspective, caring for individuals with disability is very costly and our study shows that risky behaviors are significantly increasing the burden of early disability."
While previous research has focused on life expectancy impacts from the individual behaviors, the study, released today by Health Affairs, is believed to be the first to show the effect of all three factors combined.
Of course, Mehta said, people who have avoided these unhealthy behaviors are not the norm.
"Eighty percent of Americans in their 50s either have smoked or been obese. That's huge," he said. "Our study speaks to the importance of prevention at whatever level that can occur in community health or in public policy."
The study used data from U-M's Health and Retirement Study of Americans age 50 and older that began in 1992. The research sample in 1998 included nearly 15,000 respondents ages 50–74.
The researchers defined the low-risk category as those who never smoked, drank moderately (at the top end, fewer than 14 drinks per week for men and fewer than 7 drinks per week for women) and had a body mass index that was less than the classification for obese (30+)—in other words, those who would be considered normal and overweight (18.5-29.9 BMI).
Although the study did not set out to look at what happens when people change one or more of the behaviors, the team found that non-obese people who had quit smoking for 10 years prior to the study and who drank moderately had overall and disability-free life expectancies that were only one year shorter than non-obese people who had never smoked and were moderate drinkers.
"There is some evidence that you can still do a lot to improve your health, even if you have these risk factors at some point. We've done a great job with smoking cessation but it's not clear where we're going with obesity," Mehta said, adding that current budget proposals in Washington put federal funds targeted at reducing obesity and other prevention measures in jeopardy.

More information: Neil Mehta et al. The Population Health Benefits Of A Healthy Lifestyle: Life Expectancy Increased And Onset Of Disability Delayed, Health Affairs (2017). DOI: 10.1377/hlthaff.2016.1569


Provided by University of Michigan

Self-perceptions of aging

In the 1960s, the Beatles sang about wondering whether their true love would still love them as they grew older—after they've lost their hair and are no more adventurous than wanting to knit a sweater.
A group of four studies led by University of Michigan researchers has found that however the hero of the Beatles song turns out, his health—and his wife's health—may be dictated by their perceptions of their own aging.

23 july 2017--"Beliefs about one's own aging are shared within couples, and these beliefs are predictive of future health above and beyond individual beliefs," said Shannon Mejia, a postdoctoral fellow at U-M's Institute for Social Research. "Husbands' and wives' individual experiences of physical activity and disease burden are important for their current shared beliefs and future functional health."
That is, couples who tend to view their aging negatively tend to become less healthy and less mobile than couples who view their aging positively. In addition, husbands' disease burden shape their attitudes toward both their own aging and their wives' aging. Mejia and colleagues surmise that the husbands' limitations stemming from disease negatively affect the wives' health because of the increased burden of caregiving.
Jennifer Sun, an M.D./Ph.D. candidate at the U-M Medical School who conducted the research as a psychology doctoral candidate, found that a person's self-perception of aging affects whether he or she accesses health care in a timely fashion. She found that the more negatively a person viewed his or her aging, the more likely he or she was to delay seeking health care and the more barriers he or she saw for seeking care.
This association between negative self-perceptions of aging and health care delay persisted even after Sun controlled for problems that can delay health care, such as low socioeconomic status, lack of health insurance and multiple chronic health conditions.
"While many studies have focused on financial and structural barriers to care, it is also important to consider how psychosocial, emotional and cognitive factors are affecting the decisions of older adults to delay medical care," Sun said.
A third study authored by U-M doctoral candidate Hannah Giasson found that people who experience age discrimination feel less positive about their own aging.
A fourth study found that as people aged, their explicit bias toward older people—or how they would talk out loud about how they felt toward fellow older adults—improved as they aged. But their implicit bias—how they felt internally about fellow older adults—became more negative as they aged. Giasson and William Chopik, a Michigan State University researcher, led this study.
The papers are published today in a special supplement to the August issue of The Gerontologist.
"We're interested in the way people interpret their own lives," said Jacqui Smith, the principal investigator of a project on well-being in midlife and old age and second author on some of the published papers.
"We know that the images in the world and age stereotypes play a role in how people perceive their own aging. But subtle experiences of discrimination in interactions with strangers and sometimes with your own kids or partner—that is feedback that people take to heart and either rebel against it or begin to believe it."
The AARP supported the publishing of the supplement ahead of the annual meeting of the International Association of Gerontology and Geriatrics.
"Wherever these negative perceptions come from, the damage can be profound—for individuals, communities and larger populations," said AARP CEO Jo Ann Jenkins. "We need to change the conversation about age and aging in this country. It's not about being 'polite.' It's a necessity."


Provided by University of Michigan

AARP, GSA focus on effects of negative attitudes on aging

The ways in which negative attitudes about aging can affect people's health and quality of life are the focus of 12 peer-reviewed research papers in a new AARP-sponsored supplement issue of The Gerontologist—the respected research and analysis journal published by The Gerontological Society of America (GSA) since 1961.

20 july 2017--"Attitudes and stereotypes about aging haven't changed or have gotten worse. And many ideas about aging and solutions available to us as we age, as portrayed in the media or even in conversations among families and friends, are negative and out of date," said AARP Director of Thought Leadership-Health Erwin Tan, MD.
While the papers examine a diverse range of aging-related subjects and research considerations, a common theme is the prevalence of negative associations about aging and their impact, ranging from memory performance to use of health care. The research explores cultural, geographic, community, and family influences that may play a role in shaping an individual's attitude on aging.
"Wherever these negative perceptions come from, the damage can be profound—for individuals, communities, and larger populations," said AARP CEO Jo Ann Jenkins, whose book "Disrupt Aging" examines how aging is represented in society. "We need to change the conversation about age and aging in this country. This is not about being 'polite,' it's a necessity. "
In addition to elevating a collection of timely and insightful research, the August supplement to the The Gerontologist has a broader goal, according to Jenkins.
"We seek to enlist the aid of gerontologists in helping to change the conversation about what it means to grow older," Jenkins said. "Additionally, we want to remind gerontologists of the critical role they play, not just in academia, but in people's real lives. We are all aging, every day so there is no more mainstream topic than aging."


Provided by The Gerontological Society of America

Elderly yoginis have greater cortical thickness

Yoga practitioners showed greater cortical thickness in a cluster in the left prefrontal cortex.

17 july 2017--Scientists in Brazil have imaged elderly female yoga practitioners' brains and found they have greater cortical thickness in the left prefrontal cortex, in brain areas associated with cognitive functions like attention and memory. The results suggest that yoga could be a way to protect against cognitive decline in old age.

As we age, the structure and functionality of our brains change and this often leads to cognitive decline, including impaired attention or memory. One such change in the brain involves the cerebral cortex becoming thinner, which scientists have shown is correlated with cognitive decline. So, how can we slow or reverse these changes?
You might think medication would be required, but surprisingly, the answer could lie in contemplative practices like yoga. Yoga practitioners consciously maintain postures, and perform breathing exercises and meditation.
"In the same way as muscles, the brain develops through training," explains Elisa Kozasa of Hospital Israelita Albert Einstein in São Paulo, Brazil, a researcher involved in the study, which was recently published in Frontiers in Aging Neuroscience. "Like any contemplative practice, yoga has a cognitive component in which attention and concentration are important."
Previous studies have suggested that yoga can have greater health benefits than similar aerobic exercises, and yoga practitioners have shown improved awareness, attention and memory. Older adults with mild cognitive impairment have also shown improvements after a short yoga training program.

Credit: CC0 Public Domain

But can practicing yoga over several years significantly shape your brain and if so, could it offset some of the changes that happen in the aging brain? The research team wanted to see if elderly long-term yoga practitioners had any differences in terms of brain structure compared with healthy elderly people who had never practiced yoga.
They recruited 21 female yoga practitioners (also known as yoginis) who had practiced yoga at least twice a week for a minimum of 8 years, although the group had an average of nearly 15 years of yoga practice. The researchers compared the yoginis with another group of 21 healthy women, who had never practiced yoga, meditation or any other contemplative practices, but who were well-matched to the yoginis in terms of their age (all the participants were 60 or over) and levels of physical activity. For more consistent results, the researchers only recruited women, and the participants completed surveys to see if there were any other factors at work that could affect brain structure, such as depression or level of formal education.
The researchers scanned the participants' brains using magnetic resonance imaging to see if there were any differences in brain structure. "We found greater thickness in the left prefrontal cortex in the yoginis, in brain regions associated with cognitive functions such as attention and memory," says Rui Afonso, another researcher involved in the study. As the groups were well-matched in terms of other factors that can change brain structure, such as education and levels of depression, yoga practice appears to underlie the yoginis' different brain structure.
The results suggest that practicing yoga in the long-term can change the structure of your brain and could protect against cognitive decline in old age. However, the team plan to carry out more studies to see if these brain changes result in enhanced cognitive performance in elderly yoginis.
Another possibility is that people with these brain features are more likely to be attracted to yoga. "We have compared experienced yoginis with non-practitioners, so we do not know if the yoginis already had these differences before they started yoga," explains Afonso. "This can only be confirmed by studying people for a few years from the time they start yoga."

More information: Rui F. Afonso et al, Greater Cortical Thickness in Elderly Female Yoga Practitioners—A Cross-Sectional Study, Frontiers in Aging Neuroscience (2017). DOI: 10.3389/fnagi.2017.00201


Provided by Frontiers

Surgery for early prostate cancer may not save lives

Gerald L. Andriole, M.D., (right) director of Washington University's Division of Urologic Surgery, performs surgery on a patient with prostate cancer. New research provides further evidence that surgery is unnecessary for early-stage prostate cancer, although some men whose disease is further along may benefit.

15 july 2017--A major 20-year study provides further evidence that prostate cancer surgery offers negligible benefits to many men with early-stage disease. In such men, who account for most cases of newly diagnosed prostate cancer, surgery did not prolong life and often caused serious complications such as infection, urinary incontinence and erectile dysfunction.
The study, by a national research team including Washington University School of Medicine in St. Louis, was led by the Minneapolis Veterans Administration Health Care System. It is published July 13 in The New England Journal of Medicine.
In men with early prostate cancer, the study compared surgery with observation. With the latter, men only were treated if they developed bothersome symptoms, such as urinary difficulty or bone pain. Such symptoms may indicate progression of the cancer. Many men in the observation group received no treatment at all because early-stage prostate cancer often grows slowly and rarely causes symptoms.
"The findings will go a long way in helping to improve prostate cancer care," said co-author Gerald L. Andriole, MD, director of Washington University's Division of Urologic Surgery. "About 70 percent of patients newly diagnosed with prostate cancer cases are in the early stages, meaning the cancer is confined to the prostate gland, and they have nonaggressive tumors. As such, these patients have an excellent prognosis without surgery. This study confirms that aggressive treatment usually is not necessary. We hope the findings will steer doctors away from recommending surgery or radiation to their patients with nonaggressive early-stage prostate cancer and patients away from thinking it's necessary."
The American Cancer Society ranks prostate cancer as the second most common cancer in men and the third-leading cause of cancer deaths among men, after lung and colorectal cancer. In 2017, about 161,360 men will be diagnosed with prostate cancer, and 26,730 will die from it.
The study, known as the Prostate Cancer Intervention Versus Observation Trial, or PIVOT, is one of the largest and longest involving cancer patients. It got underway in 1994 just as the prostate-specific antigen blood test for prostate cancer became routine. With many more men diagnosed with prostate cancer, the standard treatment for all prostate cancers became surgery or radiation, with the thinking that removing or irradiating the tumor would increase survival. But over the next decade, reports of treatment-related complications raised concerns, as did data indicating that most early-stage cancers grew so slowly they were unlikely to cause health problems.
To evaluate any potential benefits of surgery, the researchers randomly assigned 731 men in the U.S. with localized prostate cancer to receive either surgery or observation at one of 44 Department of Veteran Affairs Health Care Centers or eight academic medical centers, including Washington University. The average age of men in the study was 67 at the time of enrollment.
Of the men who had prostate cancer surgery, 223 (61 percent) died of other causes after up to 20 years of follow-up, compared with 245 men (66 percent) in the observation group - a difference that is not statistically different. Further, 27 (7 percent) men in the surgery group died of prostate cancer, compared with 42 men (11 percent) in the observation group, but that difference also is not statistically significant.
However, the data show that surgery may have a mortality benefit in some men, particularly those with a long life expectancy and intermediate-risk prostate cancer. (Such men generally have PSA scores of 10-20 ng/ml and a Gleason score of seven. The latter score signifies tumor aggressiveness.)
"It would be a disservice to dismiss surgery as a viable option for patients with intermediate-risk prostate cancer," said Andriole, the School of Medicine's Robert K. Royce Distinguished Professor of Urologic Surgery. He treats patients at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University. "For these patients, and for some men with high-risk prostate cancer, surgery is often beneficial, as are other other treatments such as radiation."
Technology has advanced since the study began, allowing physicians to more accurately classify tumors and avoid overtreating patients who have prostate cancer.
Of the 364 men treated with surgery, 53 (15 percent) suffered from erectile dysfunction, and 63 (17 percent) reported having incontinence. Another 45 developed other complications.
"The benefits of surgery also need to be balanced against the negative long-term consequences of surgery that occur early and often," said senior author Timothy Wilt, MD, a physician-researcher with the Center for Chronic Disease Outcomes Research at the Minneapolis VA Health Care System and a professor of medicine at the University of Minnesota. "Our results demonstrate that for the majority of men with localized prostate cancer, selecting observation for their treatment choice can help them live a similar length of life, avoid death from prostate cancer and prevent harms from surgical treatment. Physicians can use information from our study to confidently recommend observation as the preferred treatment option for men with early prostate cancer."

More information: New England Journal of Medicine (2017). DOI: 10.1056/NEJMoa1615869


Provided by Washington University in St. Louis

Cognitive function up with adherence to mediterranean diet

12 july 2017--For older adults, greater adherence to the Mediterranean diet (MedDiet) and the Mediterranean-DASH diet Intervention for Neurodegeneration Delay (MIND) is associated with improved cognitive function, according to a study published online recently in the Journal of the American Geriatrics Society.
Claire T. McEvoy, Ph.D., from the University of California in San Francisco, and colleagues conducted a cross-sectional study involving 5,907 community-dwelling older adults to examine adherence to dietary patterns. Diet scores were generated for the MedDiet and the MIND diet using food frequency questionnaires. A composite test score of global cognitive function was used to measure cognitive performance.
The researchers found that in fully adjusted models, participants with mid and high MedDiet scores were less likely to have poor cognitive performance than those with low scores (odds ratios, 0.85 [95 percent confidence interval, 0.71 to 1.02; P = 0.08] and 0.65 [95 percent confidence interval, 0.52 to 0.81; P < 0.001]). Similar results were seen for the MIND diet. In each dietary pattern, higher scores were independently correlated with significantly better cognitive function (P < 0.001) in a dose-response pattern (P_trend < 0.001).
"Clinical trials are required to elucidate the role of dietary patterns in cognitive aging," the authors write.
One author disclosed financial ties to Takeda Pharmaceuticals.

More information: Abstract
Full Text

Shingles increases risk of heart attack, stroke

Contracting shingles, a reactivation of the chickenpox virus, increases a person's risk of stroke and heart attack, according to a research letter published today in the Journal of the American College of Cardiology.

09 july 2017--According to the Centers for Disease Control and Prevention, almost 1 out of every 3 people in the United States will develop shingles in their lifetime. Anyone who has suffered from chickenpox may develop shingles; however, the risk of shingles increases as a person gets older.
Researchers in South Korea used the National Health Insurance Service's "medical check-up" database to identify patients with newly diagnosed herpes zoster—or shingles, stroke and heart attack using the relevant International Classification of Disease-10 diagnostics codes.
A total of 519,880 patients were followed from 2003-2013, during this period there were 23,233 cases of shingles. The final cohort of 23,213 was matched with the same number of shingles-free patients to serve as control subjects.
Patients with shingles were more likely to be female and common risk factors for stroke and heart attack, such as old age, high blood pressure, diabetes and high cholesterol, were also more commonly seen in these patients. However, this group was also less likely to smoke, have a lower alcohol intake, more exercise and be part of a higher socioeconomic class.
Shingles was found to raise the risk of a composite of cardiovascular events including heart attack and stroke by 41 percent, the risk of stroke by 35 percent and the risk of heart attack by 59 percent. The risk for stroke was highest in those under 40 years old, a relatively younger population with fewer risks for atherosclerosis. The risks of both stroke and heart attack were highest the first year after the onset of shingles and decreased with time. However, these risks were evenly distributed in the shingles-free group.
"While these findings require further study into the mechanism that causes shingles patients to have an increased risk of heart attack and stroke, it is important that physicians treating these patients make them aware of their increased risk," said Sung-Han Kim, MD, PhD, a physician in the department of infectious diseases at Asan Medical Center in Seoul and one of the study authors.


Provided by American College of Cardiology

Healthy lifestyle may help older adults preserve their independence

In a study of men with an average age of 71 years, lifestyle factors such as never smoking, maintaining a healthy diet, and not being obese were associated with survival and high functionality over the next 16 years.

07 july 2017--The study included 1104 men who completed a questionnaire. High functionality was defined as preserved ability in personal activities of daily living and cognitive function.
Additional studies are needed to investigate whether lifestyle changes after the age of 70 years may also lead to preserved independence.
The findings are published in the Journal of the American Geriatrics Society.

More information: Journal of the American Geriatrics Society (2017). DOI: 10.1111/jgs.14971


Provided by Wiley

Popular heartburn drugs linked to higher death risk

Millions of US residents take proton pump inhibitors which are widely prescribed to treat heartburn, ulcers and other gastrointestinal problems. The drugs also are available over the counter under brand names that include Prevacid, Prilosec and Nexium. Now, a new study from Washington University School of Medicine in St. Louis shows that long-term use of the popular drugs carries an increased risk of death.

06 july 2017--Popular heartburn drugs called proton pump inhibitors (PPIs) have been linked to a variety of health problems, including serious kidney damage, bone fractures and dementia. Now, a new study from Washington University School of Medicine in St. Louis shows that longtime use of the drugs also is associated with an increased risk of death.
Millions of U.S. residents take proton pump inhibitors which are widely prescribed to treat heartburn, ulcers and other gastrointestinal problems. The drugs also are available over the counter under brand names that include Prevacid, Prilosec and Nexium.
For the study, the researchers examined medical records of some 275,000 users of PPIs and nearly 75,000 people who took another class of drugs - known as H2 blockers - to reduce stomach acid. The research is published online July 3 in the journal BMJ Open.
"No matter how we sliced and diced the data from this large data set, we saw the same thing: There's an increased risk of death among PPI users," said senior author Ziyad Al-Aly, MD, an assistant professor of medicine. "For example, when we compared patients taking H2 blockers with those taking PPIs for one to two years, we found those on PPIs had a 50 percent increased risk of dying over the next five years. People have the idea that PPIs are very safe because they are readily available, but there are real risks to taking these drugs, particularly for long periods of time."
Both PPIs and H2 blockers are prescribed for serious medical conditions such as upper gastrointestinal tract bleeding, gastroesophageal reflux disease and esophageal cancer. Over-the-counter PPIs are most often used for heartburn and indigestion.
PPIs have become one of the most commonly used classes of drugs in the United States with 15 million monthly prescriptions in 2015 for Nexium alone, according to WebMD.
A kidney doctor by profession, Al-Aly has previously published studies linking PPIs to kidney disease, and other researchers have shown an association with other health problems. Al-Aly, first author Yan Xie, PhD, a data scientist, and colleagues reasoned that since each of these side effects carries a small risk of death, together they may affect the mortality rate of PPI users.
To find out, the researchers sifted through millions of de-identified veterans' medical records in a database maintained by the U.S. Department of Veterans Affairs. They identified 275,933 people who had been prescribed a PPI and 73,355 people prescribed an H2 blocker between October 2006 and September 2008, and noted how many died and when over the following five years. The database did not include information on cause of death.
Al-Aly and colleagues found a 25 percent increased risk of death in the PPI group compared with the H2 blocker group. The researchers calculate that, for every 500 people taking PPIs for a year, there is one extra death that would not have otherwise occurred. Given the millions of people who take PPIs regularly, this could translate into thousands of excess deaths every year, Al-Aly said.
The researchers also calculated the risk of death in people who were prescribed PPIs or H2 blockers despite not having the gastrointestinal conditions for which the drugs are recommended. Here, the researchers found that people who took PPIs had a 24 percent increased risk of death compared with people taking H2 blockers.
Further, the risk rose steadily the longer people used the drugs. After 30 days, the risk of death in the PPI and H2 blocker groups was not significantly different, but among people taking the drugs for one to two years, the risk to PPI users was nearly 50 percent higher than that of H2 blocker users.
Although the recommended treatment regimen for most PPIs is short - two to eight weeks for ulcers, for example - many people end up taking the drugs for months or years.
"A lot of times people get prescribed PPIs for a good medical reason, but then doctors don't stop it and patients just keep getting refill after refill after refill," Al-Aly said. "There needs to be periodic re-assessments as to whether people need to be on these. Most of the time, people aren't going to need to be on PPIs for a year or two or three."
As compared with the H2 blocker group, people in the PPI group were older (64 years old, on average, versus 61) and also somewhat sicker, with higher rates of diabetes, hypertension and cardiovascular disease. But these differences cannot fully account for the increased risk of death since the risk remained even when the researchers statistically controlled for age and illness.
Over-the-counter PPIs contain the same chemical compounds as in prescription PPIs, just at lower doses, and there is no way to know how long people stay on them. The Food and Drug Administration recommends taking PPIs no longer than four weeks before consulting a doctor.
Al-Aly emphasizes that deciding whether to take a PPI requires a risk-benefit calculation.
"PPIs save lives," Al-Aly said. "If I needed a PPI, I absolutely would take it. But I wouldn't take it willy-nilly if I didn't need it. And I would want my doctor to be monitoring me carefully and take me off it the moment it was no longer needed."


Provided by Washington University School of Medicine

Endocrine Society issues Scientific Statement on obesity's causes

A new Scientific Statement issued by the Endocrine Society calls for more research aimed specifically at understanding the underlying mechanisms that make it difficult to maintain long-term weight loss.

04 july 2017--Despite decades of research and billions of dollars spent each year on treatment, understanding of the underlying causes of obesity remains limited. One in three American adults is affected by obesity, and it costs an estimated $147 billion a year to treat obesity and its consequences in the United States, according to the Centers for Disease Control and Prevention.
Growing evidence suggests obesity is a disorder of the body's intricate energy balance systems. Once an individual loses weight, the body typically reduces the amount of energy expended at rest, during exercise and daily activities while increasing hunger. This combination of lower energy expenditure and hunger creates a "perfect metabolic storm" of conditions for weight gain.
"Because of the body's energy balance adjustments, most individuals who successfully lose weight struggle to maintain weight loss over time," said Michael W. Schwartz, M.D., of the University of Washington in Seattle, Wash., and the chair of the task force that authored the Society's Scientific Statement. "To effectively treat obesity, we need to better understand the mechanisms that cause this phenomenon, and to devise interventions that specifically address them. Our therapeutic focus has traditionally been on achieving weight reduction. Most patients can do this; what they have the most trouble with is keeping the weight off."
"Healthcare providers and patients need to view this tendency as the body's expected response to weight loss, rather than as a sign of a failed treatment regimen or noncompliance with treatment," Schwartz said.
The Society's statement also calls for additional research into factors influencing obesity;

• Interactions between genetics, developmental influences and the environment. Though a substantial portion of obesity risk is conveyed by genes, researchers have not yet been able to identify all of the relevant genes and to understand the nature of their interactions with developmental processes and the environment.
• The effect of endocrine-disrupting chemicals such as bisphenol A on obesity.
• The microbiome, or bacteria in the gut, and its interactions with the endocrine and digestive systems as well as the brain.
• The reasons behind the therapeutic success of bariatric surgery.
• The role that diet composition plays in the development of obesity.
• Biological markers and predictors for diabetes, heart disease and other conditions that often develop in conjunction with obesity.
• The effects of socioeconomic status on obesity risk.
• Brain imaging to better understand appetite and feeding behavior.

More information: Michael W. Schwartz et al, Obesity Pathogenesis: An Endocrine Society Scientific Statement, Endocrine Reviews (2017). DOI: 10.1210/er.2017-00111


Provided by The Endocrine Society

Alzheimer's disease patients with psychosis more likely to be misdiagnosed, study suggests

Dr. Corinne Fischer, director of the Memory Disorders Clinic at St. Michael's Hospital in Toronto and lead author of the study.

People with Alzheimer's disease who experience psychosis—including delusions and hallucinations—are five times more likely to be misdiagnosed with dementia with Lewy bodies compared to patients who do not, new research suggests.

03 july 2017--Alzheimer's disease is a type of dementia characterized by protein deposits in the brain including twisted fibers found inside brain cells. Dementia with Lewy bodies is believed to be caused by the buildup of a different abnormal protein aggregate found in nerve cells in the brain. Effective treatments for these conditions are still under development, but will almost certainly be different, according to the authors.
Researchers also found that Alzheimer's disease was misdiagnosed in 24 per cent of all cases, with false positive and false negative rates both being 12 per cent. Previous research suggested that the rate of misdiagnosis in Alzheimer's disease ranged from 12-23 per cent.
The findings, published online today in Alzheimer's & Dementia: Translational Research & Clinical Interventions, raise concern that there may be an under appreciation of how common psychotic symptoms are in Alzheimer's disease, said Dr. Corinne Fischer, director of the Memory Disorders Clinic at St. Michael's Hospital in Toronto and lead author of the study.
"Psychosis can be a symptom of Alzheimer's disease, but it is a defining clinical feature in other types of dementia, including Parkinson's disease related dementia and dementia with Lewy bodies," she said. "Consequently, clinicians are more reluctant to diagnose a patient with Alzheimer's disease when they present with delusions or hallucinations."
About 36 per cent of people with Alzheimer's are thought to have delusions and 18 per cent have hallucinations. Psychotic symptoms are significant in Alzheimer's patients because they have been shown to be associated with increased burden on caregivers, increased functional decline and more rapid progression of the disease.
Researchers examined 961 people using data from the National Alzheimer's Coordinating Centre database, collected from 29 Alzheimer's disease centres in the United States between 2005 and 2012. They included participants who had been clinically diagnosed with Alzheimer's while they were alive, as well as those whose autopsies showed they the signature physical signs of Alzheimer's in their brains.
Patients who experienced psychosis had a higher rate of false negative diagnosis and a lower rate of false positive diagnosis of Alzheimer's disease compared to those who did not. Whether patients experienced delusions, hallucinations, or a combination of both did not affect the rate of misdiagnosis, according to the authors.
The Alzheimer's Society of Canada estimates there are 564,000 people living with dementia in Canada, and that number is expected to almost double over the next 15 years, thus reinforcing the relevance of the study's findings according to Winnie Qian, a Master's student in the Neuroscience Research Program at St. Michael's and an author on the study.
"An advantage of our study is that we used the final clinical diagnosis after years of follow-up, so the rate of misdiagnosis we described is the rate under ideal conditions," she said.
"This means that it should be considered a minimum. If you extrapolate that and apply it to the general population, the magnitude of the problem could be much greater."
Dr. Fischer said when patients do not present with psychosis, clinicians should be more careful when considering alternative diagnoses to Alzheimer's disease.
"Many dementia patients never receive a definitive clinical diagnosis while they're alive, so the hope is that by understanding what factors can lead to a misdiagnosis, we can be more accurate and provide patients with the best possible care," she said.


Provided by St. Michael's Hospital

Brain stimulation no better than escitalopram for depression

Escitalopram may outperform transcranial direct-current stimulation (tDCS) in the treatment of depression, according to a study published in the June 29 issue of the New England Journal of Medicine.

01 july 2017--Andre Brunoni, M.D., Ph.D., director of the Service of Interdisciplinary Neuromodulation at the University of Sao Paulo in Brazil, and colleagues randomly assigned 245 patients with depression to one of four groups. One group had tDCS plus a placebo pill, another had sham tDCS plus escitalopram. The third group had tDCS plus escitalopram, and the final group had sham tDCS plus a placebo. The treatment was given for 15 consecutive days at 30 minutes each, then once a week for seven weeks. Escitalopram was taken daily for three weeks, after which the daily dose was increased from 10 to 20 mg for the next seven weeks.
After 10 weeks, patients receiving tDCS fared no better than those taking escitalopram. Patients receiving tDCS, however, experienced more side effects, the researchers found. Specifically, patients receiving tDCS had higher rates of skin redness, ringing in the ears, and nervousness than those receiving sham brain stimulation. In addition, two patients receiving tDCS developed new cases of mania. Patients taking escitalopram reported more frequent sleepiness and constipation.
"tDCS has been increasingly used as an off-label treatment by physicians," Brunoni told HealthDay. "Our study revealed that it cannot be recommended as a first-line therapy yet and should be investigated further."

More information:

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Understanding the epidemiology of sarcopenia throughout the lifecourse

Sarcopenia is an age-related syndrome which is characterised by progressive and generalised loss of muscle mass and strength. How prevalent is sarcopenia? As there is a lack of consensus in the operational definition used to characterized the disorder, estimates vary widely in different clinical settings, and depending on the definition used.

29 jun 2017--Recent definitions have integrated information on muscle mass, strength, and physical function. A new systematic review by researchers at the MRC Lifecourse Epidemiology Unit, University of Southampton, has now evaluated the epidemiology of these three distinct physiological components.
Specifically, the review highlights the similarities and differences between the patterns of variation in muscle mass, strength and physical function in regard to age, gender, geography, time, as well as the relation to individual risk factors. The review also describes how different approaches used to measure muscle mass, strength and function contribute to varying prevalence rates.
Observations include:

• There are differences in relation to the peak level and subsequent loss rate of muscle mass, strength and function between men and women, between ethnic groups, and over time.
• The rate of decline is most rapid in regard to physical function, followed by muscle strength. The decline of muscle mass is least rapid.
• Although men have significantly higher levels of muscle mass, strength and function than women at any given age, the rate of decline for all three parameters is similar in both genders.
• The higher levels of muscle mass in some ethnicities do not translate into higher levels of muscle strength and function.
• Asian populations tend to have similar declines in muscle mass to non-Asians, but experience much more rapid deterioration in strength and function.
• Sedentary lifestyle, adiposity and multi-morbidity are environmental risk factors affecting all three components. The role of smoking and alcohol intake is less apparent than has been observed in regard to osteoporosis or cardiovascular disease.
• Nutrition has an important influence on the development of sarcopenia. Protein intake has the potential to slow the loss of muscle mass, but is not as influential in maintaining strength and function.
• Physical activity (and in particular resistance training) when performed at higher intensities, is beneficial for muscle strength and functioning.
• Trials combining protein supplementation and physical activity show promising results in reducing the decline in muscles strength and function with advancing age.

Lead author Professor Cyrus Cooper stated: "Sarcopenia contributes to the risk of physical frailty, functional impairment, poor health-related quality of life, and premature death in older people. Understanding the epidemiological characteristics of muscle mass, strength and function is an important first step in achieving consensus in the definition of sarcopenia. This will allow us to better understand its prevalence, to determine clinically relevant thresholds for diagnosis, and ultimately, to enable the development of novel preventive and therapeutic strategies."

More information: S. C. Shaw et al, Epidemiology of Sarcopenia: Determinants Throughout the Lifecourse, Calcified Tissue International (2017). DOI: 10.1007/s00223-017-0277-0


Provided by International Osteoporosis Foundation

Task Force presents new ranking of colorectal cancer screening tests

In its latest recommendations, the US Multi-Society Task Force (MSTF) on Colorectal Cancer (CRC) Screening confirms that people at average risk should be screened beginning at age 50, and recommends colonoscopy and fecal immunochemical testing (FIT) as the "first tier" screening tests for this group. Screening continues to be a first line of defense against CRC, as it can detect pre-cancerous growths as well as cancer, which is highly treatable if caught early.

28 jun 2017--Overall, the incidence of colorectal cancer (CRC) in people age 50 and older is declining. However, the task force noted a rising incidence of CRC in younger Americans, for reasons that are unclear. While the relative incidence in younger people remains low, the increasing trend of young onset CRC is nevertheless a "major public health concern." In addition, the task force suggests beginning screening earlier in the African-American population, at age 45.
"Colorectal Cancer Screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer" was published jointly in three gastroenterology journals, Gastroenterology, The American Journal of Gastroenterology and GIE: Gastrointestinal Endoscopy (published online June 6).
Recommendations for screening are re-evaluated periodically as new evidence emerges and as shifts occur in healthcare delivery and access. The task force, made up of representatives from the American Society for Gastrointestinal Endoscopy, American College of Gastroenterology and American Gastroenterological Association, evaluated seven different types of screening tests based on effectiveness at detecting cancer and pre-cancerous polyps.
Experts know that offering screening tests systematically to people without any symptoms is the best way to prevent colorectal cancer and to detect it at an earlier, more treatable stage. However, the large number of options available for screening, and the wide variation in effectiveness, acceptability to patients and cost, suggests that guidance is needed to facilitate discussions between physicians and patients and make the process of offering screening both feasible for physicians and easily understood and accepted by patients.
"We believe these recommendations make the presentation of screening options in the office easier for providers and patients, maximizing both effectiveness and adherence. The document also addresses important issues for organized screening programs that are sometimes used in large health plans," said lead author Douglas K. Rex, MD, FASGE, AGAF, MACG. "These recommendations are informed both by available scientific evidence, as well as practical considerations and cost data."
The document includes sections on screening tests, targets, cost and quality; practical considerations; family history as a risk factor; and age considerations. Each screening test is explained, along with advantages and disadvantages. Strength of evidence is noted in the document for various recommendations.

Screening Tests

The task force ranked tests into three "tiers" according to the strength of the recommendation for average-risk people. The task force also incorporated practical considerations, such as test availability, cost effectiveness, current usage patterns, obstacles to implementation, and the likelihood that patients will repeat the test when they should.
For any test other than colonoscopy, patients need to understand that if they have a positive result, they will need to undergo a colonoscopy to follow up on those results.
Tier 1— the cornerstone tests—are colonoscopy every 10 years or annual FIT. Colonoscopy is highly sensitive for cancer and all classes of precancerous lesions, and it is the only test that allows a patient to be diagnosed and treated in a single session. FIT is less sensitive and must be repeated every year, but it is non-invasive, lower-cost, and performs very well in preventing cancer and cancer deaths when repeated annually. For these reasons, FIT is an attractive option in large health plans with organized screening programs, which also have systems in place to ensure annual testing.

Tier 2 options include:

• CT colonography every five years
• FIT-fecal DNA every three years
• Flexible sigmoidoscopy every five to 10 years

Tier 3 options include:

• Capsule colonoscopy every five years

Available tests not recommended:

• Septin9 (a blood-based test)

Highlights of the screening test recommendations include:

• Colonoscopy should be performed every 10 years or a FIT administered every year as first-tier options for screening average-risk persons for colorectal neoplasia.

Physicians performing screening colonoscopy should measure quality, including the adenoma detection rate.
Physicians performing FIT need to monitor quality. The recommended quality measurements for FIT programs are detailed in a prior publication.1
Patients who refuse colonoscopy or FIT should have CT colonography every 5 years, FIT-fecal DNA every three years, or flexible sigmoidoscopy every five to 10 years .
Capsule colonoscopy (if available) is an appropriate screening test when patients decline colonoscopy, FIT, FIT-fecal DNA, CT colonography, and flexible sigmoidoscopy.
Septin9 is not recommended for CRC screening.

Family History

A family history of CRC in a first-degree relative (parent, sibling or child) increases a person's risk of developing this type of cancer, regardless of the age when the relative is diagnosed.
Highlights of recommendations pertaining to family history include:
People with a family history of CRC in a first-degree relative diagnosed before age 60 should undergo colonoscopy every five years, beginning at age 40 or 10 years before the age at which their relative was diagnosed, whichever comes first. The same is true for those who have a first-degree relative with a documented advanced adenoma or documented advanced serrated lesions.
People with one first-degree relative diagnosed at age 60 or older are advised to begin screening at age 40.

CRC increasingly is found in younger people

The incidence of CRC is rising in people under age 50. The reasons for this trend are not known at this time. Although the rate of CRC in this age group is still low, the increase is a "major public health concern," according to the authors.
Aggressive evaluation of patients with symptoms is recommended as an important first step, particularly for symptoms involving bleeding, which may include blood in the stool, black or tarry stool with a negative upper endoscopy, or iron deficiency anemia. If a test other than colonoscopy is used to evaluate bleeding symptoms, a diagnosis should be made, and the patient should be treated and followed until resolution of the problem.
Patients who have only non-bleeding symptoms, such as abnormal bowel habits, change in bowel habits or appearance, or abdominal pain, but who have no evidence of bleeding, are no more likely to have cancer than asymptomatic persons of similar age.

Rationale for screening earlier in African-American population

In the African-American population, there is a lower screening rate for CRC, higher incidence rates of cancer, and worse survival statistics compared with other races. The task force outlined a scientific rationale for starting screening earlier based on higher cancer incidence, as well as the younger mean age of colorectal cancer onset in this population even as they acknowledge that there are few data to show that screening before age 50 improves outcomes in this group.
For the first time, the new MSTF document suggests beginning screening at age 45 for African-American patients, though the task force noted the need for additional study of the yield of CRC screening in persons under age 50, and particularly in this population.
The task force added that recommendations to screen earlier in this group "have served an important role in stimulating discussion of and research on CRC in African Americans, increasing awareness in physicians of an important public health problem and racial disparity in health outcomes in the United States, and increasing awareness of CRC in African Americans." The group added that "provider recommendation is key," and that patient navigation services can improve compliance with colonoscopy screening.

Conclusion

In summary, the task force recommends beginning CRC screening at age 50 for average-risk patients, and considers colonoscopy and FIT to be the cornerstones of screening for these patients regardless of the healthcare setting. The authors stressed that optimal results in CRC screening depend on good technical performance and reporting of tests and ensuring that patients undergo appropriate follow-up after testing.
"Screening often originates in the doctor's office, and in that setting, colonoscopy is particularly attractive, because it needs to be performed so infrequently. However, if patients decline colonoscopy, they should be offered FIT, and if they decline FIT, a second-tier test should be offered," said Dr. Rex.
"In the doctor's office, it's also reasonable to present the pros and cons of both colonoscopy every 10 years and annual FIT to patients, so they can choose between the two tests. This approach provides a framework for screening that is simple and accommodates almost every healthcare setting," Dr. Rex continued. "These recommendations constitute a practical approach toward the ultimate goal of maximizing screening rates, while using well accepted, effective and cost-effective tests."

More information: 1. Robertson DJ, Lee JK, Boland CR, et al. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the U.S. Multisociety Task Force on colorectal cancer. Gastrointest Endosc 2016: 85:2-21


Provided by American Society for Gastrointestinal Endoscopy

Older adults who take 5+ medications walk slower than those who take fewer medications

"Polypharmacy" is the term used when someone takes many (usually five or more) different medications. Experts suggest that, for most older adults, taking that many medications may not be medically necessary. Taking multiple medications also can be linked to problems such as falls, frailty, disability, and even death. 

27 jun 2017--Polypharmacy also is a problem for older adults due to side effects or interactions resulting from the use of different medications. Older adults may have difficulties taking the medications properly, and the medications may interfere with a person's ability to function well.
The ability to walk well is a sign of independence and good health for older adults, for example, and it may be affected by the use of multiple medications. Although healthcare providers know that some treatments can slow or hamper an older person's ability to walk, little is known about the effects of polypharmacy on walking while performing other tasks, like talking. In a new study, researchers examined how polypharmacy affected walking while talking. They published their study in the Journal of the American Geriatrics Society.
The researchers examined information from 482 people age 65 and older who were enrolled in the "Central Control of Mobility in Aging" study. That study's main purpose was to determine how changes to the brain and our central nervous system occur during aging, and how they might impact an older person's ability to walk.
Researchers confirmed the medications (prescriptions as well as herbal and other over-the-counter supplements) study participants were taking. The researchers defined "polypharmacy" as using five or more of these treatments.
Participants took detailed exams assessing physical health, mental well-being, and mobility at the start of the study and at yearly follow-up appointments. Among other evaluations, the researchers measured the participants' walking speed. None of the participants used walking aides (such as canes or walkers) or monitors. The participants were asked to walk at their normal pace on a special 20-foot long walkway, and to walk while talking. The research team also interviewed the participants to learn about their medical conditions, ability to think and make decisions, and brain function.
Among the 482 participants in the study, 34 percent used five or more medications during the study period (June 2011-February 2016); 10 percent used more than eight medications. The participants were mostly in their late 70s.
People in the polypharmacy group were more likely to have high blood pressure, congestive heart failure, diabetes, and a history of heart attacks. They were also more likely to have had a fall within the last year and were more overweight than people in the non-polypharmacy group.
After accounting for chronic health problems, a history of falls, and other issues, the people in the polypharmacy group had a slower walking speed (or gait) than the people in the non-polypharmacy group. Those who took 8 or more medications had slower walking speed when walking while talking. The researchers concluded that there was a link between polypharmacy and walking speed, and that more studies would be needed to follow-up on their findings and the effect specific medications might have on overall well-being.
The researchers also noted that at their check-ups, older adults should be asked about all the medications they take, including herbal and other over-the-counter supplements. They also suggested that healthcare professionals measure walking speed during regular check-ups.

More information: Claudene George et al, Polypharmacy and Gait Performance in Community-dwelling Older Adults, Journal of the American Geriatrics Society (2017). DOI: 10.1111/jgs.14957


Provided by American Geriatrics Society